News
Q2 2022 PROVIDER NEWSLETTER
Date: 05/23/22
UM Guidelines Update: Leg Stent Coding Updates
Ambetter of North Carolina Inc. is reinforcing the prior auth review for Leg Stent Coding with an effective date as of August 1, 2022.
Summary of Policy:
Ambetter of North Carolina Inc. is reminding providers to provide complete supporting clinical records, including clinical notes, for prior authorization requests for the following vascular codes, which require a medical necessity review.
CPT Description | CPT CODE |
|---|---|
ILIAC REVASC | 37220 |
ILIAC REVASC W/STENT | 37221 |
FEM/POPL REVAS W/TLA | 37224 |
FEM/POPL REVAS W/ATHER | 37225 |
FEM/POPL REVASC W/STENT | 37226 |
FEM/POPL REVASC STNT & ATHER | 37227 |
TIB/PER REVASC W/TLA | 37228 |
TIB/PER REVASC W/ATHER | 37229 |
TIB/PER REVASC W/STENT | 37230 |
TIB/PER REVASC STENT & ATHER | 37231 |
What does this mean for providers?
Providers are currently required to submit all pertinent clinical records when submitting a prior authorization request for these 10 codes.
New Resources for Providers Participating in the Continuity of Care Program
Continuity of Care Program Booklet (PDF)
Continuity of Care Training (PDF)
2022 Continuity of Care Program
PROGRAM STARTS FEBRUARY 2022
Ambetter of North Carolina is committed to supporting your efforts to provide the highest quality care to our members. As a result, we are excited to announce that our Health Plan will launch a Continuity of Care (CoC) program effective February 2022. This initiative incorporates Appointment Agendas, HEDIS measures, and pharmacy metrics into one comprehensive program.
Appointment Agenda
The CoC program is designed to support your outreach to members for annual visits and condition management, which will help us better identify members who are eligible for case management. The program achieves this goal by increasing visibility into members’ existing medical conditions for better quality of care for chronic condition management and prevention. Providers earn bonus payments for proactively coordinating preventive medicine and for thoroughly addressing patients’ current conditions to improve health and clinical quality of care. Our members benefit from this program by receiving more regular and proactive assessments for their chronic conditions. The CoC program is in addition to Ambetter of Nortch Carolina's other provider bonus programs and does not replace them.
Providers are eligible for a bonus for each completed Appointment Agenda (disease conditions / continuity of care portion only) with verified / documented diagnoses.
| Percent of appointment agendas completed | Bonus amount paid per appointment agenda |
|---|---|
| <50% | $100 |
| ≥50% TO <80% | $200 |
| ≥80% | $300 |
Quality Improvement
As part of the NCQA requirement, Ambetter of North Carolina Inc. is conducting a provider access and availability audit utilizing the vendor Faneuil.
Who is Faneuil? Faneuil 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.
What is Access and Availability surveys (audit)
“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.).
How often are these A&A survey/audits conducted for Ambetter of North Carolina Inc. - NCQA requires annual reviews but in some situations, they may be done semi-annually.
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 with Ambetter of North Carolina Inc.?
Current Market Standards meet 90% | |
|---|---|
| Appointment Standards |
PCP | Urgent Care ≤ 24 Hours (AMB) |
PED | Urgent Care ≤ 24 Hours (AMB) |
Specialist | Urgent Care ≤ 24 Hours (AMB) Routine Care ≤ 30 Calendar Days |
NCQA OBGYN | Prenatal Care ≤ 14 Calendar Days |
NCQA Oncology | Urgent Care ≤ 24 Hours (AMB) Routine Care ≤ 30 Calendar Days |
Behavioral Health | Urgent Care ≤ 48 Hours (AMB) Non-Life Threatening ≤ 6 Hours (AMB) |
CMS Guidance for Telehealth Coding
Reminders for Place of Service and Modifiers when billing telehealth:
- POS 02: Telehealth Provided Other than in Patient’s Home Descriptor: The location where health services and health related services are provided or received, through telecommunication technology. Patient is not located in their home when receiving health services or health related services through telecommunication technology.
- POS 10: Telehealth Provided in Patient’s Home Descriptor: The location where health services and health related services are provided or received through telecommunication technology. Patient is located in their home (which is a location other than a hospital or other facility where the patient receives care).
New Modifiers For 2022
- 95- For counseling and therapy provided using audio-video telecommunications
- FQ- For counseling and therapy provided using audio-only telecommunication
For more information, view the CMS Guidance: New/Modifications to the Place of Service (POS) Codes for Telehealth.
Reminder: Updating/Correcting Provider Demographic Information
Ambetter of North Carolina Inc. believes that providing easy access to care for our members is extremely important. When information about your practice, your locations, or your practitioners changes, please provide timely updates to Ambetter of North Carolina Inc.. Ambetter of North Carolina Inc. will ensure that our systems are updated quickly to provide the most current information to our members.
By calling Provider Services at 1-833-863-1310 providers will be able to access real time assistance for all their service needs.
Provider may also request and submit rosters by emailing:
If while viewing the Provider Directory you notice incorrect information, please submit a correction using the 'Suggest an Edit' button under the demographic information:
See a problem with this data? Suggest an edit.
2022 Prescription Drug List
The Ambetter of North Carolina Inc. Formulary, or Prescription Drug List (PDL), is a guide to available brand and generic drugs that are approved by the Food and Drug Administration (FDA) and covered through your prescription drug benefit. The 2022 PDL is available online:
https://www.ambetterofnorthcarolina.com/provider-resources/pharmacy.html
Have you completed your onboarding training?
During the New Provider Orientation, we will discuss the following:
- Ambetter benefits
- Verification of Eligibility and benefits
- Accessing the public website and secure web portal
- Prior Authorizations
- Claims
- Provider Billing Manual and Provider Tool kit
Ambetter of North Carolina Inc. holds New Provider Orientations monthly on the third Tuesday at 12PM.
After registering, you will receive a confirmation email containing information about joining the meeting.
Ambetter of North Carolina Inc. also has an on-demand option for your New Provider Orientation.
- View the recording
Once you complete an orientation, please submit your attestation.