2022
Quick
Reference
Guide
The Resources You Need. Right Here.
For more information, visit Ambetter.pshpgeorgia.com
If this information is not in your primary language, please call 1-877-687-1180 (TTY/TDD 1-877-941-9231)
AMB21-GA-C-00632_SELECT
Ambetter from Peach State Health Plan: --- (TTY/TDD ---) | Ambetter.pshpgeorgia.com |
Welcome to Ambetter
from Peach State Health Plan!
Thank you for choosing us as your health insurance plan.
We’re excited to help you take charge of your health and
to help you lead a healthier, more fulfilling life.
As our member, you have access to lots of helpful services and resources.
This Quick Reference Guide (QRG) will help you understand all of them. Inside,
you’ll find important information about:
• How your plan works
• Payment information
• Where to go for care
• Information on your
MemberID
• TeleHealth
• And much more!
YOUR HEALTH IS OUR PRIORITY.
If you have questions, we’re always ready to help. And don’t forget to check out
our online video library at Ambetter.pshpgeorgia.com. It’s full of useful information.
Member Services:
1-877-687-1180 (TTY/TDD 1-877-941-9231)
Ambetter.pshpgeorgia.com
AMBETTER FROM PEACH STATE HEALTH PLAN
Ambetter from Peach State Health Plan: --- (TTY/TDD ---) | Ambetter.pshpgeorgia.com |
QUICK REFERENCE GUIDE OVERVIEW
How To Contact Us
How To Contact Us
Ambetter from Peach State Health Plan
1100 Circle 75 Parkway, Suite 1100
Atlanta, GA 30339
If you want to talk, we’re available
Monday through Friday, a.m. to p.m. EST.
Member Services 1-877-687-1180
Fax 1-877-941-8071
TTY/TDD 1-877-941-9231
Make a Payment 1-877-687-1180
Behavioral Health Services 1-877-687-1180
24/7 Nurse Advice Line 1-877-687-1180
Complaints and Grievances 1-877-687-1180
Emergency 911
Website
Ambetter.pshpgeorgia.com
When you call, have these items ready:
• Your ID
• Your claim number or invoice for billing questions
Interpreter Services
Please call Member Services at 1-877-687-1180 (TTY/TDD 1-877-941-9231) for free
interpreter services as needed. Interpreter services include languages other than
English. This service allows you and your provider to talk about your medical or
behavioral health concerns in a way that is most comfortable for you. Members who
are blind or visually impaired and need help with interpretation can call Member
Services for an oral interpretation.
Ambetter from Peach State Health Plan: --- (TTY/TDD ---) | Ambetter.pshpgeorgia.com |
HOW YOUR PLAN WORKS
How Your Plan Works
So You Have Health Insurance —
Now What?
Having health insurance is exciting. To get the most out
of your plan, complete this simple checklist. If you need
assistance, call Member Services at ---
(TTY/TDD ---). We’re available Monday through
Friday, a.m. to p.m. EST.
Set up your secure online member account. Do this by visiting
the “Member Login” page on Ambetter.pshpgeorgia.com. Your
member account stores all of your plan’s benefits and coverage
information in one place. It gives you access to your Schedule of
Benefits, claims information, this QRG and more.
Our program helps you focus on your total
health. When you complete healthy activities, such as eating
right, moving more, saving smart and living well, you can
earn reward points! All you have to do is log in to your online
member account to get started.
Enroll in automatic bill pay. Call us or log in to your online
member account to sign up. Automatic bill pay automatically
withdraws your monthly premium payment from your bank
account. It’s simple, helpful, convenient and secure.
Pick your primary care provider (PCP). Just log in to your
member account and view a list of Ambetter providers in your
area by using the Provider Directory available on our website.
Remember, your PCP, also known as a personal doctor, is the
main doctor you will see for most of your medical care. This
includes your checkups, sick visits and other basic health needs.
Schedule your annual wellness exam with your PCP. After
your first checkup, you’ll earn points in
rewards! And anytime you need care, call your PCP and make an
appointment!
How Your Plan Works
Learn about how to get the
most out of your plan. Set up
your online member account
to get started.
Want more information
about our service area and
in-network providers? Visit
Ambetter.pshpgeorgia.com
Ambetter from Peach State Health Plan: --- (TTY/TDD ---) | Ambetter.pshpgeorgia.com |
HOW YOUR PLAN WORKS
Answers To Your Payment Questions
If you have questions about
paying your premium, give
member services a call at
1-877-687-1180
(TTY/TDD 1-877-941-9231).
Sign up for Paperless Billing to
receive your monthly invoices
online.
How Can I Pay My Monthly Premium?
1. Pay online (Our recommendation!)
a. Quick Payment: https://centene.softheon.com/Equity/#/search or visit
Ambetter.pshpgeorgia.com and select “pay now”
b. Secure Member Account: Create your online member account on
Ambetter.pshpgeorgia.com and enroll in automatic bill payment. You can
set up automatic bill pay using your credit card, prepaid debit card, bank
debit card or bank account. You can also make a one-time payment via your
online member account.
c. If you have earned My Health Pays
®
rewards, you can use your rewards
to help pay your monthly premiums. Log in to your secure member
account at Member.AmbetterHealth.com to learn more about the My
Health Pays
®
program and view your card balance.
2. Pay by phone
a. Pay by Automated Phone. Call us at 1-844-PAY-BETTER (729-2388) and use
our Interactive Voice Response (IVR) system. It’s quick and available 24/7!
Or
b. Call billing services at 1-877-687-1180 (TTY/TDD 1-877-941-9231)
between 8 a.m. and 8 p.m. EST. You will have the option to pay using
the Interactive Voice Response (IVR) system or by speaking to a billing
services representative.
3. Pay by mail
a. Send a check or money order to the address listed on your billing invoice
payment coupon. Be sure to mail your payment at least seven to 10
days prior to your premium payment due date. Remember to write
your member ID number on the check or money order and detach the
payment coupon from the billing invoice and mail with your payment.
b. Mailing to the correct address will ensure your payments are processed in a
timely manner.
