August Provider Newsletter

Date: 09/01/26

Provider Roster Reminder

Providers participating in Ambetter of North Carolina Inc. or Wellcare North Carolina Medicare are reminded to submit an updated roster of all participating providers on a monthly basis. Timely roster submissions help ensure accurate credentialing information and provider directory listings, support appropriate claims processing and payment, and help prevent delays or issues related to provider participation. We strongly encourage providers to submit a current roster each month, even when there are no changes to report.

Roster submissions can be sent to:

• Wellcare North Carolina Medicare: Medicarencupdates@cch-network.com
• Ambetter of North Carolina Inc.: ambetterncproviderdirectoryrequest@centene.com

Clinical Policy Updates

Ambetter of North Carolina Inc. continuously updates select clinical policies each month.
The following policy updates are effective 11/1/2026.

37 policies were reviewed and approved.

• 16 policies had no changes
• 3 policies retired
  • CP.MP.126 Sacroiliac Joint Fusion
  • CP.MP.14 Cochlear Implant Replacements
  • CP.MP.51 Reduction Mammoplasty and Gynecomastia Surgery
• 7 policies were revised making them less restrictive
• 6 policy was revised making the new version both more and less restrictive:
  • CP.MP.244 Liposuction for Lipedema
  • CP.MP.120 Pediatric Liver Transplant
  • CP.MP.54 Hospice Services
  • CP.MP.86 Neonatal Abstinence Syndrome Guidelines
  • CP.MP.150 Phototherapy for Neonatal Hyperbilirubinemia
  • CP.BH.300 Biofeedback for Behavioral Disorders
• 5 policies were revised making the new version more restrictive:
  • CP.MP.185 Skin and Soft Tissue Substitutes
  • HIM.CP.BH.500 Behavioral Health Treatment Documentation Requirements
  • CP.MP.129 Fetal Surgery in Utero for Prenatally Diagnosed Malformations
  • CP.MP.164 Caudal or Interlaminar Epidural Steroid Injections
  • CP.MP.49 Physical, Occupational, and Speech Therapy Services

This page reflects upcoming clinical policy changes. Revision notes are made available in the policy document.

Surrogacy Coverage Information

Ambetter Surrogacy Coverage

Ambetter of North Carolina Inc. does not provide surrogacy coverage. The following information outlines coverage exclusions and billing guidance for your reference.

Coverage Exclusions

• Both member and non-member surrogates are excluded from all maternity services, including prenatal appointments, the delivery (hospital stay, physician, etc.), and post-natal care.
• They are also excluded from infertility coverage treatment and corrective surgeries performed solely to enable a member to become pregnant.
• Any newborn born to a surrogate arrangement is not covered, including all newborn services.

Ambetter Surrogacy Diagnosis Codes (ICD-10-CM)

• Z33.3 - Pregnant state, gestational carrier: assigned when treating or monitoring a surrogate pregnancy, where the patient carries a child for another and is not genetically related to the baby.
• Z31.7 - Procreative management and counseling for a gestational carrier: used when a patient receives medical, educational, or psychological counseling and management to act as a surrogate or gestational carrier.
• Apply these codes only for surrogates, they must never be billed for members who are not surrogates.

Notification of Surrogacy

• Both members and providers are responsible for notifying us of surrogacy.
• The Ambetter Health Notification of Surrogacy form is different than the Ambetter Notification of Pregnancy Form.

Correct Billing and Review Policy

• Claims submitted with either surrogacy diagnosis code will trigger an automatic member review, potentially up to a year, and may result in potential claim denials and recoupments.
  • The review period is one full year, beginning from the member’s first pregnancy-related claim.
• In states without surrogacy coverage, all pregnancy-related services are denied and the member is placed on review for one year, including members who travel to a state that allows surrogacy coverage. Members must follow their originating state’s Ambetter coverage.

Please review the Ambetter Provider Manual for additional details.

Behavioral Health (BH) Type of Bill (TOB) Scenarios

In reviewing claims, it has been noted that there is significant variability regarding provider billing with inpatient, outpatient, and residential treatment center (RTC) types of bill.

A provider manual update was made for type of bill 86X to provide clear 86X billing requirements.

