June 2025 Provider Newsletter

Fecha: 12/06/25

Clinical Policy Updates

Ambetter of North Carolina Inc. continuously updates select clinical policies each month. 

The following policy updates are effective 9/01/2025.

40 policies were reviewed and approved.

• 7 policies with changes
• 16 policies had no changes
• 4 policies were revised making it less restrictive
• 2 policies were revised making it more restrictive:

• 9 policies were revised making the new version both more and less restrictive:

•  2 policies were retired

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

Payment Integrity Program Updates

Thank you for your continued partnership with Ambetter of North Carolina Inc. As you know, we are committed to continuously evaluating and improving overall Payment Integrity solutions as required by State and Federal governing entities.

We are writing today to inform you of a review process that will be implemented beginning on or after 8/15/2025.

The following additional review process will be implemented:

Thank you for your continued participation and cooperation in our ongoing efforts to render quality health care to our members.

Ambetter Fee Schedule Modifications

Ambetter Fee Schedule Modifications, Effective August 15, 2025
 
The following modifications to the Ambetter fee schedule will be implemented on August 15, 2025:

• Telehealth Modifier 95 will be priced at facility rates to align with all other telehealth pricing (Place of service 11 only)
• Payments for midlevel services (Nutritionist/Dietician/Midwife) will be modified to align with CMS pricing
• Payments for codes to which the applicable MAC (Medicare Administrative Contractor) has recently assigned a rate shall be priced to be consistent with such rate, as per with current practice.

North Carolina Medical Board Member Seats Openings

The North Carolina Medical Board is currently accepting applications for open Board Member seats. The open seats are:

• Three (3) seats for a physician

The term for these open seats will begin in November 2025. NCMB Will be accepting applications through June 23, 2025. Information about applying to serve on the Board can be found on the NCMB Review Panel website here.

New Member Benefit: Free YMCA Access for Ambetter Patients

As an Ambetter of North Carolina Inc. provider, you can now share an exciting wellness benefit with your patients—a free YMCA membership at participating locations and virtually through YMCA360!

This benefit is included with Ambetter Health coverage and gives member access to:

• State-of-the-art fitness facilities, basketball courts, and lap pools.
• Group classes like yoga, dance, and strength training.
• Access to Drop-in childcare while you work out at the YMCA.
• Youth meals (at select locations).
• Family focused events.

Encourage your Ambetter patients to stay active, healthy, and engaged—both in-person and at home.

To learn more and find a YMCA that participates visit: https://www.ncymcas.org/y-membership-ambetter

Questions? Call Member Services at 1-833-863-1310 (Relay 711).

REMINDER: Practitioner Enrollment and Provider Demographic Update Process

Accurate provider and practice information ensures members can find you easily, helps prevent claim delays, and supports smoother care coordination. Regular updates help us keep our directories accurate and ensure your services remain accessible to those who need them most. Please note the following guidelines when submitting provider updates or requests:

Joining Our Network:
Requests to join the Ambetter from Carolina Complete Health network are not processed via the forms below. To request participation, complete our Network Participation Request Form. Please allow up to five business days for a team member to contact you.

Facility Changes or Additions:
To add a new facility or update an existing location, download and complete the Ambetter Facility Roster Template (Excel | .xlsm) and email it along with credentialing documentation to AmbetterNCProviderDirectoryRequest@CENTENE.COM

Adding a New Practitioner:
To add a new practitioner to your practice, download and complete theAmbetter Practitioner Roster Template (Excel | .xlsm), and submit it with all credentialing documentation to AmbetterNCProviderDirectoryRequest@CENTENE.COM.

Ambetter of North Carolina Inc. Claims Office Hours - You Are Invited!

Join Ambetter for our upcoming bimonthly Claims Office Hours beginning July 23^rd at 12PM! The session is designed to support your practice with key insights and helpful guidance around our claims process.

Audience:
Billing staff, practice managers, and providers who want to stay informed and supported around Ambetter of NC Inc. claims processes.

During this interactive session, we will review:

• Operational workflows and systems
• Hot topics and common claim denial trends
• Available provider education and training resources
• Live Q&A – bring your questions!