Ambetter from Peach StateHealth Plan
Attn: Billing Services
PO Box 743951
Atlanta, GA 30374-3951
Ambetter from Peach State Health Plan: --- (TTY/TDD ---) | Ambetter.pshpgeorgia.com |
HOW YOUR PLAN WORKS
How Can I Pay My Monthly Premium?
(Continued)
c. To find a MoneyGram location near you, or to make an Ambetter payment
with MoneyGram go to https://www.moneygram.com/mgo/us/en/paybills
or call 1-800-926-9400.
What Happens If I Pay Late?
Your bill is due before the first day of every month. For example, if you are
paying your premium for June, it will be due May 31.
If you don’t pay your premium before its due date, you may enter a grace
period. This is the extra time we give you to pay. During a grace period, we may
hold — or pend — payment of your claims. During your grace period, you will
still have coverage. However, if you don’t pay before a grace period ends, you
run the risk of losing your coverage. Refer to your Evidence of Coverage for
grace period details.
We Care About Your Health
Member Services
We want you to have a great experience with Ambetter. Our Member Services
Department is always here for you. We can help you:
• Understand how your plan works
• Learn how to get the care you need
• Find answers to any questions you have about health insurance
• See what your plan does and does not cover
• Pick a PCP that meets your needs
• Get more information about helpful programs, like Care Management
• Find other healthcare providers (like in-network pharmacies and labs)
• Request your member ID or other member materials
If you enrolled through the Health Insurance Marketplace you must contact them
to: update your enrollment information, such as your date of birth, address
or income or life changes; or to end your coverage with Ambetter. You can do
this by visiting Healthcare.gov or calling 1-800-318-2596 (TTY: 1-855-889-4325).
When you are connected, be ready to provide your state and then ask for a
representative to help you.
If you are enrolled in an off-exchange plan, please contact Member Services
to update your enrollment information, such as your date of birth, address or
income or life changes; or to end your coverage with Ambetter.
Have total or partial hearing
loss? Call 1
-877-687-1180
(TTY/TDD 1-877-941-9231) or
visit Ambetter.pshpgeorgia.com
Ambetter from Peach State Health Plan: --- (TTY/TDD ---) | Ambetter.pshpgeorgia.com |
MEMBERSHIP & COVERAGE INFORMATION
Membership & C overage Information
Membership & Coverage Information
Your Ambetter Member Welcome Packet
When you enroll with Ambetter, you will receive a Member Welcome Packet.
Your Welcome Packet includes basic information about the health plan you
selected. You will receive your Welcome Packet before your Ambetter health
coverage begins.
Your Ambetter Member ID
Your member ID is proof that you have health insurance with us. And it’s very
important. Here are some things to keep in mind:
• Keep this card with you at all times
• You will need to present this card anytime you receive healthcare services
• You will receive your Member ID(s) before your Ambetter health coverage
begins. If you don’t get your Member ID before your coverage begins, call
Member Services at 1-877-687-1180
(TTY/TDD 1-877-941-9231). We will send you another card.
• Once you make your binder payment and first month’s premium you will
receive your Welcome Packet. Please remember to make your binder and
premium on time.
To download your Digital ID, request a replacement ID or request a temporary
ID, please log into your secure member account.
Here is an example of what a member ID typically looks like
[Member/Provider Services:
1-877-687-1180
TTY/TDD: 1-877-941-9231
24/7 Nurse Line: 1-877-687-1180
Numbers below for providers:
Pharmacy Help Desk: 1-800-261-3181
EDI Payor ID: 68069]
[Medical Claims:
Peach State Health Plan
Attn: CLAIMS
PO Box 5010
Farmington, MO
63640-5010]
[Ambetter from Peach State Health Plan is underwritten by Ambetter of Peach State Inc.
© 2021 Ambetter of Peach State, Inc. All rights reserved.]
[Ambetter.pshpgeorgia.com]
IN NETWORK
COVERAGE ONLY
Effective Date: [XX/XX/XX]
RXBIN: [004336]
RXPCN: [ADV]
RXGROUP: [RX5446]
Provider Network: [Provider
Network Name XXXXXXXXXX]
Subscriber: [Jane Doe]
Member: [John Doe]
Policy #: [XXXXXXXXX]
Member ID #: [XXXXXXXXXXXXX]
Plan: [Ambetter Balanced Care 1]
[Line 2 if needed]
[Line 3 if needed]
PCP: [$10 coin. after ded.]
Specialist: [$25 coin. after ded.]
Rx (Generic/Brand): [$5/$25 after Rx ded.]
Urgent Care: [20% coin. after ded.]
ER: [$250 copay after ded.]
Individual Deductible
INN (Med/Rx): [$5000/XXXX]
OON (Med/Rx): [$5000/XXXX]
COPAYS
[REFERRAL NOT REQUIRED]
Family Deductible
INN (Med/Rx): [$5000/XXXX]
OON (Med/Rx): [$5000/XXXX]
Individual MOOP INN: [XXXXXXXX]
Individual MOOP OON: [XXXXXXXX]
Family MOOP INN: [XXXXXXXX]
Family MOOP OON: [XXXXXXXX]
Coinsurance (Med/Rx): [50%/30%]
* Exclusions and restrictions apply. See Walgreens.com/SmartSavings for details.
Scan to receive
20% off Walgreens
brand health and
wellness items*
AMB21-GA-C-00609
Front
[Member/Provider Services:
1-877-687-1180
TTY/TDD: 1-877-941-9231
24/7 Nurse Line: 1-877-687-1180
Numbers below for providers:
Pharmacy Help Desk: 1-800-261-3181
EDI Payor ID: 68069]
[Medical Claims:
Peach State Health Plan
Attn: CLAIMS
PO Box 5010
Farmington, MO
63640-5010]
[Ambetter from Peach State Health Plan is underwritten by Ambetter of Peach State Inc.
© 2021 Ambetter of Peach State, Inc. All rights reserved.]
