PRIOR AUTHORIZATION PROVIDER NOTIFICATION 

Fecha: 29/04/25

Ambetter of North Carolina Inc. is committed to delivering cost effective quality care to our members.  This effort requires us to ensure that our members receive only treatment that is medically necessary according to current standards of practice.  Prior authorization is a process initiated by the physician in which we verify the medical necessity of a treatment in advance using independent objective medical criteria and/or in network utilization, where applicable. Ambetter of North Carolina Inc. regularly reviews and evaluates authorization codes to determine continued need.

Effective July 1, 2025, the following codes will require prior authorization to be submitted to Ambetter of North Carolina Inc.

• 31276 Nasal/sinus endoscopy, surgical, with frontal sinus exploration, including removal of tissue from frontal sinus, when performed
• 31298 Nasal/sinus endoscopy, surgical, with dilation (eg, balloon dilation); frontal and sphenoid sinus ostia
• 31295 Nasal/sinus endoscopy, surgical, with dilation (eg, balloon dilation); maxillary sinus ostium, transnasal or via canine fossa
• 31296 Nasal/sinus endoscopy, surgical, with dilation (eg, balloon dilation); frontal sinus ostium

The following codes will no longer require prior authorization:

• 20939 Bone marrow aspiration for bone grafting, spine surgery only, through separate skin or fascial incision (List separately in addition to code for primary procedure)
• 81257 HBA1/HBA2 (alpha globin 1 and alpha globin 2) (eg, alpha thalassemia, Hb Bart hydrops fetalis syndrome, HbH disease), gene analysis; common deletions or variant (eg, Southeast Asian, Thai, Filipino, Mediterranean, alpha3.7, alpha4.2, alpha20.5, Constant Spring)

As always, we appreciate your partnership in providing quality care and improved health outcomes. If you have any questions, please contact Provider Services at 1-833-863-1310.