What insurance policy changes affect North Carolina providers?

This page tracks changes from major payers (including Medicaid managed care, commercial insurers, and Medicare Advantage plans) that explicitly apply to North Carolina. Changes include prior authorization updates, billing code additions or deletions, and reimbursement rate revisions.

How often are North Carolina policy changes updated?

Our scrapers run daily and publish new findings within 24 hours of detection. Each change includes an effective date where stated so you can prioritize what requires immediate action.

How do I get alerted to new North Carolina insurance policy changes?

Create a free alert on PolicyChanges.app and filter by state to North Carolina. You will get an email when new matching changes are detected: daily or weekly, your choice, on every plan.

PAYER POLICY CHANGES

North Carolina Insurance & Medicaid Policy Updates

North Carolina providers face a continuous stream of payer policy changes: coverage edits, prior authorization expansions, billing code revisions, and Medicaid reimbursement updates that affect day-to-day practice operations. This page surfaces every tracked policy change that explicitly names North Carolina, so your billing and compliance teams can act before the effective date, not after a claim denial.

UnitedHealthcare · Effective Dec 1, 2026High impact
Obstructive and Central Sleep Apnea Treatment (for North Carolina Only)
UnitedHealthcare Community Plan of North Carolina (Medicaid) revised its sleep apnea treatment coverage policy effective December 1, 2026. The key change adds 'radiofrequency ablation of the soft palate and/or tongue base' to the list of unproven and not medically necessary surgical procedures, meaning claims for this procedure will be denied for NC Medicaid members. This policy also clarifies coverage criteria for approved treatments (oral appliances, specific surgeries, and hypoglossal nerve stimulation) and reaffirms that certain other procedures remain non-covered.
UnitedHealthcare · Effective Dec 1, 2026High impact
Molecular Oncology Testing for Solid Tumor Cancer Diagnosis, Prognosis, and Treatment Decisions (for North Carolina Only)
UnitedHealthcare Community Plan of North Carolina (Medicaid) has issued a new policy effective December 1, 2026, that restricts coverage of molecular oncology testing for solid tumors to only FDA-cleared/approved companion diagnostics and specific approved tests (lung cancer multigene panels ≤50 genes, anaplastic thyroid cancer comprehensive genomic profiling, and indeterminate thyroid nodule testing). All other molecular tests including NGS panels, cancer genomic profiling, and multicancer screening tests are now classified as unproven and non-medically necessary, requiring denial or prior authorization review.
Ambetter · Effective Dec 5, 2026High impact
October 2026 Provider Newsletter
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.
NC Medicaid - NCDHHS · Effective Dec 31, 2026High impact
NC Integrated Care for Kids Closeout and Related Billing Code Changes
NC Medicaid is closing the NC Integrated Care for Kids (InCK) pilot program effective December 2026. Two food/housing screening G codes (G9919, G9920) will be rejected after December 31, 2026, while the Kindergarten Readiness Promotion Bundle code (CPT 1003F with modifiers SE, TS) will continue indefinitely for well-child visits in children ages birth to 6. Billing teams must stop using the discontinued G codes and ensure proper use of CPT 1003F with appropriate modifiers to document bundle completion.
UnitedHealthcare · Effective Jan 1, 2027High impact
New oncology prior authorization code updates
Effective January 1, 2027, UnitedHealthcare is adding prior authorization requirements for 11 HCPCS oncology medication codes when administered in outpatient settings for cancer treatment. These codes include busulfan, leucovorin calcium, luspatercept, dexrazoxane, dinutuximab, octreotide, triptorelin, omidubicel, zoledronic acid, and cyclosporine. This change applies across commercial, Medicare Advantage, Medicaid, and Individual Exchange plans.
Ambetter · Effective Jan 1, 2027High impact
August Provider Newsletter
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.