[Ambetter.pshpgeorgia.com]
IN NETWORK
COVERAGE ONLY
Effective Date: [XX/XX/XX]
RXBIN: [004336]
RXPCN: [ADV]
RXGROUP: [RX5446]
Provider Network: [Provider
Network Name XXXXXXXXXX]
Subscriber: [Jane Doe]
Member: [John Doe]
Policy #: [XXXXXXXXX]
Member ID #: [XXXXXXXXXXXXX]
Plan: [Ambetter Balanced Care 1]
[Line 2 if needed]
[Line 3 if needed]
PCP: [$10 coin. after ded.]
Specialist: [$25 coin. after ded.]
Rx (Generic/Brand): [$5/$25 after Rx ded.]
Urgent Care: [20% coin. after ded.]
ER: [$250 copay after ded.]
Individual Deductible
INN (Med/Rx): [$5000/XXXX]
OON (Med/Rx): [$5000/XXXX]
COPAYS
[REFERRAL NOT REQUIRED]
Family Deductible
INN (Med/Rx): [$5000/XXXX]
OON (Med/Rx): [$5000/XXXX]
Individual MOOP INN: [XXXXXXXX]
Individual MOOP OON: [XXXXXXXX]
Family MOOP INN: [XXXXXXXX]
Family MOOP OON: [XXXXXXXX]
Coinsurance (Med/Rx): [50%/30%]
* Exclusions and restrictions apply. See Walgreens.com/SmartSavings for details.
Scan to receive
20% off Walgreens
brand health and
wellness items*
AMB21-GA-C-00609
Back
Refer to your Evidence of Coverage for information on Dependent Member
Coverage.
Your EOC can be found on the Ambetter member website
Ambetter from Peach State Health Plan: --- (TTY/TDD ---) | Ambetter.pshpgeorgia.com |
FINDING THE RIGHT CARE
FINDING THE RIGHT CARE
Finding the Right Care
We’re proud to offer our quality service. Our local provider network is the group of
doctors, hospitals and other heal
thcare providers who have agreed to provide you with
your healthcare services.
To search our online Provider Directory, visit guide.ambetterhealth.com and use our
Ambetter Guide- the new Ambetter provider search tool. This guide will have the
most up-to-date information about our provider network, including information such
as name, address, telephone numbers, hours of operation, professional qualifications,
specialty, and board certification. It can help you find a primary care provider (PCP),
pharmacy, lab, hospital or specialist. You can narrow your search by:
• Provider specialty
• ZIP code
• Gender
• Languages spoken
• Whether or not they are currently accepting new patients
A Provider Directory is a listing of providers near you. If you would like a printed copy of
this listing, please call Member Services at 1-877-687-1180 (TTY/TDD 1-877-941-9231).
In-Network or Network Provider means a physician or provider who is identified in the
most current list for the network shown on your Member ID.
Out-of-Network or Non-Network Provider means a physician or provider who is NOT
identified in the most current list for the network shown on your Member ID. Services
received from an out-of-network provider are not covered, except as specifically stated
in your Evidence of Coverage (EOC). If you received services from an out of network
provider, you could potentially be balanced billed for some or all services. Please refer
to you EOC for further explanation.
Throughout the year, the provider’s available in-network may change. It is important
that you review the provider directory for the latest information on whether or not the
provider you are planning to see is in-network. We encourage you to ask the providers
if they participate with Ambetter before they treat you, so you know whether you may
receive an additional bill for their services.
Remember to select an in-
network PCP! Check out our
P
rovider Directory for a full list
of your options and their contact
information. It’s on the Find a
Doctor page of
guide.ambetterhealth.com.
Refer to your Evidence of
Coverage for more information
on your Provider Directory.
Get The Right Care At The Right Place
When you need medical care, you need to be able to quickly decide where to go or
what to do. Get to know your options! They include:
1. Calling our 24/7 nurse advice line
2. Ambetter Telehealth
3. Making an appointment with your primary care provider (PCP)
4. Visiting an urgent care center
5. Going to the emergency room (ER)
Your decision will depend on your specific situation. The next section describes
each of your options in more detail, so keep reading.
And remember — always make sure your providers are in-network.
Using in-network providers can save you money on your healthcare costs.
Every time you receive medical care, you will need your member ID.
Learn more about your options https://ambetter.pshpgeorgia.com/resources/
handbooks-forms/where-to-go-for-care.html
Every time you receive care,
make sure to stay within the
Ambetter network.
Ambetter from Peach State Health Plan: --- (TTY/TDD ---) | Ambetter.pshpgeorgia.com |
FINDING THE RIGHT CARE
Your Primary Provider (PCP)
Your primary care provider is your main doctor — the one you see for regular
checkups. If your condition isn’t life-threatening, calling your PCP should be
your first choice. Use our online Ambetter Guide to find an in-network provider
in your area.
Visit or call your PCP if you need:
• Your annual wellness checkup & vaccinations
• Advice about your overall health
• Help with medical problems such as cold, the flu and fevers
• Treatments for an ongoing health issue like asthma or diabetes
Selecting A Different PCP
We want you to be happy with the care you receive from our providers. So if you
would like to change your PCP for any reason, visit Ambetter.pshpgeorgia.com. Log
in to your online member account and follow these steps
1. Click on Coverage or Edit Account
2. Under the My Primary Care Provider section, pull up the Ambetter Guide to
search for an in-network PCP.
3. Pick a PCP from the list. Make sure you select a PCP who is currently
accepting new patients.*
To learn more about a specific PCP, call member services at 1-877-687-1180 (TTY/TDD
1-877-941-9231). You can also visit Ambetter.pshpgeorgia.com to see our provider list
on our Find a Doctor web page.
*If you choose a nurse practitioner or physician assistant as your PCP, your benefit
coverage and co-payment amounts are the same as they would be for services
from other participating providers. Review your Schedule of Benefits for more
information.
Your Primary Care Provider
Ambetter from Peach State Health Plan: --- (TTY/TDD ---) | Ambetter.pshpgeorgia.com |
ACCESS TO CARE
Access to Care
When To Go To An Urgent Care Center
An urgent care center provides fast, hands-on care for illnesses or injuries that
aren’t life threatening but still need to be treated within 24 hours. Typically,
you will go to an urgent care center if your PCP cannot get you in for a visit right
away.
