Ambetter Health Updated Malnutrition Criteria Takes Effect October 1, 2026

Date: 07/30/26

Thank you for your continued partnership with Ambetter Health. As you know, we continually review and update our payment and utilization policies to ensure that they are designed to comply with industry standards while delivering the best patient experience to our members. We are writing today to inform you of the revision to existing policies Ambetter Health will be implementing effective with Dates of Service starting October 1, 2026. Posted policy on site contains a revision log explaining the updates that occurred in the annual review.

Policy Number	Policy Name	Policy Description	Lines of Business
CP.PP.145	Malnutrition	Acute care hospitalizations for malnutrition require the most appropriate and most specific level of diagnosis coding. The medical record documentation supporting the diagnosis should be clearly documented by the physician or a licensed independent practitioner. The cost difference between a Diagnosis Related Group (DRG) billed with malnutrition as a major complication or comorbidity (MCC) (in a position other than as the primary diagnosis code position) and a DRG billed without malnutrition as an MCC (in a position other than as the primary diagnosis code position) will be denied reimbursement unless meeting the documentation requirements described in this policy. The purpose of this policy is to support a retrospective review of inpatient claims billed with the diagnosis of malnutrition.	Marketplace

Policy
Number

Policy
Name

Policy
Description

Lines of Business

CP.PP.145

Malnutrition

Acute care hospitalizations for malnutrition require the most appropriate and most specific level of diagnosis coding. The medical record documentation supporting the diagnosis should be clearly documented by the physician or a licensed independent practitioner.

The cost difference between a Diagnosis Related Group (DRG) billed with malnutrition as a major complication or comorbidity (MCC) (in a position other than as the primary diagnosis code position) and a DRG billed without malnutrition as an MCC (in a position other than as the primary diagnosis code position) will be denied reimbursement unless meeting the documentation requirements described in this policy.

The purpose of this policy is to support a retrospective review of inpatient claims billed with the diagnosis of malnutrition.

Marketplace

Changes to Reviews Include

Updated Criteria I. to include non-severe (moderate) malnutrition diagnosis criteria guidelines and treatment. Added Criteria II. to include severe malnutrition diagnosis criteria guidelines and treatment. Coding and descriptions reviewed. Added ICD-10 codes E44.0 and E44.1.

Thank you for your continued participation and cooperation in our ongoing efforts to render quality health care to our members. We look forward to helping you provide the highest quality of care for our members.

Questions

Ambetter Health has a wealth of resources available to help answer your questions and address your concerns:

Provider Support Guide: Find the Right Contact
Provider Services: Call 1-877-687-1169
Secure Provider Portal: Visit the Secure Provider Portal to check member eligibility, submit claims and more.
Provider Engagement: Use the Find Your Account Manager tool to find the Provider Engagement Account Manager (PEAM) supporting your specialty and region.
Claim Concerns: Resolve outstanding claims using the Claim Concerns form.
Provider News: Bookmark Ambetter Health Provider News and Sunshine Health Provider News to keep up with the latest updates.
Provider Newsflash: Subscribe to our e-newsletter to get regular updates.
Provider Resources: Visit Ambetter Health Provider Resources to find provider manuals, important forms, scheduling standards and other provider resources.

^AMB_12412