News
August 2025 Provider Newsletter
Date: 08/14/25
Clinical Policy Updates
Ambetter of North Carolina Inc. continuously updates select clinical policies each month. The following policy updates are effective 10/15/2025.
13 policies were reviewed and approved.
- 6 policies had no changes
- 4 policies were revised making them less restrictive
- 2 policies were revised making the new version both more and less restrictive:
- CP.MP.58 Intestinal and Multivisceral Transplant
- CP.MP.87 Therapeutic Utilization of Inhaled Nitric Oxide
- 1 policy was revised making the new version more restrictive:
- CP.MP.132 Heart-Lung Transplant
This page reflects upcoming clinical policy changes. Revision notes are made available in the policy document.
Concert Genetics Policy Revisions
Ambetter continually reviews and updates 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.
The following existing Concert Genetics policies were also revised and will be implemented effective 10/15/2025
| Policy Number | Policy Name | Policy Summary |
| HIM NC.CG.CP.MP.01 | Infectious Disease: Respiratory Lab Testing | This policy outlines criteria for Syndromic/Multiplex Respiratory Panels with 6 or More Targets, SARS-CoV-2, RSV, or Influenza A/B, OR Multiplex Respiratory Viral Panels with 5 or Fewer Targets, Bacterial Respiratory Infection/Pneumonia Panels, Influenza A and B Antibody Tests, Group A Streptococcus Pharyngitis Tests, Group A Streptococcus Pharyngitis Cultures, and Group A Streptococcus Antibody Tests. |
| CG.CP.MP.02 | Infectious Disease: Multi-System Lab Testing | This policy outlines the appropriate use of tests for pathogens that can cause multisystem symptoms and/or infections. Tests for pathogens that infect multiple body systems can be targeted to detect a specific pathogen(s) or non-targeted to broadly detect nucleic acid from any potential pathogen. |
| CG.CP.MP.03 | Infectious Disease: Dermatologic Testing | This policy outlines the appropriate use of Microscopy/Peroxidase Tests, Fungal Culture, and Culture-Independent Molecular Tests (NAAT/PCR) for Onychomycosis. |
| CG.CP.MP.04 | Infectious Disease: Gastroenterologic Lab Testing | This policy outlines appropriate use of multi-pathogen panels, as well as diagnostic assays targeted at Helicobacter pylori (H. pylori). |
| CG.CP.MP.05 | Infectious Disease Primary Care and Preventive Lab Screening | This policy outlines criteria for human papillomavirus (HPV), hepatitis C virus (HCV), and group B streptococcus (GBS). |
| CG.CP.MP.06 | Infectious Disease: Vector-Borne and Tropical Diseases Lab Testing | This policy outlines criteria for Lyme disease and Zika virus testing via serologic and molecular methods. |
| CG.CP.MP.07 | Infectious Disease: Genitourinary Lab Testing | This policy outlines criteria for Targeted Vaginitis/Vaginosis Pathogen Testing, Expanded Multiplex Vaginitis/Vaginosis Pathogen Panels, Urine Culture for Asymptomatic Bacteriuria, and Molecular/Multiplex UTI Panels. |
| CG.CC.PP.01 | Concert Laboratory Payment Policy | This policy outlines correct coding requirements for lab testing, excluding and molecular testing |
For a list of all active clinical policies, view the Clinical and Payment Policy page.
For any upcoming policy changes, view the Clinical Policy Updates list.
Newborn Inpatient Stays Payment Integrity Update
We are committed to continuously evaluating and improving overall Payment Integrity solutions as required by State and Federal governing entities. We are writing today to inform you of a new policy that Ambetter of North Carolina Inc. will be implementing effective on or after 10/15/2025.
| Policy Number | CC.PP.075 |
| Policy Name | Newborn Inpatient Stays |
| Line of Business Impacted | Marketplace |
| EX Code | EXhn: Healthy Newborn Claim paid per policy, remit records for reconsideration |
| Description | Review claims for coding appropriateness when normal newborn stays with non-NICU revenue codes are billed. This policy will administer a payment based on a non- NICU stay however if you disagree you can submit a reconsideration with medical records. |
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.
Provider Notifications: Prepayment Claim Reviews with Optum
As a reminder, we have partnered with Optum who is supporting us in performing prepayment claim review. The purpose of our review is to verify the extent and nature of the services rendered for the patient’s condition and that the claim is coded correctly for the services billed.