Common urgent care issues include:
• Sprains
• Ear infections
• High fevers
• Flu symptoms with vomiting
If you think you need to go to an urgent care center, follow these steps:
• Call your PCP. Your PCP may give you care and directions over the phone
or direct you to the right place for care.
• If your PCP’s office is closed, you can do one of two options:
1. Locate an in-network urgent care center by using our online Ambetter
Guide at Guide.AmbetterHealth.com, type in “Urgent Care” and your
zip code, then click search.
2. Call our 24/7 nurse advice line at 1-877-687-1180 (TTY/TDD 1-877-941-
9231). A nurse will help you over the phone or direct you to other care.
You may have to give the nurse your phone number.
Check your Schedule of Benefits to see how much you must pay for urgent care
services.
After your visit, let your PCP know you were seen at an urgent care and why.
Call our 24/7 nurse advice
line anytime: 1
-877-687-1180
(TTY/TDD 1-877-941-9231).
When To Go To The ER
Anything that could endanger your life (or your unborn child’s life, if you’re
pregnant) without immediate medical attention is considered an emergency
situation. Emergency services treat accidental injuries or the onset of what
appears to be a medical condition. We cover emergency medical and behavioral
health services both in and out of our service area. We cover these services 24/7.
Emergency services are covered in-network and out-of-network. When receiving
Emergency Care at either an in-network or out-of-network provider the only bill
you should receive is for any applicable cost share. (e.g. co-pay, deductible or
co-insurance).
Refer to your Evidence of Coverage for information on Protection from Balance
Billing.
Have your member ID
and photo ID ready. You will
need them whenever you
receive any type of care.
Urgent care is not emergency
care. Only go to the ER if
your doctor tells you to or
if you have a life-threatening
emergency.
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ACCESS TO CARE
When To Go To The ER (Continued)
Go to the ER if you have:
• Broken bones
• Bleeding that won’t stop
• Labor pains or other bleeding (if you’re pregnant)
• Severe chest pains or heart attack symptoms
• Overdosed on drugs
• Ingested poison
• Bad burns
• Shock symptoms (sweat, thirst, dizziness, pale skin)
• Convulsions or seizures
• Trouble breathing
• The sudden inability to see, move or speak
• Gun or knife wounds
Don’t go to the ER for:
• Flus, colds, sore throats or earaches
• Sprains or strains
• Cuts or scrapes that don’t require stitches
• More medicine or prescription refills
• Diaper rash
What if you need Emergency Care out of our service area?
Our plan will pay for emergency care while you are out of the county or state.
Ifyou go to an out-of-network ER and you aren’t experiencing a true emergency,
you may be responsible for any amounts above what your plan covers. Those
additional amounts could be very large and would be in addition to your plan’s
cost sharing and deductibles.
Learn more about your options https://ambetter.pshpgeorgia.com/resources/
handbooks-forms/where-to-go-for-care.html
Always make sure your
pro
viders are in-network.
Using in-network providers
can save you money on your
healthcare costs.
If you need help deciding
where to go for care, call
our 24/7 nurse advice line
at 1-877-687-1180 (TTY/
TDD 1-877-941-9231). In
an emergency, call 911 or
head straight to the nearest
emergency room. Seek ER
services only if your life is at
risk and you need immediate,
emergency medical attention.
Ambetter from Peach State Health Plan: --- (TTY/TDD ---) | Ambetter.pshpgeorgia.com |
ACCESS TO CARE
Ambetter Telehealth
Ambetter Telehealth is our 24-hour access to in-network healthcare providers
when you have a non-emergency health issue. It’s available to use when you’re
at home, in the office or on vacation.
Before you start using Ambetter Telehealth, you will need to set up your
account at AmbetterTelehealthGA.com.
Ambetter Telehealth providers are available by phone or video when you need
medical care, a diagnosis or a prescription. As part of our Health Management
Program, Ambetter offers $0 copay for in-network Telehealth providers. You can
choose to receive immediate care or schedule an appointment for a time that fits
in your schedule.
Contact Ambetter Telehealth for illnesses such as:
• Colds, flu and fevers
• Rash, skin conditions
• Sinus problems, allergies
• Upper respiratory infections, bronchitis
• Pink Eye
Ambetter does not provide medical care. Medical care is provided by individual
providers through Teladoc Health.
$0 Telehealth copay does not apply to plans with HSA until the deductible is
met. $0 copays are for in-network medical care. Ambetter does not provide
medical care.
To find another provider
or specialist in our network,
check out our provider list
on the Find a Doctor page at
guide.ambetterhealth.com
/ Nurse Advice Line
Our free 24/7 nurse advice line makes it easy to get answers to your health
questions. You don’t even have to leave home! Staffed by licensed nurses,
our 24/7 nurse advice line runs all day, every day. Call 1-877-687-1180
(TTY/TDD 1-877-941-9231) if you have questions about:
• Your health, medications or a chronic condition
• Whether you should go to the emergency room (ER) or see your PCP
• What to do for a sick child
• How to handle a condition in the middle of the night
• Accessing our online health information library
• Urgent care
Ambetter from Peach State Health Plan: --- (TTY/TDD ---) | Ambetter.pshpgeorgia.com |
ACCESS TO CARE
WHAT TO DO IF YOU RECEIVE A BILL
FROM A PROVIDER OR PHYSICIAN:
When seeing an in network provider, including but not limited to physicians,
hospitals, pharmacies, facilities and health care professionals, you are responsible
for any applicable cost sharing amounts (e.g. co-pay, deductible or co-insurance).
Your member responsibility can be viewed on the explanation of benefits. This can be
found by logging into your secure account at Ambetter.pshpgeorgia.com.
As a member of Ambetter, non-network providers should not bill you for covered
services for any amount greater than your applicable in-network cost sharing
responsibilities when:
• You receive a covered emergency service or air ambulance service from a
non-network provider. This includes services you may get after you are in
stable condition, unless the non-network provider obtains your written
consent to bill you for their service.
• You receive non-emergency ancillary services (emergency medicine,
anesthesiology, pathology, radiology, and neonatology, as well as
diagnostic services (including radiology and laboratory services)) from
a non-network provider at a network hospital or network ambulatory
surgical facility.
