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AmbetterExchange · Prior Auth · Provider Bulletin · NC · Psychiatry, Pathology, General Surgery +5 moreHigh impact

August Provider Newsletter

Act
by Jan 1, 2027
Effective date
Jan 1, 2027
Identified
Sep 2, 2026

Summary

Ambetter of North Carolina will stop covering a list of HCPCS H codes starting January 1, 2027, and will cover H0006 from that date. Earlier changes are already effective: CPT 80320-80377 drug testing codes were no longer reimbursable from October 1, 2026, and the prior authorization changes effective October 1, 2026 took effect. The newsletter also covers surrogacy diagnosis codes Z33.3 and Z31.7, behavioral health type of bill guidance, and clinical policy updates effective 11/1/2026.

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What to do

by Jan 1, 2027 · 9 steps
01Stop billing the HCPCS H codes listed in the newsletter, which will no longer be covered beginning 01/01/2027, and bill H0006, which will be covered from that date.
02Already effective October 1, 2026: Bill the appropriate G-series bundled laboratory codes instead of CPT 80320-80377 (definitive drug testing), which are no longer reimbursable.
03Already effective October 1, 2026: Get prior authorization for CPT 31297 (sinuses) before scheduling.
04Genetic testing (86812, 86813, 86817), home visits (S9211, S9213, S9214) and transplant (38208) are listed as no PA required.
05Surrogacy: Apply Z33.3 and Z31.7 only to surrogates, never to members who are not surrogates.
06Both members and providers must notify Ambetter of surrogacy, using the Ambetter Health Notification of Surrogacy form, which is different from the Notification of Pregnancy Form.
07Claims with either surrogacy code will trigger an automatic member review, potentially up to a year, and may result in claim denials and recoupments.
08Behavioral health claims: Follow the type of bill guidance, using 11X for inpatient, 86X for residential treatment centers, and 13X and 76X for outpatient.
09Providers: Confirm each member's status on the date of service or as close to it as possible, checking the eligibility status, premium paid through date and claims paid through date, because coverage may be retroactively terminated and previous claims may be denied.

Codes mentioned

868128681386817S9211S9213S921431297382088032080377H0003H0004H0005H0006H0007H0008H0009H0010H0011H0012H0013H0014H0016H0019H0021H0024H0026H0027H0028H0029H0030H0034H0037H0039H0040H0041H0042H0043H0044H0045H0046H0047H1011H2001H2010H2011H2012H2013H2015H2016H2018H2021H2022H2028H2029H2030H2031H2032H2033H0015H0035S948090834Z33.3Z31.7

Original notice

August Provider Newsletter
ambetterhealth.com · Always check the source before changing claims.
View original ↗

Related changes

See all Ambetter changes →
Ambetter Health Billing Code Update for various HCPC H Codes: Effective 01/01/2027MediumEffective Jan 1, 2027 · Claims & BillingAmbetter Health of Delaware Billing Code Update for various HCPC H Codes: Effective 01/01/2027HighEffective Jan 1, 2027 · Claims & BillingAmbetter Health Billing Code Update for various HCPC H Codes: Effective 01/01/2027HighEffective Jan 1, 2027 · Claims & BillingJune 2026 NewsletterHighEffective Jan 1, 2027 · Provider BulletinBrowse every Ambetter change in the policy list

Related policy hubs

Ambetter policiesNC policy changesPsychiatryPathologyGeneral SurgeryOB-GYNPediatricsSpeech TherapyPhysical TherapyOccupational TherapyCode 86812Code 86813Code 86817Code S9211Code S9213Code S9214Code 31297Code 38208Code 80320Code 80377Code H0003Code H0004Code H0005Code H0006Code H0007Code H0008Code H0009Code H0010Code H0011Code H0012Code H0013Code H0014Code H0016Code H0019Code H0021Code H0024Code H0026Code H0027Code H0028Code H0029Code H0030Code H0034Code H0037Code H0039Code H0040Code H0041Code H0042Code H0043Code H0044Code H0045Code H0046Code H0047Code H1011Code H2001Code H2010Code H2011Code H2012Code H2013Code H2015Code H2016Code H2018Code H2021Code H2022Code H2028Code H2029Code H2030Code H2031Code H2032Code H2033Code H0015Code H0035Code S9480Code 90834Code Z33.3Code Z31.7

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