February Provider Newsletter

Date: 02/17/26

Clinical Policy Updates

Ambetter of North Carolina Inc. continuously updates select clinical policies each month.

The following policy updates are effective 4/15/2026.

7 policies were reviewed and approved.

• 1 policy had no changes
• 2 policies were revised making them less restrictive
• 3 policies were revised making the new version both more and less restrictive:
  • CP.MP.185 Skin and Soft Tissue Substitutes for Chronic Wounds
  • CP.MP.247 Transplant Service Documentation Requirements
  • CP.MP.248 Facility-based Sleep Studies for Obstructive Sleep Apnea
• 1 policy was revised making the new version more restrictive:
  • CP.MP.188 Pediatric Oral Function Therapy

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

Radiology Ex Code Change - EXIV to EXuZ

New Denial Code for Certain Radiology Services

To improve clarity, we are updating the denial code used when certain radiology services are billed in a non‑facility setting.

What is changing?
CMS identified specific radiology CPT codes—77385–77387, 77402, 77407, and 77412—that are payable only when performed in a facility setting. Claims for these services submitted with a non‑facility place of service are systematically denied.
 
Previously, these claims denied with:
EXIV – Deny: Invalid Deleted Missing CPT Code
This description caused confusion and did not accurately reflect the reason for denial.
 
Effective immediately, these claims will deny with:
EXuZ – Inappropriate Place of Service for Procedure Code

CP.MP.38 Ultrasound in Pregnancy Policy Revision

Thank you for your continued partnership with Ambetter of North Carolina Inc. As you know, we continually review and update 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. We are writing today to inform you of the revision to existing policies Ambetter of North Carolina Inc. will be implementing effective 04/15/2026.
 

 
Policy Updates and Reason
Coding changes bring policy into alignment with other payer policies. Changes allow payment for 76805 if billed for a second time within a rolling six months [this is the timeframe for the frequency limit that is currently in place for this code] of being billed on a previous claim, if billed by a different TIN than the previous claim with 76805. Add the following ICD-10 codes as payable with CPT code 76811: A93.0, O35.0XX1, O35.0XX2, O35.0XX3, O35.0XX4, O35.0XX5, O35.0XX9, O35.1XX0, O35.1XX1, O35.1XX2, O35.1XX3, O35.1XX4, O35.1XX5, O35.1XX9

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.

Ambetter Health Billing Code Update
for CPT Codes G2211 and G2212 Effective 4/1/2026

CPT codes G2211 & G2212 will no longer be covered by Ambetter of North Carolina Inc. beginning on Apr. 1, 2026.

• CPT Code G2211 is an add-on Medicare code used to bill for the complexity of an office or outpatient visit due to the longitudinal and ongoing nature of the practitioner-patient relationship, not the specific condition itself.
• CPT code G2212 is an add-on Medicare code used to report prolonged office or other outpatient evaluation and management (E/M) services beyond the maximum time of a primary E/M code. This code is submitted in 15-minute increments.

Providers should continue utilizing E&M codes (i.e., 99202–99205, 99211–99215) as appropriate.
 
Click here for a Special Bulletin that was sent out on this update. If you have questions about this bulletin or other provider resources, please contact your Provider Relations Representative.

Updated Evolent Authorization Requirements
Effective April 1, 2026

Effective April 1, 2026, the following procedures will be removed from prior authorization.

The following RADIOLOGY AND DIAGNOSTIC CARDIOLOGY (RBM) codes have been removed from the Evolent’s Utilization Review Matrix and no longer require prior authorization for Ambetter of North Carolina Inc.
 

2026 Premium Grace Periods and Eligibility Verification

Under the Affordable Care Act, Ambetter of North Carolina Inc. provides a three-month grace period for members receiving Advance Premium Tax Credits (APTCs) before coverage is terminated.

Important: For members not receiving APTCs, the standard grace period is 30 days and claims will not be paid during the first month of nonpayment.

Grace Period Timelines for Members Receiving APTCs:
First Month of Non-payment:

• Eligibility verification will indicate the member is delinquent due to nonpayment.
• Claims may still be submitted and will be paid during this period.

Months Two and Three:

• Eligibility verification will show the member as being in a suspended status.
• Claims submitted during this time may be pended or denied, depending on plan rules and payment status.

If full premium payment is not received by the end of the grace period, the member’s policy will be terminated retroactively to the last date for which the premium was paid. The member may be held financially responsible for:

• Any covered services received during the grace period
• Any unpaid premiums

Best practice is to check members’ eligibility before providing services. You can check eligibility, member benefits and cost shares multiple ways.

1. Ambetter of North Carolina Inc.Secure Provider Portal
2.  Use the 24/7 Toll-Free IVR Line Phone: 1-833-863-1310 (TTY: 711)
3. Call Provider Services: 1-833-863-1310 (TTY: 711)

NOTE: When checking status of a member you may see one of the following:

1. Eligible: Member is eligible for services on the date of service
2. Not Eligible: Member is not eligible for services on the date of service
3. Delinquent Premium: Claims will be processed
4. Past Due Premium: Claims may be denied

For more information please refer to the 2026 Provider and Billing Manual (PDF).

Click here to see the Special Bulletin on this subject.