• You receive other non-emergency services from a non-network provider at
a network hospital or network ambulatory surgical facility, unless the non-
network provider obtains your written consent to bill you for their service.
If you receive a bill for services in the above situations, please contact Member
Services at 1-877-687-1180 (TTY/TDD 1-877-941-9231).
Refer to your Evidence of Coverage for information on Balance Billing and Eligible
Service Expenses.
Ambetter from Peach State Health Plan: --- (TTY/TDD ---) | Ambetter.pshpgeorgia.com |
MEMBER COMPLAINTS, GRIEVANCES, & APPEALS PROCESS
Member Complaints, Grievances, &
Appeals Process
We have steps for handling any problems you may have. To keep you satisfied, we
provide processes for filing appeals or complaints. You have the right to file a
complaint, file an appeal, and right to an external review.
If You’re Not Happy With Your Care
We hope you will always be happy with our providers and us. But if you aren’t, or
you aren’t able to find answers to your questions, we have steps for you to follow:
• Inquiry Process
• Complaint Process
• Grievance Process
• Appeal Process
• External review by an independent review organization (IRO)
• Complaint to the state Department of Insurance (DOI)
Your satisfaction is very important to us. We want to know your issues and
concerns so we can improve our services. Please contact our Member Services
team at 1-877-687-1180 (TTY/TDD 1-877-941-9231) if you have questions or
concerns. We will attempt to answer your questions during initial contact, as
most concerns can be resolved with one phone call.
The following processes are available to address your concerns.
How to Make an Inquiry
An Inquiry is a request for clarification of a benefit, product, or eligibility where
no expression of dissatisfaction was made. Examples of an Inquiry could be:
• “Can I make a payment?”
• “Can you help me change my Primary Care Provider?”
• “Why did I receive this bill?”
• “Why did my premium change?”
• “Can I get a copy of my ID?”
• “Can you help me find a Provider?”
How To File A Complaint
A complaint can be an appeal or a grievance. Some complaints can be resolved
through first call resolution if they can be fully addressed and closed.
Examples of a Complaint could be:
• “I can’t get an appointment with the doctor for 4 months”
• “I can’t find a provider in my area, as the local doctors are all stating they
are not participating with my plan and the ones participating with my plan
are too far away”
• “I’ve called Member Services multiple times and my issue is still not
resolved ”
Ambetter from Peach State Health Plan: --- (TTY/TDD ---) | Ambetter.pshpgeorgia.com |
MEMBER COMPLAINTS, GRIEVANCES, & APPEALS PROCESS
How To File A Complaint (Continued)
• “I can’t get enrolled on your website”
• “I can’t find what I am needing on your website”
• “The doctor and/or the staff were rude to me”
To file a complaint, call Member Services at 1-877-687-1180 (TTY/TDD 1-877-941-9231).
For a full list of definitions,
please refer to your Evidence
of Coverage.
How to File a Grievance
Grievance means any dissatisfaction with an insurer offering a health benefit plan or
administration of a health benefit plan by the insurer that is expressed in writing in
any form to the insurer by, or on behalf of, a claimant including any of the following:
1. Providing of services.
2. Determination to rescind a policy.
3. Claims practices.
Examples of a Grievance would be:
• “My generic prescription didn’t have the generic co-pay applied”
• “I had a preventive procedure and they are making me pay out of pocket, when
it should have been covered at 100%”
• “I’m in need of home healthcare and I haven’t gotten a call back from my Case
Coordinator”
• “I did not consent to blood products during surgery but found out they gave me
some anyway ”
• “My doctor prescribed a medication that I’m allergic to and I’ve had a terrible
reaction”
• “I was told that I was active with the plan, and the plan kept taking premiums
out automatically, but now they are going back and saying I had no coverage for
10 months, and now I have over $100,000.00 in hospital bills”
To file a grievance, call Member Services at 1-877-687-1180 (TTY/TDD 1-877-941-9231).
You may file a grievance, verbally, or in writing, either by mail or by facsimile (fax
1-866-532-8855). If you require assistance in filing a grievance or if you are unable to
submit the grievance in writing, you can call Member Services at 1-877-687-1180
(TTY/TDD 1-877-941-9231) to ask for help through the process. We will send a
Grievance Acknowledgment letter after receipt of your Grievance.
Send your written Grievance form to:
Ambetter from Peach State Health Plan
Attn: Appeals & Grievances Department
1100 Circle 75 Parkway
Suite 1100
Atlanta, GA 30339
Fax: 1-866-532-8855
Expedited Grievance: If your grievance concerns an emergency or a situation in
which you may be forced to leave the hospital prematurely, or if a standard resolution
process will risk serious jeopardy to your life or health.
Ambetter from Peach State Health Plan: --- (TTY/TDD ---) | Ambetter.pshpgeorgia.com |
MEMBER COMPLAINTS, GRIEVANCES, & APPEALS PROCESS
How to File a Grievance (Continued)
Standard Grievance: A grievance that does not meet the Expedited definition.
View your Evidence of Coverage for full complaint procedures and processes,
including specific filing details and timeframes. You can access your Evidence of
Coverage in your online member account.
You may also file a Grievance with the Department of Insurance (DOI). There are
several ways to file a Grievance with the DOI. Refer to your Evidence of Coverage
for more information.
View your Evidence of
Coverage for full complaint
and appeal procedures and
processes. You can access
your Evidence of Coverage in
your online member account.
For a full list of definitions,
please refer to your Evidence of
Coverage.
How To File An Appeal
An Appeal is a formal request to reconsider a decision about the member’s
benefits where either a service or claim have been denied. A denial includes a
request for us to reconsider our decision to deny, modify, reduce, or terminate
payment, coverage, authorization, or provision of health care services or
benefits, including the admission to, or continued stay in, a health care
facility. Failure to approve or deny a prior authorization request timely may be
considered as a denial and also subject to the appeal process.
