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October 2026 Provider Newsletter

Fecha: 22/10/26

Payspan Migration to Zelis Provider Notice

With the Zelis acquisition of PaySpan, Ambetter of North Carolina Inc. in coordination with its parent company, Centene Corporation, will transition to Zelis for both claims and non-claims payments. 
 
The transition will occur in phases, with Medicare, Medicaid, and Ambetter programs moving in early 2027. To ensure uninterrupted access to electronic payments and remittance information across all participating lines of business, we encourage you to enroll now. Once enrolled, any additional eligible lines of business that move to the new platform will automatically be included, and no further action will be required.
 
How the Move to Zelis Impacts You
The transition to Zelis will offer greater efficiency and more choice in how you receive claims payments and remittance data. Your options include:

  • ZAPP Edge – the Zelis premium payments experience for providers, offering direct settlement into the provider bank accounts via ACH plus data and financial performance insights from 485+ payers in a single portal.
  • Virtual Card (VCC) – a one-time-use virtual card.
  • ePayment Center – no-cost standard EFT/ERA solution that delivers payment via ACH.
  • Paper Check – no-cost paper check delivery via USPS (default payment method).

What You Need to Know

  • If you arealready enrolled in Zelis payments on ZAPP Edge to receive claim payments via ACH or VCC, no action is needed. Following our move to Zelis, payments from [Payer] will be sent according to your current Zelis enrollment, fee schedule, and other terms and conditions.
  • If you are not enrolled in Zelis payments on ZAPP Edge, you can avoid any disruption to your payment preferences by enrolling now and selecting your preferred electronic payment method using the contact information below.
  • If you are not already enrolled with Zelis for VCC or ZAPP Edge and do not enroll in the free ePayment Center, payments will be sent by paper check through USPS.
  • If youreceive non-claims payments, you may have additional registration steps to complete. Registration for non-claims payments can be completed by visiting CenteneAlternativePayments.epayment.center. More information on this process will be provided closer to the transition.

Questions  
Ambetter and Zelis are committed to supporting you throughout this transition. If you have questions about your payment options, need additional help making your selection, or want to change your payment method, please use the contact information below.

2026 Updated Surrogacy Coverage Information

Ambetter Surrogacy Coverage

This notification outlines Ambetter's coverage requirements, billing expectations, and review processes for surrogacy-related services. Providers are expected to review this guidance and ensure compliance when treating members involved in a surrogate pregnancy.

Because surrogacy coverage varies by market and is excluded from most Ambetter plans, it is important that providers accurately identify and report surrogate pregnancies and related services in accordance with Ambetter policies. Proper use of diagnosis codes, accurate claim submission, and verification of member benefits help ensure correct claim adjudication and reduce the risk of payment delays, denials, or recoupments.

Coverage Exclusions

  • Both member and non-member surrogates are excluded from all maternity services, including prenatal appointments, the delivery (hospital stay, physician, etc.), and post-natal care.
  • They are also excluded from infertility coverage treatment and corrective surgeries performed solely to enable a member to become pregnant.
  • Newborns born through a surrogate arrangement are not automatically covered. The newborn could potentially be added to a current Ambetter policy via the dependent-enrollment provisions of the EOC if the parent(s) and/or guardian(s) do so in accordance with their contract.

Ambetter Surrogacy Diagnosis Codes (ICD-10-CM)

Apply these codes only for surrogates — they must never be billed for members who are not surrogates.

  • Z33.3 — Pregnant state, gestational carrier: assigned when treating or monitoring a surrogate pregnancy, where the patient carries a child for another and is not genetically related to the baby.
  • Z31.7 — Procreative management and counseling for a gestational carrier: used when a patient receives medical, educational, or psychological counseling and management to act as a surrogate or gestational carrier.

Correct Billing and Review Policy

  • If a member is a surrogate, Ambetter requires that all claims identify that member as a surrogate by including the necessary diagnosis codes.
  • Claims submitted with either surrogacy diagnosis code will trigger an automatic one-year member review and may result in claim denials and recoupments.
  • The review period is one full year, beginning from the member’s first pregnancy-related claim.
  • In states without surrogacy coverage, all pregnancy-related services are denied, and the member is placed on review for one year — including members who travel to a state that allows surrogacy coverage. Members are subject to the Ambetter coverage requirements of their originating state.
  • Providers, in addition to members, are responsible for notifying Ambetter of a surrogacy arrangement by completing and submitting the Notification of Surrogacy form (available on the Ambetter public website).

