Ambetter of North Carolina Inc. Provider Bulletin

Date: 11/05/24

Health Care Help for Members Affected by Hurricane Helene

Ambetter of North Carolina has services in place to help members impacted by Hurricane Helene. More details can be found online.

• Ambetter of North Carolina is suspending policy cancellations and non-renewals for 30 days, effective September 30, 2024, for members in counties affected by Hurricane Helene.
• Members can get assistance replacing lost medicines, medical equipment, or ID cards by contacting Member Services.
• Ambetter Health is temporarily pausing mail communications to impacted counties until October 31, 2024.
• A 24/7 Nurse Advice and Crisis Line is available for medical questions, urgent care, crisis support, or mental health needs.
• Assistance is available for finding healthcare providers if members have evacuated or if local providers are unavailable due to the storm.

Stay tuned to Provider News for updates. 

Network Updates as of 1/1/25

Ambetter Virtual Access

• Ambetter of North Carolina Inc. is grateful for your participation in our Ambetter Virtual Access plan and the care you provide our members. Each year, we conduct a comprehensive review of our market operations and footprint to best align our network strategy and resources. As of Jan. 1, 2025, the Ambetter Virtual Access plan in North Carolina will be discontinued. We are committed to ensuring you have all the resources available to make this transition as smooth as possible for you and your patients. Our other Ambetter offerings will still be available in North Carolina.  
• Members will be notified about this change in the coming months and may be given alternative Ambetter of North Carolina Inc. options.

Network Name Change

• As of Jan. 1, 2025, the Bronze | Silver | Gold network will be renamed to the PREMIER network. We are committed to ensuring you have all the resources available to make this transition as smooth as possible for you and your patients.
• Members will be notified through various upcoming notifications and will see this change on Ambetter Guide.

While our plan offerings are changing, our commitment to delivering quality care and services to our members is unwavering. Thank you for your continued partnership as we work to transform the health of the communities we serve, one person at a time.

Provider Appointment Standards for Scheduling

Appointment Access and Availability Survey

As part of the NCQA requirement, Ambetter of North Carolina Inc. conducts an annual provider access and availability audit utilizing the vendor Press Ganey. In the coming weeks, you may be contacted by Press Ganey to conduct this survey. Press Ganey is a third-party vendor which Ambetter of North Carolina Inc. has contracted with to conduct the annual survey/audit for Access and Availability. They are acting on behalf of Centene corporation to obtain the information needed for NCQA.

Why is this important?

The Access and Availability audit is required by NCQA (National Committee for Quality Assurance) to assess or measure availability and timeliness of provider appointments. The survey has a few questions which we are looking for providers offices to answer around the wait times for making an appointment and getting timely access to providers. These questions are based around specific appointment types. (routine, urgent, PCP, specialist, Behavioral Health, etc.).

Will provider offices see the results?

Provider will receive failure letters if they have not passed the required standards for appointment access and availability. These letters will have areas to focus on for improvement.

What are the standards NCQA is looking for?

To ensure our members receive services for medical and behavioral health appointments in a timely manner, below are the 2025 Appointment Availability Standards we ask our providers to implement accordingly.

• Access and Availability standards for 2024 can be found in the 2024 Provider Manual (PDF) beginning on page 23.
• NCQA has updated the standards for 2025. Please view the below and also our Provider Guide on Appointments Standards for Scheduling (PDF). These changes will also be in the 2025 Provider Manual.

24-Hour Access to Provider

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
• Answering service that will page the provider after a message is left

View the Provider Manual for additional details.

Telemedicine

Expanded use of telemedicine across all practitioner types helps to create alternative and additional access to care for members.

Physicians at the distant site may bill for telemedicine services and MUST utilize the appropriate modifier and place of service to identify the service was provided via telemedicine.

• E&M CPT plus the appropriate modifier. ­
• Via interactive audio and video telecommunication systems.

2025 Updated NCQA Standards

• PCP routine visit access standard changed from 30 calendar days to 15 business days.
• Specialist routine visits changed from 30 calendar days to 30 business days
• Behavioral Health initial visit changed from 14 calendar days to 10 business days.