In working with our configuration partners, a BH type of bill (TOB) scenario document has been created to provide guidance on:

• Inpatient TOB and revenue code scenarios.
  • 11x
• Residential treatment center (RTC) TOB and revenue code scenarios
  • 86x
• Outpatient TOB and revenue/procedure code scenarios
  • 13x
  • 76x

NOTE: The revenue and procedure codes listed are provided as examples only and is not an all-inclusive listing. Providers should refer to applicable billing guidance, contractual requirements, and payer-specific policies to confirm appropriate revenue code and procedure code use.

Inpatient TOB and Revenue Code Scenarios

Residential Treatment Center (RTC) TOB and Revenue Code Scenarios

Outpatient TOB and Revenue Code Scenarios

Please review the Ambetter Provider Manual for additional details.

New in Availity Essentials

Streamline Authorization Follow-Ups by Viewing and Responding to RFAI Online

Managing authorization follow-ups just got easier with request for additional information (RFAI). You can securely receive and respond to requests from Ambetter of North Carolina Inc. right within Availity Essentials.

Key benefits

• No calls or faxes — manage authorizations online.
• Keep requests moving — respond quickly with supporting clinical documentation.
• Track activity in one place — monitor and manage requests from a single dashboard.

View and respond to RFAIs

Use the Authorization/Referral Dashboard to review and respond to requests for additional information.

• On the Dashboard Summary page, look for Pending Action – Contact Payer in the Status/Last Updated column.
• Open the authorization and review the Review Reason 1 field for the payer message. Then scroll down the page to the RFAI section to review request details.
• Upload your response.
  • You can upload up to 10 attachments or a total of 64 MB.

Tip: If you submitted an authorization outside of Availity Essentials (for example, through another portal or by fax), use the Authorization/Referral Inquiry tool to access the authorization, then pin it to your dashboard to track its status.

NOTE: RFAI requests sent before the authorization is pinned to your dashboard will not appear. You will continue to receive notifications through other channels.

Training and support resources

Access training and support resources in Availity Essentials:

• Three-minute demo:
• From the Availity Essentials homepage, select Help & Training > Get Trained.
• Search “CNC” in the Learning Center catalog.
• Select Auth Request for Additional Information.

• Illustrated step-by-step instructions:
• In Availity’s Provider Help Center, go to Help & Training > Find Help.
• Search “process requests for additional information authorizations.”

Availity Learning Center Information

New to Availity Essentials or looking to sharpen your skills?

Whether you are just getting started or looking for a refresher, the Availity Learning Center offers flexible training options to help you make the most of Availity Essentials. Choose from live webinars, on-demand training and demos covering plan-specific topics as well as Availity Essential features.

Getting Started with the Availity Learning Center
To access the learning center, you must be registered on Availity and have a unique user ID and password.

• Log on to Availity Essentials.
• Select Help & Training from the top navigation bar.
• Choose Get Trained to open the learning catalog.
• To find plan-specific training, enter CNC in the search field.

You can also access live and on-demand training created specifically for our health plans directly. An Availity user ID and password are required.

Need a refresher on pre- and post-service workflows?

Join live Availity webinars in October.

The Availity Learning team will host live learning events for our health plans. Health plan representatives will also participate to help answer your questions.

• Pre-Service Workflow | October 6

Topics include eligibility & benefits and authorizations.

• Post-Service Workflow | October 8

Topics include claim submission, EDI reporting, claim status and remittance viewer.

Reserve your spot today! Register for the August and October Availity training sessions before available spaces fill up.

Additional live training opportunities

Both new and experienced Availity users can also take advantage of Availity’s monthly live webinars that apply across all health plans.

• To find and register for these sessions, enter LivGen in the Availity Learning Center catalog.
• You can also select the Live Learning tab to view all available sessions.

Provider Insights: Quarterly Provider Education Webinar Series

Join us for the launch of Ambetter of North Carolina Inc Provider Insights, a new quarterly webinar series designed to keep providers informed with timely education, clinical insights, and important Ambetter of North Carolina updates. Each webinar will feature a focused educational topic presented by a subject matter expert, followed by the latest plan updates, provider resources, policy reminders, and upcoming initiatives.

Featured Webinar | September 22

Helping Your Patients Communicate, Recover, and Thrive

Our inaugural session features Drew Ben-Aharon, Chief Revenue Officer at Great Speech, who will discuss how virtual speech therapy can help improve access to care for pediatric, adult, and geriatric patients experiencing speech, language, cognitive, voice, and neurological disorders. Learn when to consider a referral, the benefits of virtual speech therapy, and how timely intervention can improve patient outcomes.

We will also share important Ambetter of North Carolina updates, including provider resources, operational and clinical reminders, and other timely information to support your practice.

