ExchangeAdministrativeHigh impact
Reminder: Use Paid-through Dates to Verify Member Eligibility
Ambetter·KY·Marketplace
Effective date
May 28, 2026
We identified it
Aug 26, 2026
Summary
Ambetter Health issued a critical reminder that billing teams must verify member eligibility status using paid-through dates before service delivery, as Marketplace members in grace periods or with delinquent premiums may have claims retroactively denied. The policy emphasizes checking member status, premium paid-through date, and claims paid-through date in the Centene Provider portal or Availity to prevent denials and reduce administrative burden.
Action Required
Immediately effective (5/28/26): Billing and front desk staff must implement mandatory pre-service eligibility verification for all Ambetter Health Marketplace members. (1) Before each appointment, verify member status in Centene Provider portal or Availity and confirm: active status, premium paid-through date (must be current or future), and claims paid-through date relative to service date. (2) Flag members showing 'Active – Pending Investigation', 'Delinquent', or 'Suspended' status and collect payment in advance or reschedule. (3) Do not proceed with services if claims paid-through date is in the past or premium paid-through date has lapsed. (4) Update encounter workflows and front desk scripts to include eligibility verification as mandatory checkpoint. (5) Train billing team on interpreting status codes: Active = good standing; Active – Pending Investigation/Delinquent = behind on premiums; Suspended = grace period expired; Inactive = coverage terminated. Failure to verify eligibility will result in retroactive claim denials and member disputes.