Ambetter · Effective Jan 1, 2027High impact
June 2026 Newsletter
Ambetter of North Carolina's June 2026 provider newsletter says it will stop covering 48 HCPCS H codes beginning January 1, 2027, and will cover H0006 from that date. The newsletter also says drug testing codes G0482 and G0483 are no longer reimbursable under the drugs-of-abuse policy (no date is given), and it lists clinical policy revisions effective August 15, 2026 and a reminder to verify member eligibility by paid-through dates.
Ambetter · Effective Jan 1, 2027High impact
Ambetter of North Carolina Inc. Billing Code Update for various HCPC H Codes: Effective 01/01/2027
Effective January 1, 2027, Ambetter of North Carolina Inc. will discontinue coverage for 45 HCPCS H codes (primarily behavioral health and substance abuse treatment services) while adding coverage for H0006. Billing teams must immediately identify affected claims and update billing systems to prevent denials for these services beginning 2027.
NC Medicaid - NCDHHS · Effective Jan 1, 2027High impact
Transition to American Medical Association Maternity Current Procedural Terminology 2027 Code Changes Effective Jan. 1, 2027
NC Medicaid is transitioning to new AMA maternity CPT codes effective January 1, 2027. Starting September 1, 2026, providers must begin using E/M codes (99202-99215) with the TH modifier for prenatal/postpartum care when delivery is anticipated after 1/1/2027. All current maternity codes including global bundles will be deleted on 1/1/2027. Current codes may be used through 12/31/2026 for pregnancies completing before that date.
NC Medicaid - NCDHHS · Effective Apr 20, 2027High impact
Reminder: Innovations Waiver Provider Services Updates
NC Medicaid is ending the Community/Behavioral Health service under taxonomy 251S00000X on April 20, 2027. Providers must enroll in a new Innovations Waiver Service and report national accreditation (if required) to continue receiving reimbursement for Innovations Waiver services.
UnitedHealthcare · Effective Dec 1, 2026Medium impact
Transarterial Radioembolization (TARE)/Selective Internal Radiation Therapy (SIRT) for the Treatment of Malignant Cancers of the Liver (for North Carolina Only)
UnitedHealthcare Community Plan of North Carolina has revised coverage criteria for Transarterial Radioembolization (TARE)/Selective Internal Radiation Therapy (SIRT) for liver cancer treatment. The policy now specifies six covered indications (including hepatocellular carcinoma, neuroendocrine tumors, colorectal metastases, cholangiocarcinoma, and uveal melanoma metastases) for patients ages 19+ with ECOG Performance Status 0-1-2, and covers all ages under 19 without prior review. A minor terminology change replaced 'uveal/ocular melanoma' with 'uveal melanoma.' This policy becomes effective December 1, 2026.
UnitedHealthcare · Effective Dec 1, 2026Medium impact
Cardiovascular Disease Risk Tests (for North Carolina Only)
UnitedHealthcare Community Plan of North Carolina (Medicaid) is revising coverage for cardiovascular disease risk tests effective December 1, 2026. The policy removes coverage for advanced lipoprotein particle size/subfraction analysis and adds non-covered status for noninvasive point-of-care cardiac diagnostic platforms (e.g., CorVista System). CPT code 83695 has been removed from the applicable codes list. Billing teams must identify and deny claims for these services on or after the effective date.
UnitedHealthcare · Effective Dec 1, 2026Medium impact
Breast Imaging for Screening and Diagnosing Cancer (for North Carolina Only)
UnitedHealthcare Community Plan of North Carolina (Medicaid) revised its breast imaging policy effective December 1, 2026, to clarify that routine preventive mammography is excluded from this policy and to refine coverage criteria for advanced imaging (MRI, molecular breast imaging, etc.) based on high-risk indicators and genetic mutations. The policy now requires specific medical necessity documentation for MRI screening in high-risk patients and explicitly lists molecular breast imaging and other modalities as unproven for routine screening.
UnitedHealthcare · Effective Jan 1, 2027Medium impact
Treatment of Temporomandibular Joint Disorders (for North Carolina Only)
UnitedHealthcare Community Plan of North Carolina revised its Medicaid medical policy on treatment of temporomandibular joint disorders, effective 2027-01-01. The revision updates the InterQual surgical criteria references (adding Arthroplasty, TMJ and removing Arthroscopy and Discectomy references), removes CPT codes 21060, 29800 and 29804 from the applicable codes, and notes that CPT 21299 is not on the North Carolina Medicaid fee schedule and may not be covered by the state Medicaid program.
