Q4 2024 Provider Newsletter

Date: 11/27/24

2025 Provider and Billing Manual

The 2025 Ambetter of North Carolina Inc. Provider and Billing Manual is now available online.

Please review the updated manual. Revisions are noted on pages 8-9.

Please reach out to your Provider Engagement Administrator with questions. 

Ambetter of North Carolina Inc. Expands Health Insurance Offering to 63 Counties Statewide, Offering More Residents Affordable, Accessible Coverage

News Release Issued: October 2, 2024 (8:00am EDT)

To view this release online and get more information about Centene Corporation Investor Relations visit: https://investors.centene.com/2024-10-02-Ambetter-of-North-Carolina-Inc-Expands-Health-Insurance-Offering-to-63-Counties-Statewide,-Offering-More-Residents-Affordable,-Accessible-Coverage

Ambetter of North Carolina Inc. Expands Health Insurance Offering to 63 Counties Statewide, Offering More Residents Affordable, Accessible Coverage

North Carolina residents will have access to a variety of affordable plans from Ambetter of North Carolina during open enrollment beginning Nov. 1, 2024

RALEIGH, N.C., Oct. 2, 2024 /PRNewswire/ -- Ambetter of North Carolina Inc., a product offered by a Centene Corporation (NYSE: CNC) company, which provides insurance to under-insured and uninsured populations through the federal Health Insurance Marketplace®, will offer a variety of affordable health insurance plans to North Carolinians in 63 counties for plan year 2025. Open enrollment for the Health Insurance Marketplace for North Carolina runs from Nov. 1, 2024, through Jan. 15, 2025. Enroll by Dec. 15 for coverage starting Jan. 1, 2025.

"Ambetter is excited to continue to expand in North Carolina where we now offer our high-quality, affordable plans in 63 counties," said Ambetter of North Carolina Inc. Plan President, Catherine Campbell. "Our health plans provide members with access to a large network of local doctors and hospitals. We are also pleased to announce an expanded partnership with the YMCA, offering gym memberships and YMCA360 online classes for members beginning January 2025."

Ambetter of North Carolina Inc. offers its members access to quality care, convenient services and valuable rewards. The 2025 benefits and extra offerings include:

• Virtual 24/7 Care -  Virtual 24/7 Care offers members an Ambetter-designated licensed provider via telehealth for Members to access care for illnesses such as flu, skin conditions, ear infections, fever and respiratory infections – all from the comfort of their home.
• Affordable and Reliable Coverage - Ambetter of North Carolina Inc. provides coverage for all essential health benefits, including preventive and wellness services, maternity and newborn care, pediatric services, mental health services, hospitalizations and prescription drug coverage. Some plans also include dental and vision coverage.
• Convenient Online Enrollment - Through the Ambetter of North Carolina Inc. website, people can browse and compare coverage options, determine their eligibility for financial subsidies and directly enroll in coverage – all in one place. The platform is accessible through mobile devices, so people can enroll using smartphones. If a person is unable to complete enrollment all at once, the system will save progress and provide reminders to finish enrollment.
• My Health Pays - Members have access to the My Health Pays® program, where they can earn points for practicing healthy eating habits, staying active and leading a healthy lifestyle. Through the program, members can complete health-related activities and challenges, earning rewards that can be used for health-related expenses such as premiums, copays and deductibles (pharmacy copays are excluded). My Health Pays also allows members to set and reach health goals at their own pace by providing seasonal suggestions for activities and guidance to help stay on track.
• Specific Plan Design Changes for Members with Diabetes - Starting in 2025, some Ambetter Health Premier plans provide members managing diabetes with additional healthcare options and savings. Members on these plans may have lower out of pocket costs for certain medications, supplies, and clinical support. Members of these plans may also have access to $0 copays for preferred insulins as well as $0 copays for select mental health medications.
• Premier Network - Beginning Jan. 1, 2025, the Ambetter Health Bronze|Silver|Gold network will become known as the Premier Network. Members can continue to rely on the same provider network with the doctors and hospitals they know and trust.

For a full list of counties, view our coverage map.

North Carolina residents interested in learning more about Ambetter of North Carolina Inc. or enrolling in a health plan during the open enrollment period may visit ambetterhealth.com/en/nc/.

About Ambetter of North Carolina Inc

.Ambetter of North Carolina Inc. serves under-insured and uninsured populations through the federal Health Insurance Marketplace. Ambetter of North Carolina Inc. is underwritten by Ambetter of North Carolina Inc., which is a Qualified Health Plan issuer in North Carolina. For more information visit ambetterhealth.com/en/nc. This is a solicitation for insurance. For information on your right to receive an Ambetter of North Carolina Inc. plan free of discrimination, or your right to receive language, auditory and/or visual assistance services, please visit ambetterhealth.com/en/ and scroll to the bottom of the page. 

Clinical and Payment Policy Updates

Ambetter of North Carolina Inc. continuously updates select clinical policies each month. This page reflects upcoming clinical policy changes.

