December 2025 Provider Newsletter

Date: 12/17/25

Marketplace 2026 Open Enrollment

Starting November 1, 2025, Marketplace members can apply for 2026 coverage or update their application with any changes they expect in the year ahead.

Important dates:

• November 1: Open Enrollment starts — first day members can enroll in, renew, or change health plans through the Marketplace for the coming year. Coverage can start as soon as January 1.
• December 15: Last day to enroll in or change plans for coverage to start January 1.
• January 1: Coverage starts for those who enroll in or change plans by December 15 and pay their first premium.
• January 15: Open Enrollment ends — last day to enroll in or change Marketplace health plans for the year. After this date, members can enroll in or change plans only if they qualify for a Special Enrollment Period.
• February 1: Coverage starts for those who enroll in or change plans December 16 through January 15 and pay their first premium.

For more information visit: https://www.healthcare.gov/quick-guide/dates-and-deadlines/

Clinical Policy Updates

Ambetter of North Carolina Inc. continuously updates select clinical policies each month.
The following policy updates are effective 2/15/2026.

16 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.61 IV Moderate and IV Deep Sedation and Gen Anesthesia for Dental Procedures
  • CP.BH.104 Applied Behavior Analysis
• 3 policies were revised making them more restrictive
  • CP.MP.107 DME
  • CP.MP.202 Orthognathic Surgery
  • HIM.NC.CP.MP.95 Gender Affirming Procedures
• 1 policy was developed:
  • CP.MP.251 Radiation Therapy for Skin Cancer

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

2026 Ambetter of North Carolina Inc. Provider and Billing Manual

Dear Provider,

The 2026 Ambetter of North Carolina Inc. Provider and Billing Manual is now available online:
ambetterhealth.com/en/nc/provider-resources/manuals-and-forms/

Please review the updated manual here. Revisions are noted on page 7 of the manual..

Please reach out to your Provider Engagement Administrator with questions.

Thank you!

Care Talks Lunch and Learn: Health Equity Session Recap

Ambetter of North Carolina Inc., in partnership with Carolina Complete Health, recently hosted a Care Talks Live: Lunch and Learn session focused on advancing health equity in clinical practice.

During the session, providers explored how clinical leaders can influence equitable care delivery by addressing cultural and linguistic needs and removing barriers that impact our members’ health. Key topics included:

• CLAS standards and cultural competency
• Language services
• CCH Health Equity Framework
• Social Determinants of Health
• Resources and strategies to embed equity and CLAS considerations into daily practice

If you were unable to attend or would like to revisit the material, you can access the resources below:

Presentation Slides: Care Talks Slides (PDF)
Webinar Recording: Recording (Nov 12, 2025)

For additional information on Health Equity visit our Ambetter of NC Inc. Provider Resources Webpage.

Important Billing Code Update for CPT Code 0449U

Effective January 1, 2026

Please Note:

CPT Code 0449U will no longer be a covered benefit as of January 1, 2026.

The breakdown of this code is as follows:

• This is a Proprietary Laboratory Analysis (PLA) code that is only utilized by one provider.
• Similar services are available through in-network labs, such as Quest and LabCorp.

If you have questions about this bulletin or other provider resources, please contact Provider Services at 1-833-863-1310.

Avoid Common Claim Denials - Quick Tips for Providers

Top Claim Denials and How to Avoid Them

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.

1. EXy1 DENIED: SERVICES RENDERED BY NON AUTHORIZED NON PLAN PROVIDER

Provider Guidance:

• The claim was submitted for services performed by a provider or facility that is not contracted, not enrolled, or not authorized with Ambetter to deliver the billed services on the date of service. A provider may resubmit if they became credentialed during the DOS or if an authorization was approved.
• To request to join the Ambetter Network please use Network Participation Request Form
• To add a new facility to an existing contracted practice, download and complete the Ambetter of North Carolina Inc. Facility Roster Template and send to AmbetterNCProviderDirectoryRequest@CENTENE.COM.
• To add a new practitioner to your practice download and complete Ambetter Practitioner Roster Template and send to AmbetterNCProviderDirectoryRequest@CENTENE.COM

2. EX29 DENY: THE TIME LIMIT FOR FILING A CLAIM HAS EXPIRED

Please see Timely Filing standards below:

Timely Filing

3. EXL6 DENY: BILL PRIMARY INSURER 1ST RESUBMIT WITH EOB

Provider Guidance:

• Submit the claim to the members primary insurance first. Obtain the EOB and resubmit the claim. If the member did not have OIC during DOS, you should update the COB in the Ambetter Provider Portal or the member can call 1-833-863-1310 to have it updated. The call center will submit a request to have OIC updated.

4. EXm3 DRG PAID. ITEMIZED BILL REQUIRED FOR INTERNAL CLAIM REVIEW

Provider Guidance:

• Please submit an itemized bill that includes a detailed breakdown of all medical services, procedures, and supplies, along with the associated charges for each item. This documentation is required to complete the internal claim review for DRG-paid claims.

5. EXx8 MODIFIER INVALID FOR PROCEDURE OR MODIFIER NOT REPORTED

Provider Guidance:

• Please review 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)

6. 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)

7. 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 deny.
• If additional procedures are performed during the procedure, the provider must contact the health plan to update the authorization to avoid a claim denial.

8. EX28 DENIED: MEMBER NOT ELGIBILE WAS NOT EFFECTIVE ON THE DATE 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.

9. EXx9 PROCEDURE CODE PAIRS INCIDENTAL, MUTUALLY EXCLUSIVE OR UNBUNDLED

Provider Guidance:

• Mutually exclusive procedures where only one of the reported services is reimbursable.Unbundling, which is the inappropriate separation of services that are already included in a more comprehensive code. If the provider disagrees with the denial, submit a corrected claim with correspondence attached for review to determine if the services were medically necessary.
• 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.

*For additional information please refer to the 2025 Provider and Billing Manual (PDF) and the Ambetter of NC Inc. Provider Resources Webpage.

Need help?

Call : 1-833-863-1310 (Relay 711) or email your Provider Relations Coordinator, NetworkRelations@cch-network.com

Important Prior Authorization Updates Effective Feb. 1, 2026

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 can be found below. These 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.
  If you have questions about specific prior authorization codes or how these changes affect your practice, please reach out to your local Provider Engagement representative.