UnitedHealthcare · Effective Jan 1, 2027Medium impact
Surgery of the Knee (for North Carolina Only)
UnitedHealthcare Community Plan of North Carolina updated its Surgery of the Knee medical policy for North Carolina Medicaid members, effective 2027-01-01. The coverage rationale now cites InterQual Client Defined CP (AQS) (Custom) - UHG criteria in place of the prior InterQual CP criteria for knee arthrotomy, total knee replacement, knee removal and replacement, and unicondylar or patellofemoral knee replacement. The medical records documentation section was removed from the policy and moved to the UHCprovider.com resources page.
UnitedHealthcare · Effective Jan 1, 2027Medium impact
Outpatient Surgical Procedures – Site of Service (for North Carolina Only)
UnitedHealthcare Community Plan of North Carolina revised its Outpatient Surgical Procedures – Site of Service medical policy for North Carolina Medicaid members, effective 2027-01-01. Hospital outpatient department surgery is covered under the listed criteria, which now exempt individuals under 21 when federal, state, or contractual requirements call for coverage, and the definition of Poorly Controlled Hypertension was updated. The practice should confirm that planned surgeries at hospital outpatient departments for these members are documented against the revised criteria and the payer's prior authorization list.
UnitedHealthcare · Effective Jan 1, 2027Medium impact
Bariatric Surgery (for North Carolina Only)
UnitedHealthcare Community Plan of North Carolina's November 2026 Medicaid medical policy update for Bariatric Surgery removed CPT 43882 from the applicable codes list. The update also notes that CPT codes 43659, 43772, 43889, 43999, and 64999 are not on the State of North Carolina Medicaid Fee Schedule and therefore may not be covered by the North Carolina Medicaid Program. Practices should update charge entry and claim edits for these codes for North Carolina Community Plan members.
NC Medicaid - NCDHHS · Effective Jan 1, 2027Medium impact
Update on Care Coordination for High-Risk Pregnant Women and At-Risk Children
NC Medicaid is transitioning Care Management for High-Risk Pregnancies (CMHRP) and Care Management for At-Risk Children (CMARC) from State Plan Services into managed care authority effective January 1, 2027. Billing teams must monitor the programmatic guidance document for specific coding, referral, and documentation changes when the guidance is finalized, as this bulletin provides only a preview of upcoming requirements for NC Medicaid Managed Care and NC Medicaid Direct.
NC Medicaid - NCDHHS · Effective Nov 2, 2026High impact
Termination of Taxonomy 251S00000X for Records Without a Service Effective Nov. 2, 2026
NC Medicaid Managed Care and NC Medicaid Direct will terminate the Community/Behavioral Health taxonomy (251S00000X) for providers who do not have an active Service Type and Service on file. The Oct. 1, 2026 deadline to add services has passed; taxonomy termination is effective Nov. 2, 2026 for non-compliant providers. Termination of this taxonomy may result in service location or enrollment record termination if it is the only active taxonomy.
NC Medicaid - NCDHHS · Effective Nov 1, 2026High impact
Quarterly Provider Update – Summer 2026
NC Medicaid will begin verifying active DEA certification for prescribers on controlled substance claims effective November 1, 2026. Claims for controlled substances will be denied if the prescriber lacks an active DEA number in NCTracks. Additionally, providers must complete multiple compliance actions by specific deadlines, including 251S00000X taxonomy providers adding services by October 1, 2026, behavioral health organizations confirming national accreditation status, and high-risk providers preparing for expedited off-cycle reverification.
UnitedHealthcare · Effective Nov 1, 2026High impact
Spinal Fusion and Decompression (for North Carolina Only)
UnitedHealthcare Community Plan of North Carolina Medicaid is updating spinal fusion and decompression billing codes effective November 1, 2026: CPT code 0719T is being added for coverage, CPT code 0179T is being removed and should no longer be used, and CPT code 22899 is now flagged as not covered under the NC Medicaid Fee Schedule. Billing teams must update systems and encounter forms to reflect these changes before the effective date.
