April 2026 Provider Newsletter

Fecha: 16/04/26

Clinical Policy Updates

Ambetter of North Carolina Inc. continuously updates select clinical policies each month. The following policy updates are effective 6/15/2026.

46 policies were reviewed and approved.

• 18 policies had no changes
• 6 policies were revised making them less restrictive
• 12 policies were revised making the new version both more and less restrictive:
  • CP.MP.91 Obstetrical Home Care Programs
  • CP.MP.117 Spinal Cord, Peripheral Nerve, and Percutaneous Electrical Nerve Stimulation
  • CP.MP.180 Implantable Hypoglossal Nerve Stimulation for Obstructive Sleep Apnea
  • CP.MP.190 Outpatient Oxygen Use
  • CP.BH.105 Applied Behavioral Analysis Documentation Requirements
  • V2.2025 Concert Genetic Testing Oncology: Hematologic Malignancy
  • V2.2025 Concert Genetic Testing: Hereditary Cancer
  • V2.2025 Concert Genetic Testing Oncology: Solid Tumor Molecular Diagnostics
  • V2.2025 Concert Genetic Testing: Neurology
  • V2.2025 Concert Genetic Testing Oncology: Algorithmic Assays
  • V2.2025 Concert Genetic Testing: Cardiovascular
  • V2.2025 Concert Genetic Testing: Gastroenterology
• 8 policies were revised making the new version more restrictive:
  • CP.MP.168 Biofeedback
  • CP.MP.174 Selective Dorsal Rhizotomy for Spasticity in Cerebral Palsy
  • CP.MP.185 Skin and Soft Tissue Substitutes for Diabetic Foot Ulcers and Venous Leg Ulcers
  • V2.2025 Concert Genetic Testing Oncology: Cancer Screening and Surveillance
  • V2.2025 Concert Genetic Testing: Preimplantation Genetic Testing
  • V2.2025 Concert Genetic Testing: Prenatal Screening
  • V2.2025 Concert Genetic Testing: Transplant
  • V2.2025 Concert Genetic Testing: Multisystem Genetic Conditions
• 2 policies were created
  • V2.2025 Concert Genetic Testing: Identity and Forensics
  • V2.2025 Concert Genetic Testing: Nutrition and Metabolism

This page reflects upcoming clinical policy changes. Revision notes are made available in the policy document.

Ambetter Health Update for HCPCS Code E0486 Effective 07/01/2026

Effective 07/01/2026, HCPCS code E0486, a custom-fabricated mandibular advancement device (MAD) for obstructive sleep apnea, will require prior authorization.

If you have questions about this bulletin or other provider resources, please contact your Provider Relations Representative.

CP.MP.38 Ultrasound in Pregnancy Policy Revision - Reminder

As a reminder, there is a revision to the following existing policy that will be implemented on 04/15/2026. See the original notification from the Ambetter of North Carolina Inc. February 2026 Newsletter here.

Policy Updates and Reason

Coding changes bring policy into alignment with other payer policies. Changes allow payment for 76805 if billed for a second time within a rolling six months [this is the timeframe for the frequency limit that is currently in place for this code] of being billed on a previous claim, if billed by a different TIN than the previous claim with 76805. Add the following ICD-10 codes as payable with CPT code 76811: A93.0, O35.0XX1, O35.0XX2, O35.0XX3, O35.0XX4, O35.0XX5, O35.0XX9, O35.1XX0, O35.1XX1, O35.1XX2, O35.1XX3, O35.1XX4, O35.1XX5, O35.1XX9

Thank you for your continued participation and cooperation in our ongoing efforts to render quality health care to our members. We look forward to helping you provide the highest quality of care for our members.

Ambetter Health Billing Code Update for CPT Codes G2211 and G2212 Effective 4/1/2026 - Reminder

As a reminder, CPT codes G2211 & G2212 will no longer be covered by Ambetter of North Carolina Inc. beginning on Apr. 1, 2026.

• CPT Code G2211 is an add-on Medicare code used to bill for the complexity of an office or outpatient visit due to the longitudinal and ongoing nature of the practitioner-patient relationship, not the specific condition itself.
• CPT code G2212 is an add-on Medicare code used to report prolonged office or other outpatient evaluation and management (E/M) services beyond the maximum time of a primary E/M code. This code is submitted in 15-minute increments.

Providers should continue utilizing E&M codes (i.e., 99202–99205, 99211–99215) as appropriate.
 
Click here for a Special Bulletin that was sent out on this update. If you have questions about this bulletin or other provider resources, please contact your Provider Relations Representative.

Updated Evolent Authorization Requirements Effective April 1, 2026 - Reminder

As a reminder, effective April 1, 2026, the following procedures will be removed from prior authorization.
 
The following RADIOLOGY AND DIAGNOSTIC CARDIOLOGY (RBM) codes have been removed from the Evolent’s Utilization Review Matrix and no longer require prior authorization for Ambetter of North Carolina Inc.
 

Update for Procedure Codes S9083 and S9088 Effective 8/1/2026

Effective 08/01/2026, the following procedure codes will become reimbursable when billed with place of service 20 (urgent care facilities). Claims submitted with another place of service will be denied, as these codes are not reimbursable for those locations.

• Code S9083: Global fee urgent care centers
  • Represents a facility-level global urgent care service.
  • Indicates the member is physically seen in an urgent care setting.
• Code S9088: Urgent care add-on code
  • Used only in addition to an E/M or procedure code.
  • Indicates urgent care operational costs.
  • Used when services are provided in person in an urgent care setting.

If you have questions about this bulletin or other provider resources, please contact your Provider Relations Representative.