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June 2026 Newsletter

Date: 06/15/26

Clinical Policy Updates

Ambetter of North Carolina Inc. continuously updates select clinical policies each month. The following policy updates are effective 8/15/26.

33 policies were reviewed and approved.
  • 13 policies had no changes
  • 6 policies were revised making them less restrictive
  • 11 policies were revised making the new version both more and less restrictive:
    • 2025.2 Concert Genetic Testing: CG Multisystem Genetic Conditions
    • CP.MP.102 Pancreas Transplant
    • CP.MP.136 Home Births
    • CP.MP.162 Tandem Transplant
    • CP.MP.184 Home Ventilators
    • CP.MP.55 Assisted Reproductive Technology
    • CP.MP.57 Lung Transplantation
    • CP.BH.105 ABA Documentation Policy
    • CP.BH.104 Applied Behavior Analysis
    • CP.BH.200 Transcranial Magnetic Stimulation for Treatment Resistant Major Depression
    • CP.BH.201 Deep Transcranial Magnetic Stimulation for the Treatment of Obsessive Compulsive Disorder
  • 1 policy was revised making the new version more restrictive:
    • CP.MP.132 Heart-Lung Transplant
  • 1 policy was created
    • CP.MP.252 Immobilized Lipase Cartridges (Relizorb)
  • 1 policy was reviewed
    • CP.CPC.03 Preventative Health and CPG
This page reflects upcoming clinical policy changes. Revision notes are made available in the policy document.

Update for HCPCS Codes G0482 and G0483

In alignment with Clinical Policy CP.MP.50, Drugs of Abuse: Definitive Testing, which is currently in effect, the following HCPCS codes are no longer reimbursable.
  • Code G0482:
    Drug test(s), definitive, utilizing (1) drug identification methods able to identify individual drugs and distinguish between structural isomers (but not necessarily stereoisomers), including, but not limited to, GC/MS (any type, single or tandem) and LC/MS (any type, single or tandem) excluding immunoassays (e.g., IA, EIA, ELISA, EMIT, FPIA) and enzymatic methods (e.g., alcohol dehydrogenase), (2) stable isotope or other universally recognized internal standards in all samples (e.g., to control for matrix effects, interferences and variations in signal strength), and (3) method or drug-specific calibration and matrix-matched quality control material (e.g., to control for instrument variations and mass spectral drift); qualitative or quantitative, all sources, includes specimen validity testing, per day; 15 to 21 drug class(es), including metabolite(s) if performed.
     
  • Code G0483:
    Drug test(s), definitive, utilizing (1) drug identification methods able to identify individual drugs and distinguish between structural isomers (but not necessarily stereoisomers), including, but not limited to, GC/MS (any type, single or tandem) and LC/MS (any type, single or tandem) excluding immunoassays (e.g., IA, EIA, ELISA, EMIT, FPIA) and enzymatic methods (e.g., alcohol dehydrogenase), (2) stable isotope or other universally recognized internal standards in all samples (e.g., to control for matrix effects, interferences and variations in signal strength), and (3) method or drug-specific calibration and matrix-matched quality control material (e.g., to control for instrument variations and mass spectral drift); qualitative or quantitative, all sources, includes specimen validity testing, per day; 22 or more drug class(es), including metabolite(s) if performed.
Codes G0480 and G0481 are considered covered benefits when medical necessity is indicated.
If you have questions about this bulletin or other provider resources, please contact your Provider Relations Representative
 

Reminder! Our 2026 Provider Satisfaction Survey is Out Now


As mentioned in our prior newsletter, our 2026 annual provider satisfaction survey launched in April. You may have received this survey via email and we would greatly appreciate your time to provide feedback.

Your perspective is a critical element in recognizing and solving issues that are priority to all of you, so that we can work together to seamlessly care for all members.

These surveys are open now until June 26, 2026. We appreciate your time and effort to help make sure we work together for the best results possible. Thank you!
 

Ambetter of North Carolina Inc. Member Programs and Perks

Ambetter of North Carolina Inc. Member Programs and Perks

Providers can help members get more value from their Ambetter of North Carolina Inc. benefits by recommending these programs at the point of care. Consider referencing the options below during preventive visits, chronic condition follow-ups, and when members need support with healthy lifestyle changes.

Featured Programs:

YMCA Membership: Ambetter of North Carolina Inc. members may be eligible for a YMCA membership at participating locations, including access to virtual wellness resources. Benefits may include fitness facilities, group exercise classes, wellness programs, and family-focused activities that support healthy lifestyles. Members can confirm eligibility, activate their YMCA membership, and find participating locations on the Ambetter of North Carolina Inc. website or the North Carolina YMCA page.

My Health Pays® Rewards Program: My Health Pays® rewards members (up to $500) for completing eligible healthy activities. How members can earn rewards:
  • Complete an Annual Wellness Visit
  • Get qualifying screenings
  • Participate in online challenges and power-ups
  • Watch educational videos
Member enrollment and activation:
  1. Log into your Online Member Account or via the Ambetter Health App.
  2. Accept the My Health Pays terms and conditions.
  3. Complete the first My Health Pays challenge to earn your first reward!
Members may apply rewards toward eligible expenses such as rent, utilities, telecommunications, transportation, education, childcare, healthcare costs, and monthly premium payments.

Ambetter Member Perks 

Ambetter Perks go beyond just health and wellness savings. Members have access to deals on everything from mortgages to movie tickets. A few ways members can save:
  • Restaurants and entertainment
  • Travel and technology
  • Fitness memberships and programs (e.g., Anytime Fitness, Jazzercise)
  • Healthy meal options (e.g., Home Chef)
  • Dental savings offers (e.g., Aspen Dental)
Members can log in to the Ambetter of North Carolina Inc. Member Portal or Ambetter Health app to browse and redeem available discounts.
 

Scan the QR code to see more on Ambetter of North Carolina Inc. perks!!
 

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.
H0003H0004H0005H0007H0008H0009
H0010H0011H0012H0013H0014H0016
H0019H0021H0024H0026H0027H0028
H0029H0030H0034H0037H0039H0040
H0041H0042H0043H0044H0045H0046
H0047H1011H2001H2010H2011H2012
H2013H2015H2016H2018H2021H2022
H2028H2029H2030H2031H2032H2033

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

Verifying member eligibility is more important than ever as members are being affected by Marketplace changes.

Members enrolled in a Marketplace health plan are responsible for completing their premium payments each month. Members that do not make their premium payments in a timely manner enter a Grace Period, which begins with the first month a payment is missed and generally continues for 90 days when a member is receiving a premium subsidy.
 
When a member does not pay all outstanding premiums within the grace period, coverage may be retroactively terminated to an earlier date, and previous claims may be denied. Providers are encouraged to proactively confirm an Ambetter Health member’s status on the date of service or as close to the date of service as possible. Click here review step-by-step instructions on confirming a member’s eligibility status.

Please keep in mind the various status reasons in the Centene Provider portal and Availity.
  • 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.
Verifying member eligibility helps reduce denied claims, minimizes the administrative burden on your staff, and clarifies when payment may be collected from the member in advance of services. When checking eligibility, please be sure to verify the member eligibility status, the premium paid through date, and the claims paid through date.