Examples of an Appeal would be:
1. Access to healthcare benefits, including an Adverse Determination
made pursuant to utilization management;
2. Admission to or continued stay in a healthcare Facility;
3. Claims payment, handling or reimbursement for healthcare services;
4. Matters pertaining to the contractual relationship between a Member
and us;
5. Cancellation of your benefit coverage by us;
6. Other matters as specifically required by state law or regulation
To file a written appeal, you can mail or Fax your request to us. Our contact
information is below:
Ambetter from Peach State Health Plan
Attn: Appeals & Grievances Department
1100 Circle 75 Parkway Suite 1100
Atlanta, GA 30339
Fax: 1-866-532-8855
To file a verbal appeal, you can call us at 1-877-687-1180 (TTY/TDD 1-877-941-9231).
Resolution timeframes may vary based on the type of appeal filed. Please see
Evidence of Coverage for details.
Expedited Appeal: If your appeal concerns an emergency or a situation in
which you may be forced to leave the hospital prematurely, or if you believe a
standard resolution process will risk serious jeopardy to your life or health.
Standard Appeal: An appeal that does not meet the Expedited definition.
Ambetter from Peach State Health Plan: --- (TTY/TDD ---) | Ambetter.pshpgeorgia.com |
MEMBER COMPLAINTS, GRIEVANCES, & APPEALS PROCESS
Continued Coverage During An Appeal
If we are going to reduce or stop a service we had previously approved and the
time limit we have approved has not ended, you have the right to request to
keep getting the service until:
• The end of the approved treatment period
OR
• The determination of the appeal
You may be financially responsible for the continued services if your appeal is
not approved You can request continued services by calling Member Services at
1-877-687-1180 (TTY/TDD 1-877-941-9231).
NOTE: You can’t request an extension of services after the original authorization
has ended. For more details, call Member Services at 1-877-687-1180 (TTY/TDD
1-877-941-9231).
View your Evidence of Coverage for full complaint and appeal procedures and
processes, including specific filing details and timeframes. You can access your
Evidence of Coverage in your online member account
Ambetter from Peach State Health Plan: --- (TTY/TDD ---) | Ambetter.pshpgeorgia.com |
UTILIZATION MANAGEMENT
Utilization Management
What Is Utilization Management?
We want to make sure you get the right care and services. Our utilization
management (UM) process is designed to make sure you get the treatment you
need.
We will approve all covered benefits that are medically necessary. Our UM
Department checks to see if the service needed is a covered benefit. If it is a
covered benefit, the UM nurses will review it to see if the service requested meets
medical necessity criteria. They do this by reviewing the medical notes and talking
with your doctor. Ambetter does not reward practitioners, providers or employees
who perform utilization reviews, including those of the delegated entities. UM’s
decision making is based only on appropriateness of care, services, and existence
of coverage. Ambetter from Peach State Health Plan does not specifically reward
practitioners or other individuals for issuing denials of coverage. Financial
incentives for UM decision makers do not encourage decisions that result in
underutilization.
What Is Utilization Review?
Ambetter reviews services to ensure the care you receive is the best way to
help improve your health condition. Utilization review includes:
Preservice or prior authorization review
Ambetter may need to approve medical services before you receive them. This
process is known as prior authorization. Prior authorization means that we have
pre-approved a medical service.
To see if a service requires prior authorization, check with your PCP, the ordering
provider, or Ambetter Member Services. When we receive your prior authorization
request, our nurses and doctors will review it. If prior authorization is not received
on a medical service when required, you may be responsible for all charges.
Concurrent review
Concurrent utilization review evaluates your services or treatment plans
(like an inpatient stay or hospital admission) as they happen. This process
determines when treatment may no longer be medically necessary. It includes
discharge planning to ensure you receive services you need after your
discharge from the hospital.
Retrospective review
Retrospective review takes place after a service has already been provided.
Ambetter may perform a retrospective review to make sure the information
provided at the time of authorization was correct and complete. We may also
evaluate services you received due to special circumstances (for example, if we
didn’t receive an authorization request or notification because of an emergency).
Notification of Approved Services
All claims information (including prior authorizations) can be found by logging
into the member secure portal and selecting the activity and usage link.
Ambetter from Peach State Health Plan: --- (TTY/TDD ---) | Ambetter.pshpgeorgia.com |
MEMBER RESOURCES & REWARDS
What Is Utilization Review? (Continued)
Adverse determinations and appeals
An adverse determination occurs when a service is not considered medically
necessary, appropriate, or because it is experimental or investigational. You
will receive written notification to let you know if we have made an adverse
determination. In the notice, you will receive detailed information about why the
decision was made, as well as the process and time frame you should follow for
submitting appeals.
Ambetter from Peach State Health Plan: --- (TTY/TDD ---) | Ambetter.pshpgeorgia.com |
MEMBER RESOURCES & REWARDS
Member Resources & Rewards
Get Online And Get In Control
Did you know you can always access helpful resources and information about
your plan? It’s all on our website! Visit Ambetter.pshpgeorgia.com and take
charge of your health.
On our website, you can:
• Find a PCP
• Locate other providers, like a pharmacy
• Find health information
• Learn about programs and services that can help you get and stay healthy.
Log into your online member account to:
• Pay your monthly bill
• Print a temporary ID or request a replacement ID
• View your claims status and payment information
• Change your PCP
• Find pharmacy benefit information
• Send us a secure email
• Read your member materials (your Evidence of Coverage, Schedule of
Benefits, this QRG)
• Participate in the
rewards program
• Complete your Wellbeing Survey
• Contact a nurse online
• Review out-of-pocket costs, copays and progress towards deductibles.
Visit us online at
Ambetter
.pshpgeorgia.com
Our website helps you get
the answers you need to get
the right care, the right way,
including an online member
account for you to check the
status of your claim, view your
Evidence of Coverage (EOC) or
understand your out-of-pocket
costs, copays and progress
towards meeting your
annual deductible.
Rewards Program
Don’t miss out on the exciting program and
start earning points today!
Log in now and activate your account to start earning more rewards.
1. Log into your online Ambetter member account or create your account
now.
2. Click Rewards on the home page.
3. Accept Terms & Conditions. Then, start earning points!
If you already activated your account, log back in to complete healthy activities
and keep earning!
Funds expire immediately upon termination of insurance coverage.
