Fecha: 04/06/24
New Provider Guide: Preventative Care
Preventative care with regular health checkups is beneficial to your patients. Consider developing a personalized prevention plan to help them on their healthcare journey. Ambetter members can be seen at least once per calendar year for preventative care exams. Note: Healthy infants should be seen by their doctor often during the first year of life. Provider Guide: Preventative Care (PDF).
My Health Pays® Rewards Program
Our My Health Pays® program is available to Ambetter Health members. It’s a rewards program that pays members for healthy decisions such as completing their annual wellness screening and learning new ways to incorporate healthy lifestyle changes. Learn more online!
*Restrictions apply. Members must qualify for and complete all activities to earn up to $500. Visit Member.AmbetterHealth.com for more details.
**My Health Pays® rewards cannot be used for pharmacy copays.
Funds expire immediately upon termination of insurance coverage.
National Imaging Associates and New Century Healthare now Evolent
New Century Health and National Imaging Associates are now Evolent!
As you may be aware, Ambetter of North Carolina Inc. partners with New Century Health (NCH) and National Imaging Associates (NIA) for the utilization management of certain services (see list below).
As of Jan. 1, 2024, New Century Health and NIA are now Evolent Specialty Services, Inc. (“Evolent”). This name change reflects the decision by Evolent to unify its family of brands, including New Century Health and NIA under a single name, with a focus on improving outcomes across multiple specialties and primary care.
Along with this rebranding, Evolent is undertaking a coordinated effort to update New Century Health and NIA materials with the new name and logo. This should have no immediate impact on your experience or on the care of your members, and you do not need to take any action. The portals, links and processes that you currently use will remain in use. Later this year, these online resources will redirect to a new experience reflecting the company’s new name and brand.
- Interventional Pain Management, High Tech Imaging (CT, MRI, PET) and Therapy (PT, OT, ST) administered by National Imaging Associates, now known as Evolent: submit requests through the RadMD portal
- Oncology and Radiation Oncology administered by New Century Health, now known as Evolent - for information log onto NCH provider web portal
For more information regarding these Utilization Management programs, please review the 2024 Provider Manual (PDF).
Clinical and Payment Policy Updates
The following policy updates are effective August 1, 2024. Providers can view all Ambetter of North Carolina Inc. clinical policies online.
New policy:
- HIM.NC.CG.MP.01 Infectious Disease: Respiratory Lab Testing (PDF)
Reviewed and updated policies:
- See charts below and view revision notes (PDF) for additional details.
| POLICY NUMBER | POLICY TITLE | NOTES |
|---|---|---|
| CP.MP.22 | Stereotactic Body Radiation Therapy | With changes - more and less restrictive |
| CP.MP.62 | Hyperhidrosis Treatments | With changes - more restrictive |
| CP.MP.82 | NICU Apnea Bradycardia Guidelines | With changes - more and less restrictive |
| CP.MP.173 | Implantable Intrathecal or Epidural Pain Pump | With changes - more restrictive |
| CP.MP.190 | Outpatient Oxygen Use | With changes - more and less restrictive |
| CP.MP.243 | Implantable Loop Recorder | With changes - more and less restrictive |
| CP.MP.248 | Facility-based Sleep Studies for Obstructive Sleep Apnea | With changes - more and less restrictive |
| CP.BH.104 | Applied Behavioral Analysis | With changes - more restrictive |
| CP.MP.144 | Mechanical Stretching Devices for Joint Stiffness | With changes - more and less restrictive |
| CP.MP.186 | Burn Surgery | With changes - more restrictive |
| CP.MP.247 | Transplant Service Documentation Requirements | With changes - more and less restrictive |
| CP.MP.91 | OB Home Programs | With changes - more and less restrictive |
| CP.MP.40 | Gastric Electrical Stimulation | With changes - more and less restrictive |
| CP.MP.132 | Heart-Lung Transplant | With changes - more and less restrictive |
| CP.MP.141 | Non-Myeloablative Allogeneic Stem Cell Transplants | With changes - more and less restrictive |
| CP.MP.99 | Wheelchair Seating | With changes – more and less restrictive |
- Concert Genetics policies listed below have been revised to be both more and less restrictive. Please visit our Clinical Policies page to review the individual policies and view the revision log on each.
