Quick Reference Guide (QRG)

• 2023 Quick Reference Guide (QRG) (PDF)
  
• 2022 Quick Reference Guide (QRG) Essential, Balanced & Secure Care (PDF)
• 2022 Quick Reference Guide (QRG) Virtual (PDF)

Reference Materials

• Ambetter Health Member Tip Sheet
• Get Your Flu Shot
• Doctor's Office Visit Checklist (PDF) - Use this checklist to get prepared for your next doctor's appointment.
• Adult Wellness Visit Checklist (PDF)
  
• Preventive Services Guide (PDF)
• Quality Improvement (QI) Program
• Referral and Authorization Information
• Statement of Non-Discrimination
• Balance Billing Disclosures
  
• 2023 Transparency Notice
  
• 2022 Transparency Notice
• Where To Go For Care
• Women's Health and Cancer Rights Act Annual Notice
• Ambetter In-Network Hemophilia Pharmacies
  
• Ambetter Programs (PDF)
• Interoperability and Patient Access
  
• COVID-19 Home Testing Kits
  
• Cost Comparison Tool
  

Forms

• Authorization to Disclose Health Information Form (PDF)
• Revocation of Authorization Form (PDF)
• Grievance and Appeals Form (PDF)
• Member Reimbursement Medical Claim Form (PDF)
• Member Reimbursement Form - OTC Covid Test (PDF)
  
• Dental Reimbursement Form (PDF)
• Prescription Claim Reimbursement Form (PDF)
• Donor Transplant Travel Reimbursement Form (PDF)
• Recipient Transplant Travel Reimbursement Form (PDF)
• Member Transplant Travel Reimbursement Policy (PDF)

   

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