News
Q4 2021 PROVIDER NEWSLETTER
Date: 11/30/21
Ambetter of North Carolina Inc. is expanding!
26 counties are being added to the Ambetter of North Carolina Inc. coverage map for the year ahead.
Ambetter of North Carolina Inc. is now available to residents in 58 counties through the federal Health Insurance Marketplace.
Coverage Area Map: Better Healthcare is Just Around the Corner.
Reminder: 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 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.
Clinical and Payment Policy Updates
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. Ambetter of North Carolina Inc. will be implementing and/or updating the following policies effective March 1, 2022:
Policy Number | Policy Name | Policy Description | Line of Business | New or Revised Policy - Effective 3.1.22 |
|---|---|---|---|---|
CP.MP.97 | Testing for Select GU Conditions | Added procedure codes to list of non-payable codes. Removed all edits applicable to CPTs 83986 and 87210 and removed some diagnostic codes as payable | Marketplace | Revised policy-Less Restrictive |
CC.PP.055 | Physician’s Office Lab Testing | Removed CPT 87800 | Marketplace | Revised policy-Less Restrictive |
CP.PHAR.176 | Paclitaxel Protein-bound | Add the following diagnosis codes as payable with the following procedure codes: 96413, 96415, and J9264: C50.911, C50.912, C50.921, C50.922, C69.31, C69.32, C69.41, C69.42, Z85.068, Z85.840 | Marketplace | Revised policy-Less Restrictive |
CP.MP.38 | Ultrasound in Pregnancy | Changed allowed number of transvaginal ultrasounds in pregnancy within 6 months to 13. | Marketplace | Revised policy-Less Restrictive |
CP.MP.100 | Allergy Testing | Add code J30.0 as payable with CPT 86003, 86005, 86008, 95004, 95017, 95018, 95024, 95027, 95028 | Marketplace | Revised policy-Less Restrictive |
CP.MP.209 | Gastrointestinal Pathogen Nucleic Acid Detection Panel Testing | Restricts reimbursement of GI pathogen panels with 12+ targets to only inpatient settings, including inpatient, ED, and outpatient hospitals. | Marketplace | New Policy |
CC.PP.071 | Evaluation and Management Services Billed with Treatment Rooms | Disallows E&M services in treatment rooms as this does not represent a treatment type of service. | Marketplace | New Policy |
A full listing of policies can be found on Ambetter of North Carolina Inc.’s web site.
Visit Provider Resources for the newly updated 2022 Provider and Billing Manual!
Self-Administered Lab Screenings Mailed Directly to the Member's Home
The Visiting Physicians Association (VPA) LAB2U Program is designed to close gaps in care and improve HEDIS® measures and CAHPS® scores. The results of these tests can help members stay healthy, manage their long-term chronic illness, improve their experience with the plan, and reduce the cost of care.
For more information and additional Provider News, visit our website!
Pre-Authorization Check Tool
The Pre-Authorization Tool available online is an interactive tool that will help you determine whether a PA is required for a service or procedure. You will find this tool under 'For Providers' at www.ambetterofnorthcarolina.com.
This tool will also point you towards our partners for prior authorization management:
- Oncology/supportive drugs need to be verified by New Century Health.
- High Tech Imaging services are handled by NIA.
- Speech, Occupational and Physical Therapy need to be verified by NIA
For all other authorizations, the preferred method for submitting authorizations is through the Secure Provider Portal at provider.ambetterofnorthcarolina.com. Once you submit your Prior Authorization request, the quickest method to check authorization status is through the Secure Provider Portal.
Vendors for Pre-Authorization Programs:
Radiology and Specialty Therapies:
Effective January 2019, Ambetter of North Carolina Inc. has selected National Imaging Associates, Inc. (NIA) to implement a radiology benefit management program for outpatient advanced imaging services. Effective January 2021, Ambetter of North Carolina Inc. will also work with National Imaging Associates (NIA) for the Utilization Management of outpatient rehabilitative and habilitative Physical Medicine services (Physical, Occupational, and Speech Therapy).
Oncology/Supportive Drugs:
Beginning November 1, 2021, all oncology-related infused, oral chemotherapeutic drugs/supportive agents, and radiation treatments will require a prior authorization from New Century Health (NCH) before being administered in either the provider’s office, outpatient hospital, ambulatory setting, or infusion center. This requirement applies to Ambetter of North Carolina members of all ages
For more information and a list of medication this impacts, please view the August 10th news bulletin