NC Medicaid - NCDHHS · Effective Nov 1, 2026High impact
Action Required: Drug Enforcement Administration Certification Required for Prescribing Controlled Substances
NC Medicaid now requires prescribers to have an active DEA certification on file in NCTracks before controlled substance claims will be adjudicated. Beginning November 1, 2026, pharmacy claims for controlled substances will be denied if the prescribing provider lacks an active DEA number in their NCTracks provider enrollment record. Billing teams must ensure all prescribing providers have DEA certifications documented in NCTracks by this deadline.
UnitedHealthcare · Effective Oct 1, 2026High impact
Extracorporeal Shock Wave Therapy (ESWT) for Musculoskeletal Conditions and Soft Tissue Indications (for North Carolina Only)
UnitedHealthcare Community Plan (Medicaid) in North Carolina has updated its ESWT policy effective October 1, 2026, adding notation that CPT codes 0101T, 0102T, 0512T, 0513T, 0864T, and 28890 are NOT on the NC Medicaid Fee Schedule and therefore may not be covered. Billing teams must immediately identify and flag claims using these codes for NC Medicaid patients, as they will likely be denied.
UnitedHealthcare · Effective Oct 1, 2026High impact
Electric Tumor Treatment Field Therapy (for North Carolina Only)
UnitedHealthcare Community Plan of North Carolina has updated its policy on Electric Tumor Treatment Field Therapy, adding notation that HCPCS codes A4555, E0766, and E0767 are NOT on the North Carolina Medicaid Fee Schedule and therefore may not be covered by NC Medicaid. The policy also updated clinical evidence and references to reflect current information, effective October 1, 2026.
UnitedHealthcare · Effective Oct 1, 2026High impact
Bronchial Thermoplasty (for North Carolina Only)
UnitedHealthcare Community Plan of North Carolina has updated its Bronchial Thermoplasty policy, effective October 1, 2026. CPT codes 31660 and 31661 are now noted as NOT on the North Carolina Medicaid Fee Schedule and therefore may not be covered by the State of North Carolina Medicaid Program. The policy also updated clinical evidence and references to reflect current information.
Humana · Effective Oct 1, 2026High impact
Molecular Biomarkers for Prostate Cancer Risk Stratification - Medicare Advantage (Revised)
This is a comprehensive Medicare Advantage coverage policy for molecular biomarker tests used in prostate cancer risk stratification (effective 10/1/2026). The policy establishes coverage criteria for tests like ArteraAI, EpiSwitch, IsoPSA, MyProstateScore 2.0, ProMark, and ProsTAV, with coverage determinations based on MAC-specific LCDs/LCAs that vary by geographic jurisdiction. Billing teams must identify the correct MAC jurisdiction and apply the corresponding LCD requirements for each test ordered.
Humana · Effective Oct 1, 2026High impact
Bariatric Surgery - Medicare Advantage (Revised)
This is a comprehensive Medicare Advantage bariatric surgery coverage policy (HUM-1020-005) effective October 1, 2026, that outlines coverage determinations, limitations, and coding requirements for various bariatric procedures. The policy applies Humana's Medicare Advantage coverage standards and references applicable MAC Local Coverage Determinations by geographic jurisdiction, with specific rules varying by state and MAC region.
NC Medicaid - NCDHHS · Effective Oct 1, 2026High impact
ICD-10 Update Effective Oct. 1, 2026
NC Medicaid (Direct and Managed Care) has released updated ICD-10-CM and ICD-10-PCS code files effective October 1, 2026. Billing teams must download and implement the 2027 code updates for all discharges and patient encounters occurring from October 1, 2026, through September 30, 2027. Using outdated codes after this date will result in claim denials.
