ExchangeAdministrativeHigh impact
Reminder: Use Paid-through Dates to Verify Member Eligibility
Ambetter·IA·Marketplace
Effective date
May 28, 2026
We identified it
Aug 26, 2026
Summary
Ambetter Health is reminding providers to verify member eligibility using paid-through dates before service delivery, particularly due to Marketplace enrollment changes and grace period rules. Members who miss premium payments enter a 90-day grace period and may face retroactive coverage termination with claim denials. Providers must confirm eligibility status, premium paid-through date, and claims paid-through date at or near the date of service to reduce claim denials and avoid billing issues.
Action Required
Immediately: Front desk and billing staff must implement mandatory eligibility verification for all Ambetter Health Marketplace members at or as close to the date of service as possible. Specific actions: (1) Before each patient visit, check member status in both Centene Provider portal and Availity; (2) Verify and document the member's eligibility status (Active, Active-Pending Investigation, Delinquent, Suspended, or Inactive), premium paid-through date, and claims paid-through date in the patient record; (3) Alert providers if status is Delinquent or Suspended, as these indicate premium non-payment and potential retroactive termination risk; (4) Collect payment from member in advance of services if eligibility is questionable; (5) Train all patient-facing staff on the four status categories and their meanings. Failure to verify eligibility will result in increased claim denials and retroactive coverage terminations, forcing practices to absorb costs for services rendered during grace periods or after termination dates.