The following policy will retire effective February 1, 2025:

• CP.MP.53 Ferriscan R2-MRI

The following policy updates are effective February 1, 2025:Please view the revision notes for policies that were reviewed and include changes that are more restrictive:

• CP.MP.107 Durable Medical Equipment and Orthotics and Prosthetics Guidelines
• CP.MP.114 Disc Decompression Procedures
• CP.MP.117 Spinal Cord, Peripheral Nerve, and Percutaneous Electrical Nerve Stimulation
• CP.MP.126 Sacroiliac Joint Fusion
• CP.MP.184 Home Ventilators
• CP.MP.51 Reduction Mammoplasty and Gynecomastia Surgery
• CP.MP.54 Hospice
• CP.MP.93 Bone-Anchored Hearing Aid
• CP.MP.129 Fetal Surgery in Utero for Prenatally Diagnosed Malformations
• CP.MP.171 Facet Joint Interventions
• CP.BH.300 Biofeedback for Behavioral Health Disorders
• CP.MP.180 Implantable Hypoglossal Nerve Stimulation for Obstructive Sleep Apnea
• CP.MP.12 Vagus Nerve Stimulation

Ambetter of North Carolina Inc. introducing Availity Editing Services  

In a continuous effort to make it easier to do business with us, Ambetter of North Carolina Inc. is introducing Availity Editing Services (AES). Starting Jan. 24, 2025, Centene is partnering with Availity to return rejection messages on its behalf via AES messages. These messages will show in your existing workflows. AES will give you an option, but not a requirement, to edit a claim.

AES can identify a claim error upfront and return a message to you for correction before sending the claim on to the plan to be adjudicated. You should review edit messages for potential corrections to the suggested claim line(s). If you make updates to the claim, this may help the claim process correctly the first time, preventing errors, improving payment accuracy, and claims adjudication turnaround time. If, after reviewing the message, you find it does not apply, please resubmit the claim as-is and this will allow a bypass of the edit in cases where it may not be applicable.

This is not intended as a new method to deny a claim, nor does it bypass or replace downstream edits. If you choose to bypass an edit, it is possible that other downstream edits will still function as normal in our claims systems. Remember to “submit” your claim regardless of your choice to edit or bypass. This action is required in order for the claim to be processed in our systems.

If you have a Practice Management System (PMS), you can locate your edits report within your claims workbasket or que reporting. If you submit claims via the Availity portal, any of these rejections will show on your normal reports.

If you submit claims via Availity, learn how to gather your reporting by joining one of Availity’s free webinars to learn additional tips for streamlining your workflow:

• Send and Receive EDI Files – Training Demo
  This demo shows users where/how they can access reports in Availity Essentials. On these reports are where they would see edits. Please note: this demo does not say/call it AES however, this is the demo that would show the user how to locate the reports.
• EDI Reporting Preferences – Training Demo
  This demo shows users how to setup their EDI Reporting Preferences which needs to be done first by the user’s organization’s Availity Administrator to access the reports in the Send and Receive EDI Files application.

If you need assistance with registering for Availity Essentials, please call Availity Client Services at 1-800-AVAILITY (282-4548). Assistance is available Monday through Friday, 8 a.m. – 8 p.m. ET. For general questions, please reach out to your Ambetter of North Carolina Inc. Provider Engagement Administrator.

Health Equity and Cultural Humility Learning Opportunities

Ambetter of North Carolina Inc. provides a variety of Health Equity and Cultural Humility learning opportunities on our website. We have cultural humility training info, health equity trainings, as well as the Choosing Wisely initiative available and ready for use.

• Health Literacy & Cultural Competency resources can be found under Providing Quality Care on our website 

Health equity is the state in which everyone has a fair and just opportunity to attain their highest level of health. Achieving this requires ongoing societal efforts to:

• Address historical and contemporary injustices,
• Overcome economic, social, and other obstacles tohealth and healthcare; and
• Eliminate preventable health disparities

To achieve health equity, we must change the systems and policies that have resulted in the generational injustices that give rise to racial and ethnic health disparities. For more information about Culturally and Linguistically Appropriate  Services (CLAS) Standards, see https://thinkculturalhealth.hhs.gov/clas

Ambetter of North Carolina Inc. encourages our providers to engage in Cultural Humility trainings and education to promote positive interaction with diverse cultures.

For more information about the Cultural and Linguistic Competency e-Learning Program from the Office of Minority Health (OMH), see https://minorityhealth.hhs.gov/omh/browse.aspx?lvl=1&lvlid=6. This program is designed to build knowledge, skills, and awareness of cultural and linguistic competency and CLAS as a way to improve quality of care.

HELPING YOU CARE FOR YOUR PATIENTS IS OUR TOP PRIORITY

Strong communication and trust between you and your patients will help ensure they’re 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 May

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.

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. Read more now.

If you have additional questions or need specific support, call Provider Services at 1-833-863-1310.

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

Provider Manual

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