NC Medicaid - NCDHHS · Effective Oct 1, 2026High impact
Updated 1915(i) Assessment and Companion Guide Now Available
NC Medicaid has released an updated 1915(i) Assessment Tool with new fields capturing more detailed beneficiary information, effective October 1, 2026. The revised tool must be used for all new 1915(i) service requests and eligibility reassessments; previous versions published before August 3, 2026 will be rejected and returned as 'Unable to Process.' A companion guide has been created to support implementation.
NC Medicaid - NCDHHS · Effective Oct 1, 2026High impact
Deadline Extended to Oct. 1, 2026, for 251S00000X Providers With No Services Selected
NC Medicaid extended the deadline to October 1, 2026, for organizational providers with taxonomy 251S00000X to add at least one active SERVICE-TYPE and SERVICE to their enrollment. Providers failing to meet this requirement by the deadline will face termination of their taxonomy and potentially their service location and provider record. The state is adding new Services that do not require national accreditation, with details expected in early August 2026.
Ambetter · Effective Sep 28, 2026High impact
Leveling of Care: Emergency Department Evaluation and Management Overcoding for Facility Services
Effective September 28, 2026, Ambetter of North Carolina will implement automated recoding of emergency department E&M facility service claims to appropriate CPT levels based on resources utilized (nursing time, clinical staff, supplies, equipment, overhead), not physician cognitive work. Claims billed at higher levels than supported by facility resources will be automatically downleveled to the highest level meeting criteria under their peer risk adjustment process.
NC Medicaid - NCDHHS · Effective Sep 1, 2026High impact
Amendment to Clinical Coverage Policy 8G Peer Support Services
NC Medicaid amended Clinical Coverage Policy 8G for Peer Support Services effective September 1, 2026. Key changes include: (1) new prior authorization and utilization management requirements, (2) revised documentation standards requiring start/end times for interventions, (3) telehealth/telephonic services limited to less than 10% of total service time per beneficiary per fiscal year, (4) only NC Certified Peer Support Specialists (NC CPSS) may bill for services, and (5) updated supervision and training requirements for PSS Program Supervisors and Peer Support Specialists.
Humana · Effective Sep 1, 2026High impact
Spinal Fusion Surgery - Medicare Advantage (Revised)
This is a revised Medicare Advantage medical coverage policy for spinal fusion surgery (effective 09/01/2026) that consolidates coverage determination, limitations, coding information, and evidence summaries for cervical, lumbar, and thoracic spinal fusion procedures. The policy references multiple MAC-specific Local Coverage Determinations (LCDs) across geographic jurisdictions and outlines covered procedures including traditional fusion, minimally invasive approaches (DLIF, XLIF, MITLIF), sacroiliac joint fusion, and interlaminar fusion techniques. Billing teams must align claims submission with the applicable MAC LCD based on patient location and ensure procedures meet specific medical necessity criteria outlined in the referenced determinations.
Humana · Effective Sep 1, 2026High impact
Benign Prostatic Hyperplasia Treatments - Medicare Advantage (Revised)
This is a comprehensive Medicare Advantage coverage policy for Benign Prostatic Hyperplasia treatments effective September 1, 2026. The policy outlines coverage determinations for multiple BPH treatment modalities including surgical procedures (TURP, prostatectomy, laser therapies), temporary implanted devices, stents, and diagnostic testing. The policy references multiple MAC-specific Local Coverage Determinations (LCDs) that vary by geographic jurisdiction, requiring billing teams to verify applicable coverage rules based on patient location.
Humana · Effective Sep 1, 2026High impact
Ambulatory Cardiac Monitoring Devices - Medicare Advantage (Revised)
Humana Medicare Advantage has revised its Ambulatory Cardiac Monitoring Devices policy effective September 1, 2026. The policy provides updated coverage guidance for various cardiac monitoring technologies (Holter monitors, patch recorders, external loop monitors, implantable loop recorders, and mobile cardiac outpatient telemetry) with MAC-specific coverage determinations by geographic jurisdiction. The policy document appears incomplete but establishes that medical necessity determinations will follow applicable NCDs and LCDs based on the member's jurisdiction.