Additional Information

  • Ambetter reserves the right to recoup payment for any claims related to surrogacy that were paid in error, including those resulting from billing inconsistencies or billing errors.
  • Information regarding surrogacy coverage is included in the Ambetter Provider Manual.
  • For additional information, please refer to the member's EOC, which outlines the exclusion of surrogacy-related services. If you have further questions after reviewing the EOC, please contact Ambetter Customer Service for assistance.

Provider Roster Reminder

Providers participating in Ambetter of North Carolina Inc. or Wellcare North Carolina Medicare are reminded to submit an updated roster of all participating providers on a monthly basis. Timely roster submissions help ensure accurate credentialing information and provider directory listings, support appropriate claims processing and payment, and help prevent delays or issues related to provider participation. We strongly encourage providers to submit a current roster each month, even when there are no changes to report.

Roster submissions can be sent to:

Evolent Musculoskeletal Program Updates
Beginning December 5, 2026

Ambetter of North Carolina Inc. in collaboration with Evolent is implementing updates to how Musculoskeletal services are reviewed and administered to enhance the member and provider experience. These changes reflect a shared commitment to improving quality of care, efficiency, reducing administrative burden, and supporting timely, clinically appropriate care decisions.

What’s Changing

Site of care selection for shoulder, hip, knee and spine surgeries

Advances in surgical care have enabled many procedures that once required inpatient stays to be safely performed in outpatient settings.

Beginning 12/05/26, Evolent will guide ordering providers, during intake of an authorization request for Ambetter of North Carolina Inc. members, to select a preferred site of care. If a hospital-based setting is selected for a procedure that can be performed in an outpatient setting, providers will be required to either choose from a list of allowable exceptions or provide supporting clinical justification.

Clinical reviewers will evaluate both medical necessity and site of care criteria prior to rendering a determination. Once the authorization request is complete, the final authorization will reflect determinations for both the procedure and the site of care.

For questions or additional information, please contact Provider Engagement Administrator.

Critical Access Hospital Type of Bill Code Requirements

Ambetter of North Carolina Inc. is providing information regarding the billing requirements for any facility contracted with Ambetter of North Carolina Inc. as a Critical Access Hospital (CAH).

All facilities contracted as Critical Access Hospitals must submit claims using the appropriate Type of Bill (TOB) based on the services rendered. Claims submitted with an incorrect TOB will be denied and require correction and resubmission. The allowable CAH bill types are 11X, 85X, 14X, and 18X, based on the applicable service provided.

Please submit claims using the following Type of Bill designations.
 

Service TypeAppropriate Type of Bill
Inpatient Hospital Services11X
Outpatient Hospital Services85X
Laboratory Services14X
Swing Bed Services18X
Other servicesAs applicable per CMS and contractual billing requirements.

 
Ambetter of North Carolina Inc. encourages CAH providers to review their claim submission practices and make any necessary system updates to avoid disruptions in claims adjudication.

For additional information regarding this claim submission requirement, please review the applicable Ambetter of North Carolina Inc. Provider Manual. If you have questions, contact your Ambetter of North Carolina Inc. Provider Relations Representative or Provider Services team for assistance.

Thank you for your continued partnership and commitment to serving our members.

Provider Insights: Quarterly Provider
Education Webinar Series

Quarterly Provider Education Webinar Series

Join us for the launch of Ambetter of North Carolina Inc Provider Insights, a new quarterly webinar series designed to keep providers informed with timely education, clinical insights, and important Ambetter of North Carolina updates. Each webinar will feature a focused educational topic presented by a subject matter expert, followed by the latest plan updates, provider resources, policy reminders, and upcoming initiatives.

Date: December 22
Time: 12PM
Register Here

We look forward to connecting with you during our Ambetter of North Carolina Provider Insights webinar!

Clinical Quality Validation and
Centene Clinical Action Webinars

CQV/CCA Webinars

Attention Primary Care Providers:

A new webinar is available to help providers learn about accessing and navigating the health plan’s Centene Clinical Action and Clinical Quality Validation tools.

  • Centene Clinical Action (CCA): Enables providers with assigned members to view their members’ HEDIS® measures status and claim-related clinical data. It also includes access to COC+.
  • Clinical Quality Validation (CQV): Enables providers to efficiently address and electronically submit documentation for open HEDIS quality care gaps within their work queue.

The webinar is available on demand and can be accessed here.