Q4 2023 PROVIDER NEWSLETTER

Date: 11/22/23

Ambetter of North Carolina Inc. will Expand  to New Hanover and Pender in 2024!

Ambetter of North Carolina Inc. adds New Hanover and Pender counties to the coverage map in 2024! View a list of all counties covered in 2024

Since launching in 2019, Ambetter of North Carolina Inc. has been very successful in attracting and retaining our target population, and we continue to focus on engaging and acquiring these subsidy-eligible consumers through:

• Network Design: Focusing on partners that are in our members’ communities.
• Incentive Programs: Incentivizing healthy behaviors with rewards that members find valuable, such as allowing members to earn money toward premiums or copays by completing activities like getting their annual wellness checks.
• Outreach and Marketing: Performing meaningful outreach and educating consumers and providers on the covered benefits of health insurance.Welcome New Hanover and Pender County providers!

Ambetter Virtual Access is also expanding to New Hanover and Pender counties on January 1, 2024!

Ambetter Virtual Access features a PCP-centric approach to care delivery. Primary care physicians (PCPs) coordinate our members’ medical care, as appropriate, either by providing treatment or by issuing referrals to other in-network providers. Services must be provided by or referred by a PCP to be covered. The only exclusions from this requirement are emergency care, urgent care, and in-network mental health, behavioral health, and obstetrical or gynecological services.

Ambetter Virtual Access provides adult members (ages 18+) with unlimited virtual primary care services for both medical and behavioral health benefits through Teladoc. This simplifies our members’ healthcare journey by offering:

• A PCP-Centric Network: Members are automatically assigned to a Virtual Teladoc PCP upon enrollment but may switch to a different Virtual Teladoc PCP or a traditional (in-person) in-network PCP, if they wish.
• Trusted Referrals for Care: PCPs help navigate care needs by providing appropriate referrals to other in-network providers for any other non-virtual care services needed, excluding emergency or urgent care services. Referrals are also not required for in-network mental or behavioral health services, obstetrical or gynecological services.

Your current network participation agreement with Ambetter of North Carolina Inc., grants you automatic participation in this new network. There is no action needed on your part at this time. Once live, you may receive referrals from other Ambetter Virtual Access providers or be selected as a PCP by an Ambetter Virtual Access member.

In the coming months, we will share more information and resources to help you prepare to see Ambetter Virtual Access members alongside your other Ambetter members. If you have any questions about Ambetter Virtual Access, please call 1-833-863-1310 (Relay 711).

New Claims Provider Guide: Upfront Rejections

Ambetter of North Carolina Inc. analyzed claims data submitted by providers to identify the top five claims rejection reasons. This provider guide will share billing guidance to assist in reducing up-front claims rejections. 

• NEW: Claims and Billing Provider Guide - Upfront Rejections (PDF)

2024 Provider Manual Update

The 2024 Provider and Billing Manual for Ambetter of North Carolina Inc. is now published to the Provider Resources webpage. A notable update for calendar year 2024 include details on National Imaging Associates providing utilization management for Interventional Pain Management (IPM) services for Ambetter of North Carolina Inc members, which launched June 1, 2023. Clarification was made to the Utilization Determination Timeframes table in addition to other updates throughout.

Epic Payer Platform

We are pleased to be participating in Epic Payer Platform, a platform that enables more secure, efficient bi-directional data exchange between providers and health plans, as part of our broader interoperability strategy.

How does Epic Payer Platform benefit you?

Epic Payer Platform benefits providers by reducing friction, combining knowledge to improve care, and ultimately improving the patient experience. It is available for health systems and providers on Epic.

What are the features of Epic Payer Platform and how do they help?

• In our initial work with Payer Platform, we are live with clinical data exchange, which automatically releases appropriate clinical records to health plans. This helps reduce manual record requests, reducing administrative burden for providers.
• Following our initial work on risk adjustment, we intend to focus on HEDIS/Quality use similarly, receiving information from Epic Payer Platform to improve the accuracy of quality measurement, also reducing manual records requests.
• We plan to develop additional features and continue to refine our roadmap:
  • Actionable insights (such as our members’ gaps in care and historical conditions and diagnoses) can be provided at the point of care directly into a clinician’s existing workflow. This helps our provider-partners receive a more complete picture of their patients to help improve their quality of care.
  • Plans to pilot prior authorization can help streamline the process and further reduce administrative frictions involved.

How do I learn more?

