News
Ambetter of North Carolina Prior Authorization Change Summary
Date: 05/16/23
Ambetter Prior Authorization
List effective 8/1/2023
Ambetter of North Carolina Inc. requires prior authorization (PA) as a condition of payment for many services. This Notice contains information regarding such prior authorization requirements and is applicable to all Ambetter products offered by Ambetter of North Carolina Inc.
Ambetter of North Carolina Inc. is committed to delivering cost effective quality care to our members. This effort requires us to ensure that our members receive only treatment that is medically necessary according to current standards of practice. Prior authorization is a process initiated by the physician in which we verify the medical necessity of a treatment in advance using independent objective medical criteria and/or in network utilization, where applicable.
It is the ordering/prescribing provider’s responsibility to determine which specific codes require prior authorization.
Please verify eligibility and benefits prior to rendering services for all members. Payment, regardless of authorization, is contingent on the member’s eligibility at the time service is rendered. NON-PAR PROVIDERS & FACILITIES REQUIRE AUTHORIZATION FOR ALL HMO SERVICES EXCEPT WHERE INDICATED.
For complete CPT/HCPCS code listing, please see Online Prior Authorization Tool on our website at https://www.ambetterofnorthcarolina.com/provider-resources/clinical-payment-policies.html
Effective August 1st, 2023, the following are changes to prior authorization requirements:
Behavioral Health
PA RULE | SERVICES | PROCEDURE CODES |
|---|---|---|
PA Added | Behavioral health partial hospitalization | Rev code: 912, 913 |
PA Removed | Alcohol and/or drug services | H0004, H0005, H0007, H0014 |
PA Removed | Crisis intervention services | H2011 |
PA Removed | Substance abuse/detoxification and mental health services | S9475, S9484 |
Breast reconstruction
PA RULE | SERVICES | PROCEDURE CODES |
|---|---|---|
PA added except with breast cancer diagnosis | Breast reconstruction, prosthesis | 19316, 19318, 19325, 19328, 19340, 19342, 19350, 19370, 19371, 19499, L8039 |
Cardiovascular
PA RULE | SERVICES | PROCEDURE CODES |
|---|---|---|
PA Added | Insertion/removal of cardiac rhythm monitor | 33285 |
PA Added | Unlisted procedure | 37799 |
PA Added | Implantable wireless pulmonary artery wireless pressure sensor | C2624 |
PA Added | External counterpulsation | G0166 |
PA Removed | Cardiac rehab program | G0422, G0423, S9472 |
Diagnostic and Therapeutic Radiology
PA RULE | SERVICES | PROCEDURE CODES |
|---|---|---|
PA Added | Indium in-111 ibritumomab, dx | A9542 |
DME & Supplies
PA RULE | SERVICES | PROCEDURE CODES |
|---|---|---|
PA Added | Osteogenesis stimulator | E0749 |
PA Added | Wheelchairs, power operated vehicles, and accessories | E2603, E2604, E2605, E2606, E2607, E2608, E2609, E2613, E2614, E2615, E2616, E2617, E2620, E2621, E2622, E2624 |
PA Added | Supplies for home delivery of infant | S8415 |
PA Removed | Infusion pumps | B9002, E0781, K0455 |
PA Removed | Catheter Angioplasty | C2623 |
PA Removed | Respiratory equipment | E0550, E0565 |
PA Removed | Standard wheelchair and accessories | E2611, K0001 |
PA Removed | Hearing supplies | L8616, L8617, L8618, L8621, L8622, L8623, L8624, L8625 |
PA Removed | Vision supplies | S0515 |
Gastroenterology
PA RULE | SERVICES | PROCEDURE CODES |
|---|---|---|
PA Added | Gastrointestinal transit and pressure measurement | 91112 |
Home care
PA RULE | SERVICES | PROCEDURE CODES |
|---|---|---|
PA Added | Home health skilled nursing visit | Rev code: 551, G0490 |
PA Added | Home Care Management Services | G0087 |
PA Added | Home therapy* | G2168, G2169 |
PA Removed | Home dialysis (ESRD) | 90966 |
PA Removed | Home visit for prenatal monitoring and assessment | 99500 |
PA Removed | Home care training | G0248 |
PA Removed | In-home visit post-discharge and care plan oversight | G2001, G2002, G2003, G2004, G2005, G2006, G2007, G2008, G2009, G2013, G2014, G2015 |
PA Removed | Coordinated Care Home Monitoring | G9006 |
PA Removed | BPCI home visit | G9187 |