For claims received on or after 10/15/2025, providers may experience a slight increase in written requests for medical record submission prior to payment based on the areas outlined below. These requests will come from Optum and will contain instructions for providing the documentation. Should the requested documents not be returned, the claim(s) will be denied. Providers will have the ability to dispute findings through Optum directly in the event of a disagreement.
| Editing Area | Description |
| Critical Care Coding Requirements Unlikely to be Met | This review seeks to ensure appropriate critical care billing for illnesses or injuries. |
| Upcoding of Percutaneous Nephrostolithotomy (PCNL) Procedures | This review of professional and outpatient claims seeks to ensure that documentation supports billing a complex Percutaneous Nephrostolithotomy (PCNL) Procedure. |
| Associated Code for EOP | Description |
| CPIMR | Medical Records and/or Other Service Documentation Required |
| Editing Area | Description |
| Trauma Activation with No Ambulance Service | This analytic will identify outpatient claims with revenue codes for trauma response (Rev 681 – 689) when there are no claims in history for ambulance services with HCPCS codes between A0021 and A0999 for the same member on the same date of service. |
| High Dollar Hardware | This analytic identifies outpatient claims billing high dollar pass-through payment for hardware with code C1713 (anchors/screws). |
| Unsupported Lab Tests on High Dollar Claims | This analytic reviews high dollar lab claims with at least 5 lines and a payment greater than $500 that are potentially unsupported by an order from a qualified healthcare professional. |
| Cross-coder Outpatient Facility Surgical Claims | This analytic identifies outpatient facility claims with surgical procedure codes that do not match the professional claim codes for similar services provided to the same patient on the same date of service. Records will be reviewed to ensure coding/documentation guidelines are met. |
| Digital Spike Analysis | This analytic will target when a Digital Spike Analysis of EEG (95957) is billed in addition to the primary EEG procedure to verify the required additional time and extra work was done to support the billing of this code. |
| Upcoding of Incision and Drainage Codes | This analytic identifies claims billing incision and drainage (I&D) procedure codes that are suspected to be non-incision or lower-level incision and drainage which may have been incorrectly submitted to achieve additional reimbursement, reviewing simple I&D procedure codes 10060, 10080, 10140 and complicated/multiple I&D procedure codes 10061, 10081 |
| Misbilling of Third Order Selective Catheter Placement | This algorithm targets codes for arterial selective catheter placement of the third order for placement above the diaphragm (36217) and below the diaphragm (36247) when claim details suggest that a first or second order arterial branch above the diaphragm or below the diaphragm was more likely the location of the procedure. Records will be reviewed to determine if the coding guidelines required to bill arterial selective catheter placement of the third order are met. |
| Cross-coder Professional vs. Outpatient Facility Surgery Claims | This analytic identifies professional claims with surgical procedure codes that do not match the outpatient facility claim codes for similar services provided to the same patient on the same date of service. Records will be reviewed to ensure coding/documentation guidelines are met |
| Associated Code for EOP | Description |
| AMISYS: EXbo | MEDICAL RECORDS AND/OR OTHER SERVICE DOCUMENTATION REQUIRED |
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.
Cotiviti EM Leveling
Ambetter of North Carolina is committed to continuously improving its claims review and payment processes. This letter is to notify you that effective 10/15/2025, we will begin applying national CPT billing guidelines for the appropriate coding of physician emergency department Evaluation and Management (E&M) code levels.
Both Centers for Medicare & Medicaid Services (CMS) and the Office of Inspector General (OIG) have documented that E&M services are among the most likely services to be incorrectly coded, resulting in improper payments to practitioners. The OIG has also recommended that payers continue to help to educate practitioners on coding and documentation for E&M services and develop programs to review E&M services billed for by high-coding practitioners.
Overview of Ambetter of North Carolina Inc. E&M Program;
- Evaluates and reviews only high-level E&M services based upon diagnostic information that appears on the claim.
- Applies the relevant E&M policy and recoding of the claim line to the corrected E&M level of service.
- Allows reimbursement at the highest E&M service code level for which the criteria is satisfied based on our comparative peer risk adjustment process.
Providers should report E&M service in accordance with American Medical Association’s (AMA) CPT Manual and the Centers for Medicare and Medicaid Services (CMS') guidelines for billing E&M service codes; “Documentation Guidelines for Evaluation and Management” The proper reporting of E&M Services enables Ambetter of North Carolina to more precisely apply reimbursement-coding guidelines and ensure that an accurate record of patient care history is maintained.
Determinations should be made with reference to accepted standards of medical practice and the medical circumstances of the individual case.
| Policy Number | CC.PP.066 & CC.PP.076 |
| Policy Name | Leveling of Care Office Based EM Overcoding & Leveling of Care Emergency Department EM Overcoding |
| EX Code | Explanation of Payment (EOP) Description |
| EXyG | DENY: REIMBURSED AS LOWER COMPLEXITY E/M PER PAYMENT POLICY |
| EXyH | PAY: REDUCED RATE FOR LOWER COMPLEXITY E/M SERVICE PER PAYMENT POLICY |
Thank you for your continued participation and cooperation in our ongoing efforts to render the highest quality health care to our members.
Avoid Common Claim Denials — Quick Tips for Providers
To support accurate and timely claim payments, Ambetter of North Carolina Inc. has compiled the top denial reasons from the past two months, along with actionable guidance to help you prevent them. Review the list below and share it with your billing team. A few proactive steps now can reduce rework and help ensure faster, smoother claim payments.