NC Medicaid - NCDHHS · Effective Aug 11, 2026High impact
Provider Categorical Risk Level Adjustment
North Carolina Medicaid has implemented a Provider Categorical Risk Level Adjustment policy that automatically escalates providers from Limited or Moderate risk to High risk based on specific triggering events (fraud allegations, OIG exclusions, outstanding overpayments, conviction exemptions, etc.). Providers bumped to High risk must complete site visits and fingerprinting within specified timeframes or face termination from all NCDHHS programs. An off-cycle revalidation is required two years after the bump-up, then providers return to the standard five-year revalidation cycle.
Humana · Effective Aug 6, 2026High impact
Neuroablative Techniques for Chronic Pain - Medicare Advantage (Revised)
This is a comprehensive Medicare Advantage coverage policy for neuroablative techniques used to treat chronic pain, effective 08/06/2026. The policy defines coverage criteria, eligible procedures (including radiofrequency ablation, cryoablation, chemical neurolysis, and specialized devices like Intracept), and references MAC-specific LCDs and billing codes by geographic jurisdiction. Billing teams must verify applicable MAC guidelines for their state and ensure claims comply with local coverage determinations.
Humana · Effective Aug 6, 2026High impact
Neuroablative Techniques for Chronic Pain - Medicare Advantage (Revised)
This is a comprehensive Medicare Advantage policy on neuroablative techniques for chronic pain management, effective 08/06/2026. The policy defines covered denervation procedures (radiofrequency ablation, cryoablation, facet denervation, basivertebral nerve ablation, and others) and references MAC-specific LCDs and NCDs that vary by geographic jurisdiction. Billing teams must verify applicable MAC requirements for their region before processing claims for these procedures.
Blue Cross NC · Effective Aug 5, 2026High impact
Medical Policy Updates August 5, 2026
Blue Cross NC issued a comprehensive medical policy update effective August 5, 2026, affecting 11 clinical policies including allergen testing, cardiovascular risk assessment, sexually transmitted infection testing, and colorectal cancer screening. Multiple billing codes were added, removed, or modified across these policies, requiring immediate system updates and billing team training to ensure accurate claim submission and avoid denials.
Humana · Effective Aug 3, 2026High impact
Genetic Testing for Hereditary Cancer - Medicare Advantage (Revised)
This is a comprehensive Medicare Advantage policy on genetic testing for hereditary cancer syndromes, effective August 3, 2026. The policy establishes coverage guidelines for germline genetic testing across multiple cancer types (melanoma, gastric cancer, neuroendocrine tumors, renal cell carcinoma, and others) and references specific MAC-based Local Coverage Determinations (LCDs) that vary by geographic jurisdiction. Billing teams must verify applicable MAC jurisdiction and LCD requirements before processing claims.
Humana · Effective Aug 3, 2026High impact
Breast Reconstruction - Medicare Advantage (Revised)
Humana Medicare Advantage has revised its breast reconstruction coverage policy (effective 08/03/2026) to clarify medical necessity criteria for reconstruction procedures following mastectomy, trauma, or congenital abnormalities. The policy applies MAC-specific Local Coverage Determinations (LCDs) by geographic jurisdiction and establishes criteria for determining coverage of implant removal, reduction mammaplasty, and related procedures. Billing teams must identify the appropriate MAC jurisdiction for each claim and apply the correct LCD requirements.
Humana · Effective Aug 3, 2026High impact
Benign Prostatic Hyperplasia Treatments - Medicare Advantage (Revised)
This is a comprehensive Medicare Advantage policy for Benign Prostatic Hyperplasia (BPH) treatments that became effective on August 3, 2026. The policy outlines coverage for multiple surgical and minimally invasive treatment modalities including TURP, laser therapies, temporary implanted devices, and stents, with specific coverage determinations varying by MAC jurisdiction. Billing teams must verify applicable MAC-specific LCDs and NCDs by geographic location before processing BPH treatment claims.