| Policy |
|---|
| Concert Genetics Genetic Testing: Prenatal Diagnosis (via Amniocentesis, CVS, or PUBS) and Pregnancy Loss |
| Concert Genetics Genetic Testing: Aortopathies and Connective Tissue Disorders |
| Concert Genetics Genetic Testing: Cardiac Disorders |
| Concert Genetics Genetic Testing: Dermatologic Conditions |
| Concert Genetics Genetic Testing: Epilepsy, Neurodegenerative, and Neuromuscular Disorders |
| Concert Genetics Genetic Testing: Exome and Genome Sequencing for the Diagnosis of Genetic Disorders |
| Concert Genetics Genetic Testing: Eye Disorders |
| Concert Genetics Genetic Testing: Gastroenterologic Disorders (Non-Cancerous) |
| Concert Genetics Genetic Testing: General Approach to Genetic and Molecular Testing |
| Concert Genetics Genetic Testing: Hearing Loss |
| Concert Genetics Genetic Testing: Hematologic Conditions (Non-Cancerous) |
| Concert Genetics Genetic Testing: Immune, Autoimmune, and Rheumatoid Disorders |
| Concert Genetics Genetic Testing: Kidney Disorders |
| Concert Genetics Genetic Testing: Lung Disorders |
| Concert Genetics Genetic Testing: Multisystem Inherited Disorders, Intellectual Disability, and Developmental Delay |
| Concert Genetics Genetic Testing: Non-Invasive Prenatal Screening (NIPS) |
| Concert Genetics Oncology: Molecular Analysis of Solid Tumors and Hematologic Malignancies |
| Concert Genetics Oncology: Circulating Tumor DNA and Circulating Tumor Cells (Liquid Biopsy) |
| Concert Genetics Oncology: Algorithmic Testing |
| Concert Genetics Oncology: Cancer Screening |
| Concert Genetics Oncology: Cytogenetic Testing |
| Concert Genetics Genetic Testing: Pharmacogenetics |
| Concert Genetics Genetic Testing: Preimplantation Genetic Testing |
| Concert Genetics Genetic Testing: Skeletal Dysplasia and Rare Bone Disorders |
| Concert Genetic Testing: Hereditary Cancer Susceptibility |
| Concert Genetic Testing: Metabolic, Endocrine, and Mitochondrial Disorders |
| Concert Genetic Testing: Prenatal and Preconception Carrier Screening (PDF) |
Payment Integrity Updates
Commencing August 1, 2024, Ambetter of North Carolina Inc. will begin pre-payment reviews of inpatient claims to verify payment accuracy of our facilities. Ambetter of North Carolina Inc. has engaged the services of Cotiviti to conduct these claim audits.
Cotiviti is a Business Associate of Ambetter of North Carolina Inc. as defined in 45 CFR, Section 160.103 of the Health Insurance Portability and Accountability Act of 1996 (“HIPAA”) and will perform its responsibilities on behalf of Ambetter of North Carolina Inc. in full compliance with HIPAA requirements.
Consistent with this business relationship, we request your assistance in providing Cotiviti with the information necessary to complete these reviews to the same extent Ambetter of North Carolina Inc. staff would be allowed.
What you should expect:
- Certain claims will be identified for pre-payment audit based on standard clinical or correct coding criteria.
- If a claim is identified for audit, your Medical Records Department will receive a letter requesting medical records for specific paid claims. You will have 30 days to provide the requested medical records to Cotiviti.
- If records are not received within the required timeframe, you will receive a second notice. Failure to submit the requested records may result in an administrative denial and recovery of the original payment by Ambetter of North Carolina Inc.
- If you disagree with the Audit Determination, you will have 30 days to submit a request for reconsideration with supporting information to Cotiviti.
- If you do not respond to these notifications, we assume you agree and Ambetter of North Carolina Inc. will proceed with a payment adjustment in accordance with your contract.
- If you disagree with the audit findings you will be allowed two (2) cycles of reconsiderations. Ambetter of North Carolina Inc. considers the second reconsideration decision from Cotiviti to be final.
