Ambetter Provider Credentialing Guide

Are you having trouble finding information about Ambetter’s credentialing process? We have created a step-by-step enrollment roadmap just for you! Ambetter Health is a health insurance brand of Centene Corporation, the largest Medicaid managed care organization in the country. The company has been offering insurance products for nearly a decade.

The best part? All of its plans adhere to the requirements of the Affordable Care Act (ACA), meaning they are certified as Qualified Health Plans (QHPs) on the Health Insurance Marketplace. Ambetter’s notable quality for healthcare providers? It is the largest carrier of marketplace insurance and serves nearly 5 million members in the U.S.

So, if you also want to access a large influx of low-income patients, you should definitely enroll in Ambetter’s network.

A Step-by-Step Guide to Ambetter Credentialing Application

Ambetter, a Marketplace product of Centene, generally follows a standard credentialing process with some state-specific variations. However, it would be quite overwhelming to cover every variation in one article. That’s why we have focused only on Texas. So, without further ado, here is what you need for credentialing with Ambetter in Texas:

1. Gather Required Information and Documents

Advanced preparation can help you save a considerable amount of time. Therefore, you shouldn’t ignore the pre-application steps. So, what should you do before starting your Ambetter credentialing application? You must gather all the necessary documents and information.

This includes understanding the requirements, obtaining your NPI, and ensuring that all certifications, malpractice insurance coverage, and official documents are in one place.

2. Self-Register with CAQH ProView or Update Your Profile

Like most major insurance companies, Ambetter requires access to your CAQH profile for credentialing. Therefore, the next pre-application step in Ambetter provider credentialing is to create a CAQH ProView account if you don’t already have one. The registration process is quite straightforward. Simply visit https://proview.caqh.org to create your account. If you already have a profile, just make sure all information is accurate and up to date.

3. Confirm Your Credentialing Status

The last pre-application step is to confirm whether you are already enrolled in the Superior HealthPlan network. If you are, then you don’t need to go through a separate credentialing process for Ambetter. 

Simply visit Superior’s Add a Product page and add Ambetter to your contract after completing and submitting the online form. If you are not part of its network, simply proceed to the next step.

4. Fill Out the Online Provider Inquiry Form

Go to the state-specific ‘Join Our Network’ page on Ambetter’s website and complete the online inquiry form. This will help you receive the correct instructions for enrolling in Ambetter.

5. Complete the Ambetter Credentialing Application

After reviewing your inquiry, an Ambetter representative will contact you with detailed instructions. Follow their guidance to complete the application. There are two ways to do that. You can either:

• Use a standardized Ambetter credentialing form, or
• Make sure that your CAQH profile is fully updated and attested (electronically signed).

6. Submit the Application to Superior HealthPlan

As you may have already guessed, Superior HealthPlan manages Ambetter in Texas. Therefore, provide your CAQH credentials to Superior HealthPlan or send them your completed application along with all supporting documents. For potential information changes, notify Superior HealthPlan within 10 days of any change to keep your profile current.

7. Wait for Primary-Source Verification and Approval

Once your Ambetter provider credentialing application is submitted, wait for the committee’s approval. The process can take up to 90 days. To provide some context, here is what happens behind the scenes:

Superior HealthPlan forwards your application to Verisys, a credentialing verification organization (CVO). Then, Verisys performs primary-source verification of the following documents:

• State licensure
• Board certifications, residency training, and professional education.
• Malpractice history and license agency actions through the National Practitioner Data Bank (NPDB).
• Federal sanction activity, including OIG/Medicare/Medicaid exclusions.

Next, the Medical Director or Credentials Committee reviews the verified application and issues a written decision, either approving or denying your Ambetter credentialing request.

8. Complete Contracting with Superior HealthPlan

If your application is approved, finalize your enrollment by completing the contracting process with Superior HealthPlan/Ambetter. Keep in mind that this step is mandatory for all professional and organizational providers.

