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Fecha: 18/05/23

FQHC Pay Class Changes

Ambetter of North Carolina Inc. has historically allowed Federally Qualified Health Centers to submit claims on the CMS 1450 and CMS 1500 forms using CPT codes. To align with CMS guidelines, effective July 1, 2023, Ambetter of North Carolina Inc. will only accept claims with FQHC specific encounter and revenue codes on a UB-04/CMS 1450 form or in the 837I electronic file format when billing encounters. This claim format would be the same as your Medicare billing format. Please refer to the CMS Medicare Claims Processing Manual, Chapter 9 for RHC/FQHC billing and payment requirements.  

FQHC pay class changes:

  • Encounters:
    • Must be billed with one of these revenue codes: "521", "522", "524", "525", "527", "528", "519", "900"
    • And one of these HCPCS: "G0466", "G0467", "G0468", "G0469", "G0470", "G0511", "G0512"
    • Must be billed on a UB04
  • Non-Encounters (adjunct codes):
    • Must be billed on a CMS 1500

Please make appropriate changes in your EHR before July 1, 2023, to avoid an interruption in payments. FQHC specific encounter and revenues codes submitted on the CMS 1500 form or 837P electronic file format will deny beginning July 1, 2023.

Free Provider Training: Suicide Prevention

As Centene continues our collaboration with the Association of Clinicians for the Underserved (ACU), we have another opportunity for providers: a virtual  suicide prevention training at no cost.
On July 11 at 2-3 p.m. ET, ACU is  planning to offer a national Suicide Safer Care webinar intended to support newly practicing clinicians and clinicians in training with practical tools/tips for suicide prevention.
Please register in advance:

Clinical Payment Policy Updates

Ambetter of North Carolina Inc. has reviewed and updated the following Clinical Policies effective 8/1/23. You can find all policies on our website:

Policy # CP.MP.100
Policy Name: Allergy Testing and Therapy
Restriction Level: More

  • Change codes 86160, 86161 and 86162 from not payable to NOT payable only when billed with the following diagnosis codes:, B44.81, H10.01* through H10.45, J30.1 through J30.9, J30.0, J31.0, J45.2* through J45.998 , L20.84  , L20.89, L20.9, L23.0 through L23.9*, L25.1 through L25.9, L27.0 through L27.9 , L50.0, L50.1, L50.6, L50.8, L50.9, L56.1, L56.2, L56.3, R06.2, T36.0X5A through T50.995S , T63.001* - T63.94*, T78.00X* through T78.1XXS, T78.49XA through T78.49XS , T80.52XA through T80.52XS, T88.6XXA through T88.6XXS , Z88.0 through Z88.9, Z91.010 through Z91.018
  • Add the following diagnosis codes as payable with 86003, 86005, 86008, 95004, 95017, 95018, 95024, 95027 and 95028. L20.0, L20.81-L20.83, L24.9, L30.2.
  • Add CPT 86001 as NOT payable.

Policy # CP.MP.97
Policy Name: Testing for Select Genitourinary Conditions
Restriction Level: More

  • Added 0330U and 0352U as not med nec for members over age 13 (new code for July '22 with no utilization/cost data).
  • Changed matching requirements for ICD-10 B37.3 to apply to B37.31 and B37.32 which together now replace B37.3. There will be no savings change from this edit.
  • Changed CPT 87481 from not medically necessary in any circumstance to not med nec when paired with the following dx codes, and only applied to members 13 years and over. Required the same dx code matching for new code 0353U (with no utilization/cost data):

B37.31, B37.32, L29.2, L29.3, N39.0,N72, N76.0, N76.1, N76.2, N76.3, N76.81, N76.89, N77.1, N89.8, N89.9, N90.89, N90.9, N91.0 –N91.5, N92.0, N93.0, N93.8, N93.9, N94.3, N94.4 – N94.6, N94.89, N94.9, O09.00-O09.03, O09.10-O09.13, O09.A0-O09.A3, O09.211-O09. 219,O09. 291-O09. 299,O09.30-O09.33,O09. 40-O09.43, O09.511-O09.519, O09.521- O09. 529, O09.611-O09.619, O09.621-O09.629, O09.70-O09.73, O09.811-O09.819,  O09.821-O09.829, O09.891-O09.899, O09.90-O09.93, O23.511– O23.93, Z00.00,Z00.8,Z01.419,Z11.3,Z11.51,Z22.330,Z23,Z30.011 – Z30.019,Z30.02, Z30.09,Z30.40 – Z30.9,Z32.00, Z33.1, Z34.00 – Z34.03, Z34.80 – Z34.83, Z34.90 – Z34.93, Z36.0-Z36.5, Z36.81-Z36.9, Z38.00 – Z38.01, Z38.30 – Z38.31, Z38.61 – Z38.69, Z39.0 – Z39.2, Z3A.00 – Z3A.49, Z72.51 – Z72.53, Z86.19, Z97.5

Payment Integrity Notifications
Hemodialysis Modifier and Optum CPI Amisys Phase 

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. Below, we are sharing two notifications regarding Hemodialysis Modifier and Optum prepayment claim auditing that Ambetter of North Carolina Inc. will be implementing effective on or after 8/1/2023.

Hemodialysis Modifier Notification:

Edit Name


Implementation Date

Hemodialysis Modifier

Based on CMS guidelines, hemodialysis (CPT 90999) will be denied when the required modifier (G1-G6) is not present.


Optum CPI AMISYS Phase 1 Notification:

As a reminder, we have partnered with Optum who is supporting us in performing prepayment claim auditing. The purpose of our review is to verify the extent and nature of the services rendered for the patient’s condition and that the claim is coded correctly for the services billed.