- EXy1 DENIED: OUT-OF-NETWORK PROVIDER NOT COVERED PER HMO/EPO POLICY
Provider Guidance:
- No action is needed if services were provided out of network
- Ensure timely updates to practitioner enrollment. Practitioner Enrollment and Provider Demographic Updates
- EXx8 MODIFIER INVALID FOR PROCEDURE OR MODIFIER NOT REPORTED
Provider Guidance:
- Please review the modifier and procedure codes to ensure compatibility with Ambetter billing guidelines.
- Additional information can be found in our Provider Manual. 2025 Provider and Billing Manual (PDF)
- EX18 DENIED: DUPLICATE CLAIM RECEIVED
Provider Guidance:
- Please review claim history; services most likely were previously processed under a historical claim with the same DOS and same provider.
When submitting a corrected claim, include:
- Frequency code (7 = replacement or corrected; 8 = voided or cancelled)
- Original claim number in Field 22 (CMS-1500) or Field 4 (UB-04)
- EX29 DENIED: CLAIM WAS NOT SUBMITTED WITHIN REQUIRED TIMEFRAME
Provider Guidance:
- Denied for Timely filing. The timely filing is 180 days of DOS or date of discharge, please refer to the 2025 Provider and Billing Manual (PDF)
- EXA1 DENIED: NO RECORD OF PRIOR AUTHORIZATION FOR SERVICE BILLED
Provider Guidance:
- No authorization on file for services reported. Please use the Pre-Auth Tool.
- PAs are granted at the CPT code level. Claims with unauthorized codes will be denied.
- If additional procedures are performed during the procedure, the provider must contact the health plan to update the authorization to avoid a claim denial.
- EX28 DENIED: MEMBER'S COVERAGE WAS NOT EFFECTIVE AT THE TIME OF SERVICE
Provider Guidance:
- Providers must verify eligibility at the time of service by using Ambetter Secure Portal https://provider.ambetterofnorthcarolina.com or by calling 1-833-863-1310.
- EXx9 PROCEDURE CODE PAIRS INCIDENTAL, MUTUALLY EXCLUSIVE OR UNBUNDLED
Provider Guidance:
- Submit corrected claim with correspondence or medical records attached for review. See page 71 of the 2025 Provider and Billing Manual (PDF)
- Should you disagree with the denial, submit a corrected claim with MR or correspondence attached file. You may submit a Claim dispute using the Claim Dispute Form (PDF) once the claim is out of pending status, you can then submit a void or corrected claim.
- EXVF GLOBAL FEE
Provider Guidance:
- Reimburse included in global fee/procedure.
- EXpE INAPPROPRIATE LEVEL OF E M SERVICE BILLED, SEE POLICY ON PLAN WEBSITE
Provider Guidance:
- Please review claim history for level E/M reported.
- Please refer to page88-89 in the 2025 Provider and Billing Manual (PDF) for guidelines.
- EXzV INCORRECT PROCEDURE CODE FOR DIAGNOSIS PER NCD
Provider Guidance:
- Please review the procedure code and diagnosis code to make sure they are compatible.
Need help?
Call: 1-833-863-1310 (Relay 711) or Contact Your Provider Relations Coordinator, NetworkRelations@cch-network.com
Ambetter of North Carolina Inc. Claims Office Hours - You Are Invited!
Join Ambetter for our next Claims Office Hours on September 23th at 12PM! The session is designed to support your practice with key insights and helpful guidance around our claims process.
Audience:
Billing staff, practice managers, and providers who want to stay informed and supported around Ambetter of NC Inc. claims processes.
During this interactive session, we will review:
- Operational workflows and systems
- Hot topics and common claim denial trends
- Available provider education and training resources
- Live Q&A – bring your questions!
Note: For privacy and compliance, do not submit or ask questions containing any PHI during the session.
Registration Required: Click Here!
We look forward to seeing you and helping ensure your claims run smoothly!
New Provider Orientation
During the New Provider Orientation, we will discuss the following:
- Ambetter benefits
- Verification of Eligibility and benefits
- Accessing the public website and secure web portal
- Prior Authorizations
- Claims
- Provider Billing Manual and Provider Tool kit
Ambetter of North Carolina Inc. holds New Provider Orientations monthly on the third Tuesday of the month at 12PM ET.
- Register in advance for this meeting
- After registering, you will receive a confirmation email containing information about joining the meeting.
Ambetter of North Carolina Inc. also has an on-demand option for your New Provider Orientation.
Once you complete an orientation, please submit your attestation.
Provider Manual
Visit Provider Resources for the most up-to-date version of the Ambetter of North Carolina Inc. Provider and Billing Manual:
https://www.ambetterofnorthcarolina.com/provider-resources/manuals-and-forms
Availity Essentials
Providers are reminded that they can use Availity Essentials to submit prior authorizations quickly and efficiently. For more information and alternative submission methods, please reference the Provider Toolkit Authorization Guide.