If you have any questions, please contact Ambetter of North Carolina Inc. Provider Services at 1-833-863-1310. We appreciate your participation in our network and your dedication to the health and welfare of our members and your patients.
Legal Disclaimer: Please note that contractual terms may include exceptions to the above referenced material. Refer to your specific agreement terms for more information.
Ambetter of North Carolina Inc. prior authorization updates effective 8/1/2024 for new American Medical Association Current Procedural Terminology (CPT®) codes.
Ambetter of North Carolina Inc. prior authorization updates effective 8/1/2024 for new American Medical Association Current Procedural Terminology (CPT®) codes.
The following new CPT Proprietary Laboratory Analyses (PLA) codes and CPT Category III codes will require prior auth, unless determined to be a non-covered service, upon their effective date of 8/1/2024. For other established codes, please use the Pre-Auth Check Tool on our website to confirm if the code(s) requires prior authorization. Prior authorization requirements vary based on the line of business, so please select the applicable Pre-Auth Check Tool by the line of business.
| CODE | DESCRIPTION |
|---|---|
| 0020M | ONC CNS ALYS 30000 DNA METHYLATION LOCI TUM TISS |
| 0450U | ONC MM LC-MS/MS MONOCLONAL P-PRTN SEQ ALYS SERUM |
| 0451U | ONC MM LC-MS/MS PEPTIDE ION QUANTIFICATION SERUM |
| 0452U | ONC BLADDER MTHYL PENK DNA DETCJ LTE-QMSP URINE |
| 0453U | ONC CLRCT CA CFDNA MTHYLTN BSD QUAN PCR ASY PLSM |
| 0454U | RARE DS ID VRTJ INVRJ INSJ TLCJ OPT GENOME MAPG |
| 0456U | AI RA NGS GEN XPRSN 19 GEN WHL BLD ALYS ANTI-CCP |
| 0457U | PFAS 9 PFAS COMPOUNDS LC-MS/MS PLASMA/SERUM QUAN |
| 0458U | ONC BREAST CA S100 A8&A9 ELISA TEAR FLUID ALG |
| 0459U | ABETA42 & TTAU ECLIA CEREBRAL SPINAL FLUID RATIO |
| 0460U | ONC WHL BLD/BUCCAL DNA SNP GNOTYP RT-PCR 24 GENE |
| 0461U | ONC RX-GENOMIC ALYS SNP GNOTYP RT-PCR 24 GENES |
| 0462U | MELATONIN LVL TEST SLEEP STUDY 7/9 SAMPLE ELISA |
| 0463U | ONC CERVIX MRNA GENXPRSN 14 BMRK E6&E7 HPV NASBA |
| 0465U | ONC UROTHELIAL CARC DNA QMSP 2 GENES ALG ALYS |
| 0466U | CRD CAD DNA GWAS 564856 SNP TRGT VARIANT GNOTYP |
| 0467U | ONC BLDR DNA NGS 60 GEN&WHL GENOME ANEUP UR ALG |
| 0468U | HEP NASH MIR-34A-5P A2M YKL40 HBA1C SRM&WHL BLD |
| 0469U | RARE DS WHL GENOM SEQ ALYS CHRMOML ABNR FTL SAMP |
| 0470U | ONC OROP DETCJ MRD NGS QUAN EVAL 8DNA CFHPV16&18 |
| 0472U | CA VI PSP&SP1 ANTB ELISA SEMIQL BLD SJOGREN SYND |
| 0473U | ONC SOLID TUMOR NGS DNA FFPE TISS BLD/SLV 648GEN |
| 0474U | HERED PAN CA GSAP 88 GENES 20DUP/DEL NGS BLD/SLV |
| 0475U | HERED PRST8 CA-RLTD DO GSAP NGS CGH EVAL 23 GENE |
| 0867T | TPLA B9 PROSTATIC HYPERPLASIA PRST8 VOL>=50 ML |
| 0868T | HIGH-RESOLUTION GASTRIC ELECTROPHYSIOLOGY MAPG |
| 0869T | NJX B1 SUB MATRL B1&/SFT TISSUE HW FIXJ AGMNTJ |
| 0870T | IMPLANTATION SUBQ PERITONEAL ASCITES PUMP SYS |
| 0871T | REPLACEMENT SUBCUTANEOUS PERITONEAL ASCITES PUMP |
| 0872T | RPLCMT INDWELLING BLADDER & PERITONEAL CATHETERS |
| 0873T | REVJ SUBQ IMPL PERITONEAL ASCITES PUMP SYSTEM |
| 0874T | REMOVAL PERITONEAL ASCITES PUMP SYSTEM |
| 0876T | DUPLEX SCAN HEMODIALYSIS FISTULA CPTR AIDED LMTD |
| 0877T | AUGMNT ALYS CH CT IMG DATA ILD WO CNCRNT CT EXAM |