For claims received on or after 8/1/2023, providers may experience a slight increase in written requests for medical record submission prior to payment based on the areas outlined below. These requests will come from Optum and will contain instructions for providing the documentation. Should the requested documents not be returned, the claim(s) will be denied. Providers will have the ability to dispute findings through Optum directly in the event of a disagreement.

Editing Area


Implementation Date

High Dollar IV Hydration

Requesting medical records to determine if documentation supports services billed and that those services were in accordance with policies and regulations related to IV hydration therapy.


Custom Fitted or Custom Fabricated Prosthetics or Orthotics

Requesting medical records to verify documentation supports high-dollar custom DME codes billed by the provider


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.

Prior Authorization Change Summary; Effective 8/1/2023

Ambetter of North Carolina Inc. requires prior authorization (PA) as a condition of payment for many services.  This Notice contains information regarding such prior authorization requirements and is applicable to all Ambetter products offered by Ambetter of North Carolina Inc.

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.
It is the ordering/prescribing provider’s responsibility to determine which specific codes require prior authorization. 
Please verify eligibility and benefits prior to rendering services for all members. Payment, regardless of authorization, is contingent on the member’s eligibility at the time service is rendered. NON-PAR PROVIDERS & FACILITIES REQUIRE AUTHORIZATION FOR ALL HMO SERVICES EXCEPT WHERE INDICATED.       
To check on whether an authorization is needed for a specific CPT/HCPCS code, see Online Prior Authorization Tool on our website at

Effective August 1st, 2023, the following are changes to prior authorization requirements

To view this information in full, and to see where PA is removed, please visit Provider News.

For items listed with an asterisk ‘*’, providers may be required to request prior authorization through National Imaging Associates:

  • Effective January 2019, Ambetter of North Carolina Inc. will work with National Imaging Associates, Inc. (NIA) to implement a radiology benefit management program for outpatient advanced imaging services.
  • Effective January 2021, Ambetter of North Carolina Inc. will also work with National Imaging Associates (NIA) for the Utilization Management of outpatient rehabilitative and habilitative Physical Medicine services (Physical, Occupational, and Speech Therapy).
  • Effective June 2023, Ambetter of North Carolina Inc. will also work with National Imaging Associations, Inc. (NIA) to provide the management and prior authorization of non-emergent outpatient Interventional Pain Management (IPM) procedures.
  • Please refer to the Ambetter of NC Inc. Provider Manual for more information on Pre-Auth Programs.

PA Removed for Home-based Sleep Studies

Ambetter is very pleased to share that we are no longer requiring prior authorization for Home-Based (Unattended) Sleep Studies (G0398, G0399, G0400, 95800, 95806) with an effective date as of 08/01/2023 for Ambetter of North Carolina Inc.
Summary of Policy:

  • Prior authorization will no longer be required for Home-Based (Unattended) Sleep Studies (G0398, G0399, G0400, 95800, 95806).
  • Facility-based (Attended) studies (95805, 95807, 95808, 95810,95811) will continue to require prior authorization.

What does this mean for providers?
Providers will no longer need to provide medical records or seek prior authorization for Home-Based (Unattended) Sleep Studies. Providers can review the complete policy at:

Please contact Provider Services for general inquiries regarding this program. 

Launch of Pay-for-Performance Program and New Suite of Quality Resources

Exciting announcement!

Ambetter of North Carolina Inc. is proud to invite you to participate in our pay-for-performance (P4P) program.  The program is designed to enhance quality of care through a focus on preventative and screening services while promoting engagement with our members.  Based on program performance, you are eligible to earn additional compensation beyond what you are paid through your Participating Provider Agreement.  The P4P program is “upside only” and involves no risk to you.  Furthermore, contract document is not required to participate in this program. This P4P program is based on a standard contract and may vary based on participation in other value-based contracting arrangements. Refer to your specific agreement terms for more information.

The P4P program provides financial incentives for engaging with our members and closing care gaps based on NCQA and HEDIS quality performance standards.  Each care gap has its own incentive amount, and payment is rendered for each compliant member event once the target has been achieved for that specific measure.

Incentives are paid based on member primary care assignment.  In other words, a closed care gap results in an incentive to the tax identification numbers (TINs) for the primary care provider of record for that member.  Incentives are paid three times including a final reconciliation in the course of the measurement period.

New Quality Resources

A suite of quality resources is available on the Ambetter of North Carolina Inc. Provider Website: Provider Resources

  1. Quick Reference Guide: HEDIS® MY 2022: to help you increase your practice’s HEDIS® rates and to use to address care opportunities for your patients.
  2. HEDIS® Adult Pocket Guide: a summary of the adult measures 
  3. HEDIS® Pediatric Pocket Guide: a summary of pediatric measures
  4. Supplemental Data System (SuDS) Submission Process Implementation Guide: SuDs stands for Supplemental Data System, which is a proprietary application focused on end-to-end SDS process management

Additional provider education will be forthcoming!

Reminder: NIA to provide utilization management for Interventional Pain Management (IPM) services for Ambetter of North Carolina Inc members

Beginning June 1, 2023, Ambetter of North Carolina Inc. is pleased to announce our expanded partnership with National Imaging Associates, Inc. (NIA) to provide utilization management for Interventional Pain Management (IPM) services for Ambetter of North Carolina Inc.’s members. This program is consistent with industry-wide efforts ensuring that IPM services provided to our members are consistent with nationally recognized clinical guidelines.

  • Question: If there is an authorization on file, what will happen to the authorization on June 1?
  • Answer: The authorization on file is good through the end of the validity period. For subsequent authorizations for IPM services, reach out to National Imaging Associations for review and authorization

View this information in full, along with a Quick Reference Guide and FAQ in Provider News

2023 New Provider Orientation and Manual

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 at 12PM ET.

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: