Ambetter provides the tools and support you need to deliver the best quality of care.

Reference Materials

• 2025 Provider and Billing Manual (PDF)
  
• 2024 Provider and Billing Manual (PDF)
• Provider Booklet (PDF)
• Quick Reference Guide (PDF)
• Pharmacy Guide (PDF)
• Claims, Disputes & Recovery/CCU Guide (PDF)
• Appeals/Reconsiderations (Medical) And Grievances Guide (PDF)
• Payspan (PDF)
• Secure Portal (PDF)
• ICD-10 Information
• Taxonomy Reference Guide (PDF)
• Provider Portal Enhancements (PDF)
• Payspan Provider Training
• Behavioral Health Resources
• NEW for 2023: Fight Against the Flu Provider Guide (PDF)
• Non-Formulary And Step Therapy Exception Request Form (PDF)
• Ambetter of North Carolina Inc. General Flyer (PDF)
• Ambetter of North Carolina Inc. Network Flyer (PDF)
• Respiratory syncytial virus (RSV) Provider Guide (PDF)
• Ambetter Preventative Care (PDF)
• 2025 Provider Appointment Standards for Scheduling (PDF)
• Care Options for Ambetter Patients (PDF)

New Provider Orientation

• Welcome Letter (PDF)
• Quick Reference Guide (PDF)
• Provider Orientation Presentation (PDF)
• Instructions for Attending a New Provider Orientation
• Provider Orientation Attestation of Completion

Claims Office Hours

Join Ambetter of North Carolina Inc. for our bimonthly Claims Office Hours session, starting July 23rd at 12 PM!

Audience: Billing staff, practice managers, and providers who want to stay informed and supported around Ambetter of North Carolina Inc. claims processes.

During this interactive session, we’ll review:

• Operational workflows and systems
• Hot topics and common claim denial trends
• Review available provider education and training resources
• Live Q&A – bring your questions!

Please Note: For privacy and compliance, do not submit or ask questions containing any PHI during the session.

Registration Required: Register in Advance

Claims and Claims Payment

• Claim Dispute Form (PDF)
• Consent for Sterilization Form (PDF)
• No Surprises Act Open Negotiation Form (PDF)
• NEW: Claims and Billing Provider Guide - Upfront Rejections (PDF)

Practitioner Enrollment and Provider Demographic Updates

• Requests to join our network are not processed using these forms. To request to join our network, please use our Network Participation Request Form. Once you have completed this form, please allow up to five business days days for a member of our team to contact you.
• To add a new facility to an existing application or to submit location changes, please download and fill out the Ambetter Facility Roster Template (Excel | .xlsm) and submit these forms along with all credentialing documentation to AmbetterNCProviderDirectoryRequest@CENTENE.COM.
• To add a new practitioner to your practice, please download and fill out the Ambetter Practitioner Roster Template (Excel | .xlsm) and submit these forms along with all credentialing documentation to AmbetterNCProviderDirectoryRequest@CENTENE.COM.

Health Equity Toolkit

• Help Your Patients Understand Their Health and Health Care (PDF)
• AHRQ Health Literacy Universal Precautions Toolkit

Quality Improvement

• HEDIS® Adult Pocket Guide: 2025 Measurement Year (PDF)
• HEDIS® Pediatric Pocket Guide: 2025 Measurement Year (PDF)
• Supplemental Data System (SuDS) Submission Process (PDF)
• The Supplemental Data Journey Flyer (PDF)
• 2021 QUALITY RATING SYSTEM (QRS) AT-A-GLANCE (PDF)
• Consumer Assessment of Healthcare Providers and Systems (CAHPS®) Provider Resource Guide (PDF)
• Improve Patient Experience (PDF)
• 2025 Marketplace P4P Program (PDF)
• Provider Tip Sheets
  • Appropriate Testing for Pharyngitis (CWP) (PDF)
  • Cervical Cancer Screening (CCS) Tip Sheet (PDF)
  • Childhood Immunizations Status (CIS) (PDF)
  • Child and Adolescent Well-Care Visits (WCV) (PDF)
  • Chlamydia Screening in Women (CHL) (PDF)
  • Controlling Blood Pressure (CBP) (PDF)
  • Eye Exam for Patients with Diabetes (EED) (PDF)
  • Immunization for Adolescents (IMA) (PDF)
  • International Normalizing Ratio Monitoring for Individuals on Warfarin (INR) (PDF)
  • Proportion of Days Covered: Diabetes All Class (PDC-DR) (PDF)
  • Timeliness of Prenatal & Postpartum Care (PPC) (PDF)
  • Use of Imaging Studies for Low Back Pain (LBP) (PDF)
  • Weight Assessment and Counseling for Nutrition and Physical Activity for Children and Adolescents (WCC) (PDF)

Risk Adjustment

• 2025 Continuity of Care Program Guide (PDF)
  
• Continuity of Care Appointment Agenda (PDF)
• Continuity of Care Program Tiered Incentive Payment Chart (PDF)

Medical Management

• Prior Authorization Guide
• Inpatient Prior Authorization Fax Form (PDF)
• Outpatient Prior Authorization Fax Form (PDF)
• Prior Authorization Request Form for Non-Specialty Drugs (PDF)
• Clinical Policy: Brand Name Override and Non-Formulary Medications (PDF)
• Retrospective Authorization Review Request (PDF)
• Discharge Planner Checklist (PDF)

Quality

• Practice Guidelines (PDF)
• Providing Quality Care
• Quality Rating System (QRS) Behavioral Health Measure Toolkit (PDF)

Notification of Pregnancy Provider Report

• Notification of Pregnancy Report Provider Education (PDF)
• Notification of Pregnancy Report Flyer (PDF)

Other

• Centene Vision Services
• Centene Dental Services