Avoid Common Claim Denials - Quick Tips for Providers

Avoid Common Claim Denials: February Claims Reminders for Providers
To help ensure prompt and accurate claims payment, Ambetter of North Carolina Inc. reviewed claim denials from the past month and identified several recurring issues. In addition to authorization, coverage, and coding-related denials, we have also noticed an increase in claims denied due to missing or invalid taxonomy codes. Many of these denials can be avoided by verifying claim details prior to submission.

Providers are encouraged to review the following frequent denial categories and apply the guidance below when submitting claims.

Most Common Claim Denial Reasons:

1. No record of Prior Authorization for service billed

Use the Ambetter of North Carolina Inc. Pre-Auth Tool to determine whether services require prior authorization. Please note:

• Prior authorizations 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.

1. Denial due to duplicate claim received

Check claim history: these services were likely processed previously under a claim with the same date of service and provider.
To submit 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)

1. Choose the Correct E/M Level

Pick Evaluation and Management (E/M) codes that match the actual service level documented and follow Ambetter of North Carolina Inc.’ s payment policies and clinical guidelines. Coding too high or too low could lead to reduced payments or denial of reimbursement.

1. Service is not a covered benefit in the member’s plan

Providers must verify member eligibility and covered benefits at the time of service and confirm that services are covered under the member’s plan.
Eligibility can be verified via:

• Ambetter of North Carolina Inc. Secure Provider Portal
• Provider Services: 1-833-863-1310

While the portal provides benefit visibility, providers should also review applicable Clinical Policies and prior authorization requirements to confirm whether a service is covered and payable under the member’s specific plan.

1. Invalid or missing taxonomy

Please ensure that:

• Billing and rendering provider taxonomy codes are included on claims
• Taxonomy codes match the provider’s enrollment record and contracted specialty
• Refer to the Taxonomy Reference Guide

*For additional information please refer to the 2026 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.

Provider Access and Availability and Telemedicine

As part of our ongoing monitoring of provider access and availability, and to ensure compliance and improve the experience for your patients, we are providing education, timelines, and expectations. In addition, see the chart below that outlines detailed information based on Visit Type of Appointment Wait Time Standards.

Urgent Care Standards 

• Requirement: Urgent care appointments must be available within 24 hours.
• Expectation: Practices should have clear processes in place to accommodate urgent care needs promptly.
• Next Steps: Please review scheduling workflows to ensure urgent appointment slots are consistently available.

Access and Availability Standards

• Ambetter of North Carolina Inc. follows the accessibility requirements set forth by applicable regulatory and accrediting agencies. Ambetter of North Carolina Inc. monitors compliance with these standards on an annual basis and will use the results of appointment standards monitoring to first, ensure adequate appointment availability and second, reduce unnecessary emergency department utilization. Providers who fail to comply with published appointment standards may be subject to corrective action. This information can also be found in the Provider Manual.

After-Hours Access

• Requirement: Providers are required to maintain after-hours access for patients.
• Expectation: An answering service or recorded message must be available when the office is closed. Messaging must provide instructions for reaching an on-call clinician or accessing urgent care. Limited hours or voicemail without appropriate messaging does not meet the standard.

24-Hour Access to Providers

• PCPs and specialist providers are required to maintain sufficient access to needed health care services on an ongoing basis and must ensure that such services are accessible to members as needed 24 hours a day, 365 days a year. After hours passing standards include
  • Answering service or system that will page physician
  • Answering system with option to page physician
  • Advise nurse with access to physician
• The selected method of 24-hour coverage chosen by the provider must connect the caller to someone who can render a clinical decision or reach the PCP or specialist provider for a clinical decision. Whenever possible, PCP, specialist providers, or a covering professional must return the call within 30 minutes of the initial contact. After-hours coverage must be accessible using the medical office’s daytime telephone number. Ambetter of North Carolina Inc. will monitor provider’s compliance with this provision through scheduled and unscheduled visits and audits conducted by Ambetter of North Carolina Inc. staff. View the Provider Manual for additional details.

                                                           
Virtual 24/7 Care

Ambetter of North Carolina Inc., offers options that are not limited to certain hours of the day or even in-person appointments. Your patients can get the care they need when they need it with the options listed below:

Virtual Urgent Care
Help is available and fast, 24/7 with on-demand health care providers that can treat over 100 non-emergency illnesses and injuries, all without an appointment.
 
Virtual Mental Health
Do therapy from home. Patients can connect with a therapist or psychiatrist who can help with their mental health needs like:

• Anxiety and Depression
• Addiction
• ADHD
• Grief and Loss
• Stress Management
• Trauma and PTSD
• Aging and Caregiver Support
• And much more

Virtual Dermatology
Help for all things skin related. Board-certified dermatologists can help with conditions like:

• Acne
• Eczema
• Psoriasis
• Rashes
• Rosacea
• Skin Infections
• Suspicious moles
• And much more

Virtual Speech Therapy
With Ambetter of North Carolina Inc., your patients are able to find and work with a speech therapist to create unique therapy plans that help with:

• Articulation
• Autism Spectrum Disorder
• Executive Function Disorder
• Voice & Language Disorders
• Parkinson’s Disease
• Stroke and Traumatic Brain Injury
• Stuttering
• And more

Patients can get the care they need, when they need it. Explore options here: https://www.ambetterhealth.com/en/nc/health-plans/our-benefits/ambetter-telehealth/

Thank you for your immediate attention to these requirements and for your continued partnership in providing timely, high-quality care to our members. Please reach out if you have any questions.