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Ambetter of North Carolina Prior Authorization Change Summary

Date: 05/16/23

Ambetter Prior Authorization
List 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.       

For complete CPT/HCPCS code listing, please see Online Prior Authorization Tool on our website at https://www.ambetterofnorthcarolina.com/provider-resources/clinical-payment-policies.html

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

Behavioral Health

PA RULE

SERVICES

PROCEDURE CODES

PA Added

Behavioral health partial hospitalization

Rev code: 912, 913

PA Removed

Alcohol and/or drug services

H0004, H0005, H0007, H0014

PA Removed

Crisis intervention services

H2011

PA Removed

Substance abuse/detoxification and mental health services

S9475, S9484

Breast reconstruction

PA RULE

SERVICES

PROCEDURE CODES

PA added except with breast cancer diagnosis

Breast reconstruction, prosthesis

19316, 19318, 19325, 19328, 19340, 19342, 19350, 19370, 19371, 19499, L8039

Cardiovascular

PA RULE

SERVICES

PROCEDURE CODES

PA Added

Insertion/removal of cardiac rhythm monitor

33285

PA Added

Unlisted procedure

37799

PA Added

Implantable wireless pulmonary artery wireless pressure sensor

C2624

PA Added

External counterpulsation

G0166

PA Removed

Cardiac rehab program

G0422, G0423, S9472

Diagnostic and Therapeutic Radiology

PA RULE

SERVICES

PROCEDURE CODES

PA Added

Indium in-111 ibritumomab, dx

A9542

DME & Supplies

PA RULE

SERVICES

PROCEDURE CODES

PA Added

Osteogenesis stimulator

E0749

PA Added

Wheelchairs, power operated vehicles, and accessories

E2603, E2604, E2605, E2606, E2607, E2608, E2609, E2613, E2614, E2615, E2616, E2617, E2620, E2621, E2622, E2624

PA Added

Supplies for home delivery of infant

S8415 

PA Removed

Infusion pumps

B9002, E0781, K0455

PA Removed

Catheter Angioplasty

C2623

PA Removed

Respiratory equipment

E0550, E0565

PA Removed

Standard wheelchair and accessories

E2611, K0001

PA Removed

Hearing supplies

L8616, L8617, L8618, L8621, L8622, L8623, L8624, L8625

PA Removed

Vision supplies

S0515

Gastroenterology

PA RULE

SERVICES

PROCEDURE CODES

PA Added

Gastrointestinal transit and pressure measurement

91112

Home care

PA RULE

SERVICES

PROCEDURE CODES

PA Added

Home health skilled nursing visit

Rev code: 551, G0490

PA Added

Home Care Management Services

G0087

PA Added

Home therapy*

G2168, G2169

PA Removed

Home dialysis (ESRD)

90966

PA Removed

Home visit for prenatal monitoring and assessment

99500

PA Removed

Home care training

G0248

PA Removed

In-home visit post-discharge and care plan oversight

G2001, G2002, G2003, G2004, G2005, G2006, G2007, G2008, G2009, G2013, G2014, G2015

PA Removed

Coordinated Care Home Monitoring

G9006

PA Removed

BPCI home visit

G9187

PA Removed

Remote in-home visits

G9978, G9979, G9980, G9981, G9982, G9983, G9984, G9985, G9986, G9987

PA Removed

Management of patient home care

S0270, S0271, S0272, S0273, S0274

PA Removed

Medical home program

S0280, S0281

PA Removed

Home visit, wound care

S9097, S9098

PA Removed

Home therapy hemodialysis and peritoneal dialysis

S9335, S9339

PA Removed

Diabetic Mgmt. Nurse Visit

S9460

Hospice

PA RULE

SERVICES

PROCEDURE CODES

PA Removed

Counseling Services

G9473, G9474, G9475, G9476, G9477, G9478, G9479, S0255

PA Removed

Physician Supervision in Hospice

G0182

Infusion services

PA RULE

SERVICES

PROCEDURE CODES

PA Removed

Home infusion therapy

S5035, S5036, S5108, S5109, S5110, S5111, S5115, S5116, S9347, Q2052

Laboratory

PA RULE

SERVICES

PROCEDURE CODES

PA Added

Genetic testing

0089U

PA Added

Genetic analysis/studies, surgical pathology procedures

81235, 81263, 81265, 81267, 81268, 81270, 81275, 81310, 81315, 88237, 88377

PA Removed

Blood and blood products

P9010, P9011, P9016, P9021, P9022, P9051, P9054, P9056, P9057, P9058

PA Removed

Routine venipuncture

S9529

Ophthalmology

PA RULE

SERVICES

PROCEDURE CODES

PA Added

Collagen cross-linking of cornea

0402T

Orthopedic

PA RULE

SERVICES

PROCEDURE CODES

PA Added

Procedures lower extremities

28285, 28299

PA Added

Endoscopy procedure wrist

29848

Other medical items or services

PA RULE

SERVICES

PROCEDURE CODES

PA Added

Personal care services

T1020

Pain management

PA RULE

SERVICES

PROCEDURE CODES

PA added unless performed on the same day as surgery

Injection*, anesthetic agent or steroid

62320, 62321, 62322, 62323, 62325, 62327, 64400, 64405, 64415, 64417, 64418, 64420, 64421, 64430, 64445, 64447, 64448, 64450, 64451, 64454, 64479, 64480, 64483, 64484, 64505, 64510, 64517, 64520, 64530

PA Removed

Transversus abdominis plane (TAP) block

64486, 64488

PA Removed

Nerve block

64632

Preventive

PA RULE

SERVICES

PROCEDURE CODES

PA Removed

Developmental and behavioral screening

96110, 96112

Professional services

PA RULE

SERVICES

PROCEDURE CODES

PA Added

Respite Care Services not in home

H0045

PA Removed

Professional services for drug admin

G0068, G0069, G0070, T1502, T1503

PA Removed

Skilled nursing service - outpatient

G0128

PA Removed

Inpatient telehealth

G0406, G0407, G0408, G0425, G0426, G0427, G0459

PA Removed

Services provided by non-physician

S5190

PA Removed

Enterostomal therapy by nurse

S9474

Radiology Treatments

PA RULE

SERVICES

PROCEDURE CODES

PA Added

Ablation of Prostate*

0421T

PA Added

Indium in-111 ibritumomab, dx*

A9542

PA Added

Ablation Liver Tumor*

47382

PA Removed

Radiolabeled item

C9898

Skin substitute

PA RULE

SERVICES

PROCEDURE CODES

PA Added

Skin substitute products

Q4205, Q4206, Q4208, Q4209, Q4210, Q4211, Q4212, Q4213, Q4214, Q4215, Q4216, Q4217, Q4218, Q4219, Q4220, Q4221, Q4222, Q4226

Note:

For services 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.