| 0878T | AUGMNT ALYS CH CT IMG DATA ILD W/CNCRNT CT EXAM |
| 0879T | AUGMNT ALYS CH CT IMG DATA ILD DATA PREP&TRNSMS |
| 0880T | AUGMNT ALYS CH CT IMG DATA ILD PHYS/QHP I&R |
| 0881T | CRTX ORAL CAVITY TEMP REGULATED FLU COOLING SYS |
| 0884T | ESPHGSC FLX TRNSORL 1ST TNDSC DILAT RX BALO CATH |
| 0885T | COLSC FLX TRNSORL 1ST TNDSC DILAT RX BALO CATH |
| 0886T | SGMDSC FLX TRNSORL 1ST TNDSC DILAT RX BALO CATH |
| 0888T | HISTOTRIPSY MALIGNANT RENAL TISSUE W/IMG GDN |
| 0889T | PERSONALIZED TARGET DEVELOPMENT ARHFCMRIGTBS |
| 0890T | ARHFCMRIGTBS 1ST MOTOR THRESHOLD DETER 1ST TX D |
| 0891T | ARHFCMRIGTBS SUBSEQUENT TREATMENT DAY |
| 0892T | ARHFCMRIGTBS SBSQ MOTOR THRESHLD REDETER PR TX D |
| 0893T | N-INVAS ASSMT BLD OXY GAS XCHNG EFF&CARDRESP I&R |
| 0897T | N-INVAS AUGMNT ARRHYT ALYS QUAN CAR ARRHYT SIMUL |
| 0898T | NONINVASIVE PROSTATE CANCER ESTIMATION MAP |
| 0899T | N-INVAS DETER AQMBF AUGMNT ALG ALYS DATASET CMR |
| 0900T | N-INVAS EST AQMBF ASSITIVE ALG ALYS DATASET CMR |
Notification of Pregnancy Improvements Reduce Completion Time and Increase Care Coordination
Your partnership is essential. The time you spend filling out the Notification of Pregnancy (NOP) for your patient provides an irreplaceable opportunity to identify existing and potential risks as early in pregnancy as possible.
Your time is valuable, and so is this information. Without the NOP, we cannot provide the additional support a patient may need to achieve a healthy pregnancy and delivery. Ambetter of North Carolina Inc. has recently updated the NOP form making it more efficient and refocusing questions to help identify risk factors and barriers that may be impacting their health. The NOP includes questions to assess environmental, social, physical and behavioral health concerns which are known to influence risk factors. This information helps to establish meaningful interactions and align support for your patients.
The new NOP is available for use in your Ambetter of North Carolina Inc. provider portal.
We have resources for pregnant patients. Receipt of an NOP initiates enrollment for a pregnant patient in our Start Smart for Your Baby® (SSFB) program. With SSFB, expectant parents have access to clinically vetted health education that addresses common questions and concerns related to prenatal, postpartum and newborn care, with special focus on forming healthy habits. The suite of resources discusses general wellness, as well as specific needs such as alcohol use, asthma, and gestational diabetes. The information from the NOP and our assessments helps us identify those at higher risk of potential complications. Ambetter of North Carolina Inc. Care Managers engage these patients to assist them in accessing medical and behavioral healthcare, wellness programs, medical equipment and social resources to fully equip them to manage their health leading up to delivery and beyond.
Check it out for yourself! Visit startsmartforyourbaby.com. Thank you for being a trusted partner of those you care for.
For more information about Start Smart for Your Baby or how to connect members to additional support for their pregnancy, 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.
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.