Note: For privacy and compliance, do not submit or ask questions containing any PHI during the session.

Registration Required: Click Here!

We look forward to seeing you and helping ensure your claims run smoothly!

New 2025 HEDIS® Pocket Guides Now Available for Adult and Pediatric Care

We are excited to share the newly released HEDIS® Pocket Guides for the 2025 Measurement Year, available in two versions: one for Adult care and one for Pediatric care. These quick-reference tools are designed to support providers in delivering high-quality, evidence-based care by outlining key HEDIS (Healthcare Effectiveness Data and Information Set) measures. HEDIS is a widely used performance improvement tool in healthcare, helping to track and enhance the quality of care and services provided to members. Each guide offers clear, measure-specific information to support accurate documentation, coding, and preventive care that are critical elements for quality reporting and improved patient outcomes. We encourage all Ambetter providers to review and integrate these guides into their daily practice!

To access these guides please visit:
HEDIS® Adult Pocket Guide: 2025 Measurement Year (PDF)
HEDIS® Pediatric Pocket Guide: 2025 Measurement Year (PDF)

Ambetter Pay-for-Performance (P4P) Program

The Pay-for-Performance (P4P) program is designed to incentivize providers to deliver high-quality, value-based care. Through this program, providers can earn financial incentives by meeting key performance measures such as preventive care, chronic disease management, and patient engagement. By aligning provider efforts with quality improvement goals, the P4P program supports better health outcomes for Ambetter’s members while enhancing provider reimbursement opportunities. Please review 2025 Marketplace P4P Program (PDF) for provider participation requirements, the specific performance measures evaluated, target thresholds for financial incentives, and the payment schedule.

For more information, feel free to reach out to the Provider Engagement team via email: ProviderEngagement@cch-network.com.

Updated Guidance on Retrospective Authorization Review Request

Ambetter of North Carolina Inc. has updated the Retrospective Authorization Review process to provide clearer guidance for providers when submitting requests for services rendered without prior authorization due to extenuating circumstances.

Retrospective authorization reviews are appropriate when authorization was not obtained at the time of service for reasons such as: the member being unconscious, lacking ID, or coverage initially assumed under another payer.

What's New:

• Avality Essentials is now an accepted submission method for retrospective requests within 30 days post-service.
• The Secure Provider Portal also accepts requests, but only within 3 days post-service.
• You may still Phone request at 1-833-863-1310
• Or Fax: 1-844-536-2412

Note: If faxing, providers should use the Prior Authorization Form located online

• Requests must include:
  • Clinical documentation supporting medical necessity
  • A detailed explanation of the extenuating circumstances

 Ambetter has 30 calendar days to finalize a decision after receiving the request.

Providers may contact their Engagement Administrator for support or submit a Peer-to-Peer or appeal if the request is denied.

For full details please review Retrospective Authorization Review Request (PDF) or contact your Provider Engagement Administrator.

Know Where to Send It: Appeals and Grievances vs. Claim Disputes

To help prevent processing delays or returned mail, here is a reminder and clarification on the difference between Medical Appeals and Grievances and Claims Corrections, Reconsideration and Disputes. Please see below:

Medical Appeals & Member Grievances

• Authorization-related appeals
• Member complaints and grievances

Form: Grievance & Appeals Form - English (PDF)
Please refer to the Appeals/ Reconsiderations (Medical) and Grievances Guide.

Mail to:
Ambetter of North Carolina Inc.
Attn: Appeals and Grievances Department
PO Box 10341
Van Nuys, CA 91410
Fax: 1-833-886-7956

Claim Corrections, Reconsiderations & Disputes

• Billing or payment issues
• Requesting claim reviews or corrections

Form: Claim dispute form

Mail to:
Ambetter of North Carolina Inc.
Attn: Claim Dispute
PO Box 5010
Farmington, MO 63640-50

Preferred method: Ambetter Secure Provider Portal

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: 
https://www.ambetterofnorthcarolina.com/provider-resources/manuals-and-forms.html