Summary
Ambetter of North Carolina's October 2026 provider newsletter, dated 10/22/26, announces that beginning 12/05/26 Evolent will guide ordering providers to select a preferred site of care when they request authorization for shoulder, hip, knee and spine surgeries. The newsletter also says claims from Critical Access Hospitals with an incorrect Type of Bill will be denied and require correction and resubmission, that claims with surrogacy diagnosis codes Z33.3 or Z31.7 trigger an automatic one-year member review, and that Ambetter payments are moving to Zelis, with Medicare, Medicaid, and Ambetter programs moving in early 2027.
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What to do
Action · 14 steps
01Beginning 12/05/26: Providers ordering shoulder, hip, knee or spine surgery for Ambetter of North Carolina members must select a preferred site of care during Evolent authorization intake.
02If a hospital-based setting is selected for a procedure that can be performed in an outpatient setting, providers must either choose from the list of allowable exceptions or provide supporting clinical justification, and the final authorization will reflect the determinations for both the procedure and the site of care.
03Billing team: For Critical Access Hospital claims, use Type of Bill 11X for inpatient hospital services, 85X for outpatient hospital services, 14X for laboratory services and 18X for swing bed services, and make any necessary claim system updates, because claims submitted with an incorrect TOB will be denied and require correction and resubmission.
04Billing team: Use surrogacy diagnosis codes Z33.3 and Z31.7 only for surrogates, never for members who are not surrogates.
05Claims with either code trigger an automatic one-year member review and may result in claim denials and recoupments.
06Providers, in addition to members, must notify Ambetter of a surrogacy arrangement by completing and submitting the Notification of Surrogacy form available on the Ambetter public website.
07Surrogates are excluded from all maternity services.
08In states without surrogacy coverage, all pregnancy-related services are denied and the member is placed on review for one year.
09Ambetter reserves the right to recoup payment for surrogacy claims paid in error.
10Providers participating in Ambetter of North Carolina or Wellcare North Carolina Medicare are reminded to submit an updated provider roster monthly, even when there are no changes.
11Before the Zelis transition in early 2027: if you are already enrolled in Zelis payments on ZAPP Edge to receive claim payments via ACH or VCC, no action is needed.
12If you are not, enroll now by calling a Zelis Advisor at 855-496-1571 for ZAPP Edge or VCC, or by registering for the no-cost ePayment Center at centeneclaimspayment.epayment.center/Registration.
13If you are not enrolled in Zelis for VCC or ZAPP Edge and do not enroll in the free ePayment Center, payments will be sent by paper check through USPS.
14Non-claims payments may require additional registration at CenteneAlternativePayments.epayment.center, with more information to be provided closer to the transition.
Codes mentioned
Z33.3Z31.7
Original notice
October 2026 Provider Newsletter
ambetterhealth.com · Always check the source before changing claims.
Related changes
See all Ambetter changes →August Provider NewsletterHighEffective Jan 1, 2027 · Provider BulletinPayspan Migration to Zelis (ZAPP)MediumEffective Dec 1, 2026 · Provider BulletinPayspan transitioning to Zelis (PDF)HighNo effective date · Provider BulletinRevision to Payment Platform Transition from Payspan to ZelisHighEffective Dec 2, 2026 · Claims & BillingBrowse every Ambetter change in the policy list