Ambetter from Peach State Health Plan: --- (TTY/TDD ---) | Ambetter.pshpgeorgia.com |
AMBETTER | FROM PEACH STATE HEALTH PLAN
Connecting Your Healthcare:
NEW OPTIONS FOR MANAGING YOUR
DIGITAL MEDICAL RECORDS
Starting July 1, 2021, a new federal rule named the Interoperability and Patient
Access rule (CMS-915-F) made it easier for Ambetter members to access their
health information when they need it most. You will now have complete access
to your health information on your mobile device which will allow you to manage
your health better and know what healthcare resources are available to you.
Imagine:
• You go to a new healthcare provider because you don’t feel well and
pulling up your health history from the past five years on your mobile
device.
• Finding a provider or specialist by checking an up-to-date provider
directory who can use your health history to diagnose you and ensure you
receive the best care you can.
• You have a question about a claim, so you go to your computer and see if
it’s paid, denied, or still being processed.
• Taking your health history data, at your request, with you as you move
between health plans.*
*Beginning January 1, 2022, members will have this ability to request that their
health information be transferred with them as they move between health
plans.
THE NEW RULE MAKES IT SO YOU CAN EASILY FIND INFORMATION** ON:
• Claims (paid and denied)
• Specific parts of your clinical information
• Pharmacy drug coverage
• Healthcare providers
**Information is available for dates of service on or after January 1, 2016
For more information, visit your Ambetter online member account.
Ambetter from Peach State Health Plan: --- (TTY/TDD ---) | Ambetter.pshpgeorgia.com |
WORDS TO KNOW
Words To Know
For a full list of complete
definitions, please refer to your
Evidence of Coverage.
Your Healthcare Glossary
We know that health insurance can feel confusing sometimes. To help you out,
we put together a list of words you may need to know as you read through this
QRG. Check it out!
Adverse Benefit Determination
This is the notice you receive if we deny coverage for a service you have requested.
Appeal
An Appeal is a formal request either, orally, or in writing or by electronic
transmission to reconsider a decision about the member’s benefits where
either a service or claim have been denied. A denial includes a request for us
to reconsider our decision to deny, modify, reduce, or terminate payment,
coverage, authorization, or provision of health care services or benefits,
including the admission to, or continued stay in, a health care facility. Failure
to approve or deny a prior authorization request timely may be considered as a
denial and also subject to the appeal process.
Complaint
A complaint can be an appeal or a grievance against the health plan or
providers. Some complaints can be resolved through first call resolution if they
can be fully addressed and closed.
Copay or Copayment
The set amount of money you pay every time you receive a medical service
or pick up a prescription.
Emergency Care/Emergencies
Emergency care is care that you receive in an emergency room (ER).
Only go to the ER if your life is at risk or you need immediate, emergency
medical attention.
Evidence of Coverage
The document that lists all of the services and benefits that your particular plan
covers. Your Evidence of Coverage has information about the specific benefits
covered and excluded under your health plan. Read through your Evidence
of Coverage — it can help you understand exactly what your plan does and
doesn’t cover.
Grievance
Any complaint about quality of service or medical care is a grievance, including
dissatisfaction with the quality of medical care, waiting time for medical
services, provider or staff attitude or demeanor, or dissatisfaction with service
provided by the health carrier.
In-Network (Providers and/or Services)
The Ambetter network is the group of providers and hospitals we partner with to
provide care for you. If your provider or service is within our network, it is covered
on your health plan. If a provider or service is out-of-network, you could be
responsible for services you receive. When possible, always stay in-network.
Inquiry
A request for clarification of a benefit, product, or eligibility where no
expression of dissatisfaction was made.
Ambetter from Peach State Health Plan: --- (TTY/TDD ---) | Ambetter.pshpgeorgia.com |
WORDS TO KNOW
Your Healthcare Glossary (Continued)
Out-of-Network Provider
Means a physician or provider who is NOT identified in the most current list
for the network shown on your Member ID. Services received from an out-of-
network provider are not covered, except as specifically stated in your Evidence
of Coverage (EOC). Refer to your Evidence of Coverage for details regarding out-
of-network providers, care, services and expenses.
Premium Payment
Your premium is the amount of money you’ll pay every month for health
insurance coverage. Your monthly bill shows your premium payment.
Preventive Care Services
Preventive care services are regular healthcare services designed to keep you
healthy and catch problems before they start. For example: your checkups,
blood pressure tests, certain cancer screenings and more. A list of Preventive
Care services can be found within your Evidence of Coverage, as well as on our
website at Ambetter.pshpgeorgia.com.
Primary Care Provider (PCP)
Your PCP is the main doctor you will see for your healthcare needs. Get to know
your PCP well and always stay up-to-date with your well-visits. The better your
PCP knows your health, the better they are able to serve you.
Prior Authorization
Prior authorization may be required for covered services. When a service
requires prior authorization, then the covered service needs to be approved
before you visit your provider. Your provider will need to submit a prior
authorization request.
Schedule of Benefits
Your Schedule of Benefits is a document that lists covered benefits available to
you. Your Schedule of Benefits has information about your specific copayment,
cost sharing and deductible amounts for covered benefits.
Subsidy
A subsidy is a tax credit that lowers your monthly premium. Subsidies come
from the government. Whether or not you qualify for one depends on your
family size, your income and where you live.
Urgent Care
Urgent care is medical care that you need quickly. You can get urgent care at an
urgent care center.
Utilization Management
This is the process we go through to make sure you get the right treatment.
We review your medical and health circumstances and then decide the best
course of action.
Ambetter from Peach State Health Plan is underwritten by Ambetter of Peach State Inc.
© Ambetter of Peach State Inc.
All rights reserved.
AMB-GA-C-_SELECT
Ambetter from Peach State Health Plan: --- (TTY/TDD ---) | Ambetter.pshpgeorgia.com |
AMBETTER | FROM PEACH STATE HEALTH PLAN
Statement of Non-Discrimination
Ambetter from Peach State Health Plan complies with
applicable Federal civil rights laws and does not discriminate
on the basis of race, color, national origin, age, disability, or
sex. Ambetter from Peach State Health Plan does not exclude
people or treat them differently because of race, color,
national origin, age, disability, or sex.
