ExchangeCoverageHigh impact
Intraoperative Neurophysiologic Monitoring (IONM) Update: Effective 6/15/26
Ambetter·AZ · Anesthesiology, Neurosurgery, General Surgery·Claims & Billing
Effective date
Jun 15, 2026
We identified it
Aug 26, 2026
Summary
Effective June 15, 2026, Ambetter from Arizona Complete Health is updating IONM billing requirements for Marketplace plans. Only CMS-recognized payable code 95940/G0453 is covered; code 95941 is non-covered. Billing must comply with strict CMS criteria including exclusive patient attention, maximum 4 units per 60 minutes, appropriate place of service codes, and cannot be billed by surgeon or anesthesia provider.
Action Required
By June 15, 2026: Billing team must update billing software to enforce IONM coverage restrictions for Ambetter Marketplace plans in Arizona. (1) Configure system to ONLY accept CPT 95940 or HCPCS G0453 for reimbursement; automatically deny CPT 95941 claims. (2) Add validation rules to reject claims that bill >4 units per 60-minute period or exceed total monitoring time available. (3) Add validation to reject claims with Place of Service codes other than 19, 21, 22, or 24. (4) Add provider education to prevent surgeon and anesthesia provider billing of IONM services. (5) Update claim scrubbing logic to flag non-compliant claims for manual review before submission. Providers should implement encounter form updates and staff training on new requirements. Failure to comply will result in claim denials for Marketplace members.