Date: September 22
Time: 12PM
Register Here

We look forward to connecting with you during our first Ambetter of North Carolina Provider Insights webinar!

Provider Spotlight - Great Speech Virtual Speech Therapy

Many patients with communication and cognitive disorders never receive the speech therapy services that could significantly improve their daily functioning and quality of life. Great Speech (www.greatspeech.com) is a national virtual speech therapy provider serving children, adults, and seniors through licensed speech-language pathologists. We provide evaluation and treatment for speech and language disorders, autism spectrum disorder, stuttering, aphasia following stroke, traumatic brain injury, Parkinson's disease, Alzheimer's disease and dementia, cognitive-communication disorders, voice disorders, Augmentative and Alternative Communication (AAC), myofunctional therapy, and gender-affirming voice therapy.

Virtual care makes it easier than ever to connect patients with specialized speech therapy, regardless of where they live. If your patient is experiencing communication, cognitive, or neurological challenges that impact daily life, consider referring them to Great Speech. Their experienced clinicians offer flexible scheduling, including evenings and weekends, helping members access timely, high-quality care that improves communication, independence, and overall quality of life.

Refer eligible members to Great Speech for convenient virtual evaluation and treatment.

For referral instructions or additional information, please contact: Great Speech
Contact: 954-820-7400

Email the referral to info@greatspeech.com

Visit our website and request a consult for your patients: www.greatspeech.com

Learn More

Join our Ambetter of North Carolina Provider Insights webinar on September 22 at 12 PM to hear Drew Ben-Aharon, Chief Revenue Officer at Great Speech, discuss how virtual speech therapy can improve patient outcomes and when to consider referrals.

Register Here

Important Prior Authorization Updates - Effective October 1, 2026

Provider Reminder

As we previously mentioned and posted on Ambetter Provider News, as part of our ongoing work to improve the prior authorization (PA) process for both providers and members, Ambetter of North Carolina Inc. wants to share some important updates to our PA requirements. Our goal is to reduce administrative burden, simplify submission and approval processes, and facilitate timely access to appropriate, high-quality care.

Code change details are noted in the table below. The changes may include:

• Removing PA requirements based on criticality of review and clinical need.
• Creating a more uniform set of prior authorization requirements across our markets and lines of businesses, including adding and changing some PA requirements, to simplify processes, reduce confusion for providers, and support future efforts to expand real-time responses to requests.

For questions about specific prior authorization codes or how these changes affect your practice, please reach out to your local Provider Engagement representative.

Clinical Quality Validation and Centene Clinical Action Webinars

CQV/CCA Webinars

Attention Primary Care Providers:

A new webinar is available to help providers learn about accessing and navigating the health plan’s Centene Clinical Action and Clinical Quality Validation tools.

• Centene Clinical Action (CCA): Enables providers with assigned members to view their members’ HEDIS® measures status and claim-related clinical data. It also includes access to COC+.
• Clinical Quality Validation (CQV): Enables providers to efficiently address and electronically submit documentation for open HEDIS quality care gaps within their work queue.
  The webinar is available on demand and can be accessed here.

Ambetter Health Billing Code Update for CPT Codes

80320 - 80377 Effective 10/01/2026
Provider Reminder

As previously posted on Ambetter Provider News, CPT codes 80320-80377 (Definitive Drug Testing Procedures) will no longer be reimbursable effective October 1, 2026.

Providers should continue to bill the appropriate G-series bundled laboratory codes.

If you have questions about this bulletin or other provider resources, please contact your Provider Relations Representative.

Billing Code Update for various HCPC H Codes

Effective 01/01/2027

The H codes outlined below will no longer be covered by Ambetter of North Carolina Inc. beginning on 01/01/2027.

The H code below will be covered by Ambetter of North Carolina Inc. beginning on 01/01/2027.

• HCPC Code H0006

If you have questions about this bulletin or other provider resources, please contact your Provider Relations Representative.

Reminder: Use Paid-through Dates to Verify Member Eligibility

• Active: The member is in good standing and has paid premiums in full.
• Active – Pending Investigation (Availity Only): The member is behind in paying the premium.
• Delinquent (non-Availity Secure Portals Only): The member is behind in paying the premium and the Claims Paid Through Date is in the future.
• Suspended (non-Availity Secure Portals Only): The member is behind in paying the premium and the Claims Paid Through Date is in the past.
• Inactive: The member is ineligible, and coverage has been terminated.