ExchangeAdministrativeHigh impact
Reminder: Use Paid-through Dates to Verify Member Eligibility
Ambetter·NC·Marketplace
Effective date
May 28, 2026
We identified it
Aug 26, 2026
Summary
Ambetter Health is emphasizing the critical importance of verifying member eligibility using paid-through dates before providing services. Members in grace periods (due to missed premium payments) may have coverage retroactively terminated, resulting in claim denials. Providers must proactively confirm eligibility status, premium paid-through date, and claims paid-through date at or near the date of service to avoid denied claims and unexpected patient balance collection.
Action Required
Immediately: All billing and front-desk staff must implement mandatory eligibility verification for ALL Ambetter Health members before or on the date of service. (1) Front desk: Verify member status in Centene Provider portal or Availity for every Ambetter member, specifically checking eligibility status, premium paid-through date, and claims paid-through date. (2) Billing team: Do not process claims for members showing 'Active – Pending Investigation', 'Delinquent', or 'Suspended' status without first clarifying coverage with the member and obtaining written confirmation of financial responsibility. (3) Training: Educate all clinical and administrative staff on the four eligibility status meanings (Active, Active – Pending Investigation, Delinquent, Suspended, Inactive) and the 90-day grace period rules. (4) Workflow: Add eligibility verification checkpoint to encounter forms and billing system prior to claim submission. Consequence: Claims will be denied and retroactively terminated if member status is not verified at time of service, resulting in outstanding patient balances and write-offs.