Ambetter Provider Credentialing Requirements

You are advised to compile the following documents as part of Ambetter’s credentialing requirements in Texas. While most of these are consistent across all covered locations, you should review your state-specific instructions to avoid delays in the credentialing process:

Key Requirements	Details
Attested CAQH Profile	You must attest your CAQH profile to confirm that it is accurate and complete.
Ownership & Control Disclosure Form	All applicants in Texas are required to submit a complete ownership and disclosure form.
Malpractice Insurance Coverage	Provide the current policy face sheet showing the insured date and coverage amount.
CSR Certificate (if applicable)	Also, provide complete controlled substance registration (CSR) information if you prescribe, administer, or order controlled substances.
DEA Registration	You must also submit a valid Drug Enforcement Administration (DEA) registration for every state in which you practice.
W-9 Form	Ambetter also requires a complete and signed W-9 tax form for initial credentialing.
ECFMG Certificate (if applicable)	All foreign graduates must provide the latest Educational Commission for Foreign Medical Graduates (ECFMG) certificates.
Latest CV	Your curriculum vitae (CV) must provide at least 5 years of work history and explain employment gaps of over 6 months.
Release of Information Form	This form must be signed and not older than 180 days.
Admitting Privileges	You must either have hospital admitting privileges at an in-network facility or an agreement with in-network doctors who will hospitalize and care for your Ambetter beneficiaries at a participating hospital.
CLIA Certificate (if applicable)	You must also provide the latest Clinical Laboratory Improvement Amendments (CLIA) if necessary.

Challenges in Getting Credentialed with Ambetter

So, what obstacles do most providers face when getting credentialed with Ambetter? If we are honest, Ambetter’s enrollment process can feel more complicated than others, mainly due to the following challenges:

Limited or Hard-to-Find Information

Want to know the biggest hurdle in Ambetter’s credentialing process? It is the lack of a single, comprehensive guide! The insurer offers only high-level instructions on its website, making it difficult to follow the appropriate steps. 

The main reason? Ambetter operates under varying state-specific health-insurance regulations and licensing agreements. As a result, it outlines detailed credentialing instructions in state-specific provider manuals, which are quite difficult to track down. Another problem? They are updated annually.

Varying Requirements and Local Administrators

Ambetter relies on local plan administrators in many states. For example, Superior HealthPlan manages the Ambetter insurance credentialing process in Texas. Each administrator has its own forms, portals, and submission procedures, making the credentialing process more confusing. 

Additionally, providers struggle to determine whether to reach out to Ambetter’s national team or the relevant state-level administrator for questions or concerns. This uncertainty often results in communication gaps and, consequently, in delayed enrollments.

Time-Consuming Primary Source Verification

Another frustrating obstacle? Slow primary source verification. It takes several weeks for CVOs to verify your information, which extends your credentialing timeline. The main reason? Licensing boards, educational institutions, and other official agencies sometimes take weeks to respond to CVOs’ verification requests.  

Best Practices for Ambetter Insurance Credentialing

While Ambetter’s credentialing challenges are unique and overwhelming, you can easily overcome these obstacles. Just follow these practices:

Understand Your State’s Requirements

In many states, Ambetter’s plans are usually managed by local Centene subsidiaries. The best way to learn the local credentialing requirements is to visit Ambetter’s ‘Join Our Network’ page for your state and complete the inquiry form. 

After reviewing your information, the insurer will provide you with all the details you need to participate in its network. You can also download your state’s Ambetter Provider Manual for more comprehensive requirements.

Get to Know the Local Administrator

Does a local administrator handle Ambetter’s healthcare provider enrollment and credentialing in your state? Our advice is to understand the administrator’s requirements first. This includes their application submission process, documentation needs, and any unique procedures.

Follow Up Regularly

Consistent follow-ups can help you avoid more than one common problem, including miscommunication and unexpected delays. The best way to do that? You should stay in contact with the appropriate administrator or a representative to track your Ambetter credentialing application status.

Work with a Credentialing Specialist

Credentialing is not an easy task, especially with unique issues, such as limited public information, varying requirements, and time-consuming primary source verification. How to address these problems? 

You can work with one of the best medical credentialing companies in the country to avoid months of waiting and paperwork. Professionals employed at such companies can help you enroll in Ambetter’s network much faster. Moreover, they can help you organize documents, meet deadlines, and manage state-specific requirements.

Partner with MediBillMD for a Smooth & Quicker Enrollment

Looking for an experienced credentialing expert? MediBillMD guarantees a smooth Ambetter healthcare provider enrollment process! Our experts understand how Ambetter operates in each state. Hence, we efficiently manage all of its unique credentialing requirements and state-specific rules. 

Choose our insurance credentialing services if you also want to participate in Ambetter’s network, but are hesitating due to its complicated application process. Focus on your patients and let us handle your credentialing problems.

Frequently Asked Questions