PA Removed | Remote in-home visits | G9978, G9979, G9980, G9981, G9982, G9983, G9984, G9985, G9986, G9987 |
PA Removed | Management of patient home care | S0270, S0271, S0272, S0273, S0274 |
PA Removed | Medical home program | S0280, S0281 |
PA Removed | Home visit, wound care | S9097, S9098 |
PA Removed | Home therapy hemodialysis and peritoneal dialysis | S9335, S9339 |
PA Removed | Diabetic Mgmt. Nurse Visit | S9460 |
Hospice
PA RULE | SERVICES | PROCEDURE CODES |
|---|---|---|
PA Removed | Counseling Services | G9473, G9474, G9475, G9476, G9477, G9478, G9479, S0255 |
PA Removed | Physician Supervision in Hospice | G0182 |
Infusion services
PA RULE | SERVICES | PROCEDURE CODES |
|---|---|---|
PA Removed | Home infusion therapy | S5035, S5036, S5108, S5109, S5110, S5111, S5115, S5116, S9347, Q2052 |
Laboratory
PA RULE | SERVICES | PROCEDURE CODES |
|---|---|---|
PA Added | Genetic testing | 0089U |
PA Added | Genetic analysis/studies, surgical pathology procedures | 81235, 81263, 81265, 81267, 81268, 81270, 81275, 81310, 81315, 88237, 88377 |
PA Removed | Blood and blood products | P9010, P9011, P9016, P9021, P9022, P9051, P9054, P9056, P9057, P9058 |
PA Removed | Routine venipuncture | S9529 |
Ophthalmology
PA RULE | SERVICES | PROCEDURE CODES |
|---|---|---|
PA Added | Collagen cross-linking of cornea | 0402T |
Orthopedic
PA RULE | SERVICES | PROCEDURE CODES |
|---|---|---|
PA Added | Procedures lower extremities | 28285, 28299 |
PA Added | Endoscopy procedure wrist | 29848 |
Other medical items or services
PA RULE | SERVICES | PROCEDURE CODES |
|---|---|---|
PA Added | Personal care services | T1020 |
Pain management
PA RULE | SERVICES | PROCEDURE CODES |
|---|---|---|
PA added unless performed on the same day as surgery | Injection*, anesthetic agent or steroid | 62320, 62321, 62322, 62323, 62325, 62327, 64400, 64405, 64415, 64417, 64418, 64420, 64421, 64430, 64445, 64447, 64448, 64450, 64451, 64454, 64479, 64480, 64483, 64484, 64505, 64510, 64517, 64520, 64530 |
PA Removed | Transversus abdominis plane (TAP) block | 64486, 64488 |
PA Removed | Nerve block | 64632 |
Preventive
PA RULE | SERVICES | PROCEDURE CODES |
|---|---|---|
PA Removed | Developmental and behavioral screening | 96110, 96112 |
Professional services
PA RULE | SERVICES | PROCEDURE CODES |
|---|---|---|
PA Added | Respite Care Services not in home | H0045 |
PA Removed | Professional services for drug admin | G0068, G0069, G0070, T1502, T1503 |
PA Removed | Skilled nursing service - outpatient | G0128 |
PA Removed | Inpatient telehealth | G0406, G0407, G0408, G0425, G0426, G0427, G0459 |
PA Removed | Services provided by non-physician | S5190 |
PA Removed | Enterostomal therapy by nurse | S9474 |
Radiology Treatments
PA RULE | SERVICES | PROCEDURE CODES |
|---|---|---|
PA Added | Ablation of Prostate* | 0421T |
PA Added | Indium in-111 ibritumomab, dx* | A9542 |
PA Added | Ablation Liver Tumor* | 47382 |
PA Removed | Radiolabeled item | C9898 |
Skin substitute
PA RULE | SERVICES | PROCEDURE CODES |
|---|---|---|
PA Added | Skin substitute products | Q4205, Q4206, Q4208, Q4209, Q4210, Q4211, Q4212, Q4213, Q4214, Q4215, Q4216, Q4217, Q4218, Q4219, Q4220, Q4221, Q4222, Q4226 |
Note:
For services listed with an asterisk ‘*’, providers may be required to request prior authorization through National Imaging Associates:
- Effective January 2019, Ambetter of North Carolina Inc. will work with National Imaging Associates, Inc. (NIA) to implement a radiology benefit management program for outpatient advanced imaging services.
- Effective January 2021, Ambetter of North Carolina Inc. will also work with National Imaging Associates (NIA) for the Utilization Management of outpatient rehabilitative and habilitative Physical Medicine services (Physical, Occupational, and Speech Therapy).
- Effective June 2023, Ambetter of North Carolina Inc. will also work with National Imaging Associations, Inc. (NIA) to provide the management and prior authorization of non-emergent outpatient Interventional Pain Management (IPM) procedures.
- Please refer to the Ambetter of NC Inc. Provider Manual for more information on Pre-Auth Programs.