• For more information on risk adjustment use cases, please contact Jennifer Holman at Jennifer.l.holman@centene.com
• For other information about Epic Payer Platform, please contact: epic_emr_integration@CENTENE.COM

Open Enrollment Reminder and Provider Portal Tips: Viewing your Panel and Checking Member Eligibility

Open Enrollment started on November 1st and ends on January 15th. Ambetter of North Carolina Inc. offers a variety of affordable options to help fit the needs and budget of our members. As this is a time where members' marketplace insurance may change, providers can continue to view the Ambetter of North Carolina Inc. panel using the provider portal and continuously check member eligibility. 

Viewing your patient list:

Primary Care Providers are able to view and download a list of their assigned members. The Patient List displays:

• Member Name
• Member ID #
• DOB
• Preferred language
• Eligibility status
• Phone number
• Alerts

Tips:

• Click on a member’s name to access their eligibility, health record, etc. information
• Patients list can be exported to excel for more filtering options

Checking member eligibility:

On the landing page of the provider portal, you can check member eligibility under Quick Actions: Within Eligibility Check results, the Patient Overview displays patient demographic, claims, authorizations and other pieces of information. It can be used to identify Care Gaps, view ER visits, and PCP history.

Eligibility Check Tips:

• When checking eligibility, if the member does not pull up, verify data entered
• If Member ID + DOB does not pull up the member, try Member Last Name + DOB
• As best practice, always check member eligibility before creating a web authorization or web claim 

Coming Soon in 4th Quarter! Enhancements to the 835

• Providers will be able to auto-reconcile and auto-post using the Provider Level Balance (PLB) segment within the 835.
• The Trace Number and Patient Control Number will be listed on each PLB segment for the creation of a negative balance, a partial offset, & final offset.
• The update will allow our providers to auto-reconcile on a go-forward basis once the enhancement is moved into production in Q4 2023, reducing the need for negative balance reports for future offsets and recoupments.

Important Pharmacy Claims Processing Change, Effective January 1, 2024

We are pleased to announce that, effective January 1, 2024, Express Scripts® will begin processing pharmacy claims for our plan members.

Express Scripts is a pharmacy benefit management (PBM) company serving more than 100 million Americans. Express Scripts Pharmacy delivers specialized care that puts patients first through a smarter approach to pharmacy services.

Members have been notified in advance and will receive a new ID card with updated pharmacy information, so that they are prepared to begin having their prescriptions filled at participating network pharmacies when this change occurs.

Providers can direct members to call the Member Services phone number listed on their ID card should they have questions about this change.

View the Express Scripts Transition FAQ for more information!

Helping you Care for your Patients is our Top Priority

Strong communication and trust between you and your patients will help ensure they are satisfied and have good outcomes. You can rely on Ambetter of North Carolina Inc. for information and support to help you keep those patient relationships strong.

Annual CAHPS Survey

Happening February Through June
The Consumer Assessment of Healthcare Providers and Systems (CAHPS) Health Plan Survey is an opportunity for your patients to share their healthcare experiences with you as their provider and with their health plan. Your patients are asked specific questions, which include how well their doctor communicates, if they felt their doctor listened to them, and if their doctor explained things in a way that was easy to understand. Also included are questions on how well different healthcare providers are communicating about care coordination and a (0-10) rating of the patient’s overall satisfaction with their healthcare, personal doctor, and specialists. Access the CAHPS Provider Resource Guide (PDF) on our website for additional guidance.

Annual Provider Satisfaction Survey

You are essential to providing the highest quality healthcare possible for our members, and your satisfaction is very important to us, too. We assess your experience with us through an annual Provider Satisfaction Survey. These survey results are reviewed by the health plan and are key to helping us improve your experience, so please be sure to complete the survey if you receive one.

Our Support Doesn’t Stop There

Our provider website contains essential information, including member surveys, health equity resources, language services and resources, provider credentialing rights, the utilization management process, how to access care management services and other sources of support for you.  If you have additional questions or need specific support, call Provider Services at 1-833-863-1310.

Access and Availability Standards

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.? 

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. 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 will monitor provider’s compliance with this provision through scheduled and unscheduled visits and audits conducted by Ambetter staff. View the Provider Manual for additional details.

New Provider Guide: Flu Vaccine

Flu season is right around the corner, and it is time for everyone to get up to date on vaccinations. With your patient’s trust and best interest at heart, it is up to you to recommend they get their flu vaccine. View our new Provider Guide for tips to encourage members. The flu vaccine is an important component of the Childhood Immunizations (CIS) measure which demonstrates the percentage of children 2 years of age who completed immunizations on or before the child’s second birthday. View the HEDIS Quick Reference Guide for additional information!

New Provider Orientation

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 of the month at 12PM ET.

• Register in advance for this meeting
• 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.

Provider Manual

Visit Provider Resources for the most up-to-date version of the Ambetter of North Carolina Inc. Provider and Billing Manual.