Ambetter from Peach State Health Plan:
• Provides free aids and services to people with disabilities to communicate
effectively with us,such as:
– Qualified sign language interpreters
– Written information in other formats (large print, audio, accessible
electronic formats, other formats)
• Provides free language services to people whose primary language is not
English, such as:
– Qualified interpreters
– Information written in other languages
If you need these services, contact Ambetter from Peach State Health Plan at
1-877-687-1180 (TTY/TDD 1-877-941-9231).
If you believe that Ambetter from Peach State Health Plan has failed to provide
these services or discriminated in another way on the basis of race, color,
national origin, age, disability, or sex, you can file a grievance with: Ambetter
from Peach State Health Plan Complaints Department, 1100 Circle 75 Parkway,
Suite 1100, Atlanta, GA 30339, 1-877-687-1180 (TTY/TDD 1-877-941-9231), Fax
1-866-532-8855. You can file a grievance by mail, fax, or email. If you need
help filing a grievance, Ambetter from Peach State Health Plan is available to
help you. You can also file a civil rights complaint with the U.S. Department of
Health and Human Services, Office for Civil Rights electronically through the
Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/
ocr/portal/lobby.jsf, or by mail or phone at: U.S. Department of Health and
Human Services, 200 Independence Avenue SW., Room 509F, HHH Building,
Washington, DC 20201, 1-800-368-1019, 800-537-7697 (TDD).
Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.
AMB16-GA-C-00076
Spanish:
Si usted, o alguien a quien está ayudando, tiene preguntas acerca de Ambetter de Peach State Health Plan, tiene derecho a obtener
ayuda e información en su idioma sin costo alguno. Para hablar con un intérprete, llame al 1-877-687-1180
(TTY/TDD 1-877-941-9231).
Vietnamese:
Nếu quý vị, hay người mà quý vị đang giúp đỡ, có câu hỏi về Ambetter from Peach State Health Plan, quý vị sẽ có quyền được giúp và
có thêm thông tin bằng ngôn ngữ của mình miễn phí. Để nói chuyện với một thông dịch viên, xin gọi 1-877-687-1180
(TTY/TDD 1-877-941-9231).
Korean:
만약 귀하 또는 귀하가 돕고 있는 어떤 사람이 Ambetter from Peach State Health Plan 에 관해서 질문이 있다면 귀하는 그러한 도움과
정보를 귀하의 언어로 비용 부담없이 얻을 수 있는 권리가 있습니다. 그렇게 통역사와 얘기하기 위해서는 1-877-687-1180
(TTY/TDD 1-877-941-9231)로 전화하십시오.
Chinese:
如果您，或是您正在協助的對象，有關於 Ambetter from Peach State Health Plan 方面的問題，您有權利免費以您的母語得到幫助和訊
息。如果要與一位翻譯員講話，請撥電話 1-877-687-1180 (TTY/TDD 1-877-941-9231)。
Gujarati:
, Ambetter from Peach State Health Plan ,
. 1-877-687-1180 (TTY/TDD 1-877-941-9231)
.
French:
Si vous-même ou une personne que vous aidez avez des questions à propos d’Ambetter from Peach State Health Plan, vous avez le
droit de bénéficier gratuitement d’aide et d’informations dans votre langue. Pour parler à un interprète, appelez le
1-877-687-1180 (TTY/TDD 1-877-941-9231).
Amharic:
እርስዎ ወይም እርሰዎ የሚርዱት ሰው ስለ Ambetter from Peach State Health Plan ግብር ጥያቄ ካለዎት ያለምንም ወጪ በቋንቋዎ ድጋፍ እንዲሁም መረጃ የማግኘት መብት
አለዎት፣ ፣ አስተርጓሚ ለማነጋገር በ 1-877-687-1180 (TTY/TDD 1-877-941-9231) ይደውሉ፤ ፤
Hindi:
, Ambetter from Peach State Health Plan ,
1-877-687-1180
(TTY/TDD 1-877-941-9231)
French
Creole:
Si oumenm, oubyen yon moun w ap ede, gen kesyon nou ta renmen poze sou Ambetter from Peach State Health Plan, ou gen tout
dwa pou w jwenn èd ak enfòmasyon nan lang manman w san sa pa koute w anyen. Pou w pale avèk yon entèprèt, sonnen nimewo
1-877-687-1180 (TTY/TDD 1-877-941-9231).
Russian:
В случае возникновения у вас или у лица, которому вы помогаете, каких-либо вопросов о программе страхования Ambetter
from Peach State Health Plan вы имеете право получить бесплатную помощь и информацию на своем родном языке. Чтобы
поговорить с переводчиком, позвоните по телефону 1-877-687-1180 (TTY/TDD 1-877-941-9231).
Arabic:
Ambetter from Peach State Health Plan
(TTY/TDD 1-877-941-9231) 1-877-687-1180
Portuguese:
Se você, ou alguém a quem você está ajudando, tem perguntas sobre o Ambetter from Peach State Health Plan, você tem o direito de
obter ajuda e informação em seu idioma e sem custos. Para falar com um intérprete, ligue para 1-877-687-1180
(TTY/TDD 1-877-941-9231).
Persian:
Ambetter from Peach State Health Plan
687-1180877(TTY/TDD 1-877-941-9231)
German:
Falls Sie oder jemand, dem Sie helfen, Fragen zu Ambetter from Peach State Health Plan hat, haben Sie das Recht, kostenlose Hilfe
und Informationen in Ihrer Sprache zu erhalten. Um mit einem Dolmetscher zu sprechen, rufen Sie bitte die Nummer
1-877-687-1180 (TTY/TDD 1-877-941-9231) an.
Japanese:
Ambetter from Peach State Health Plan について何かご質問がございましたらご連絡ください。 ご希望の言語によるサポートや情報を無料でご提供いた
します。 通訳が必要な場合は、1-877-687-1180 (TTY/TDD 1-877-941-9231)までお電話ください。
Ambetter from Peach State Health Plan: --- (TTY/TDD ---) | Ambetter.pshpgeorgia.com |
AMBETTER | FROM PEACH STATE HEALTH PLAN