NC Medicaid - NCDHHS · Effective Aug 1, 2026High impact
Updated Reminder: Requirements for Research-Based Behavioral Health Treatment Service Delivery – Aug. 31, 2026
NC Medicaid published an updated Clinical Coverage Policy 8F for Research-Based Behavioral Health Treatment (RB-BHT) services, effective Aug. 1, 2026, and it applies to NC Medicaid Direct and NC Medicaid Managed Care. Paraprofessionals must hold a qualifying RBT certification from the BACB or ABAT certification from QABA for their RB-BHT services to be reimbursed, and telehealth is removed for paraprofessional RB-BHT services under CPT 97152 through 97154. Existing paraprofessionals without a qualifying certification have a 120-day grace period that starts Aug. 1, 2026.
Ambetter · Effective Aug 1, 2026High impact
Intraoperative Neurophysiologic Monitoring (IONM) Update: Effective 8/1/26
Effective August 1, 2026, Ambetter of North Carolina is updating IONM (Intraoperative Neurophysiologic Monitoring) reimbursement requirements for Marketplace plans. Only CMS-recognized payable codes (95940, G0453) will be covered; CPT 95941 is no longer 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.
NC Medicaid - NCDHHS · Effective Aug 1, 2026High impact
Updated Reminder: Requirements for Research-Based Behavioral Health Treatment Service Delivery – Aug. 5, 2026
NC Medicaid updated Clinical Coverage Policy 8F for research-based behavioral health treatment (RB-BHT) services, effective August 1, 2026. Paraprofessionals must hold at least one qualifying certification, either the Registered Behavior Technician certification from the BACB or the ABAT certification from QABA, for their services provided to Medicaid beneficiaries to be reimbursed. Telehealth is removed for paraprofessional RB-BHT services under CPT codes 97152-97154, and telehealth may be used for up to 50% of total 97155 billing per beneficiary per 180-calendar day period.
NC Medicaid - NCDHHS · Effective Aug 1, 2026High impact
Updates to Rate Increase for Personal Care Services and the Community Alternatives Program
Effective August 1, 2026, NC Medicaid is applying an 18% rate increase across all Personal Care Services (PCS) procedure codes for NC Medicaid Direct, CAP/C, CAP/DA, and CAP/CD programs. This replaces the previous July 31, 2026 bulletin and also applies to PCS furnished through NC Medicaid Managed Care (Standard Plans and Tailored Plans). Billing teams must update fee schedules in their systems and ensure claims reflect the new rates.
NC Medicaid - NCDHHS · Effective Aug 1, 2026High impact
Rate Increase for Personal Care Services and the Community Alternatives Program
Effective August 1, 2026, North Carolina Medicaid is implementing an 18% rate increase for all Personal Care Services (PCS) procedure codes across NC Medicaid Direct, CAP/C, CAP/DA, and CAP/CD programs. Billing teams must update fee schedules in their systems and ensure managed care plans load new rates within 45 days of DHB notification, with an additional 30-day claims reprocessing window.
NC Medicaid - NCDHHS · Effective Jul 15, 2026High impact
Update to North Carolina Medicaid Due Process/Appeals Unit Fax Number for Claim Review
North Carolina Medicaid has updated the fax number for the Due Process/Appeals Unit, which handles claim payment and denial reviews. Providers must immediately begin using the new fax number 984-687-9569 (effective July 15, 2026) when requesting claim reviews to ensure timely receipt of appeals.
Blue Cross NC · Effective Jul 15, 2026High impact
Medical Policy Update July 15, 2026
Blue Cross NC released a comprehensive medical policy update effective July 15, 2026, affecting 30+ clinical policies across cardiology, endocrinology, ophthalmology, orthopedics, and other specialties. Key changes include: removal of specific billing codes (99091, 98925-98929), expansion of coverage for artificial pancreas devices in type 2 diabetes, archival of three policies (Fundus Photography, Refractive Surgery, Sensory Integration Therapy), and clarification edits to multiple cardiac and ophthalmic procedures. Billing teams must identify affected services within their patient populations and update claims processing logic accordingly.
NC Medicaid - NCDHHS · Effective Jul 12, 2026High impact
Recent Behavioral Health Enrollment Updates for Organizations
North Carolina Medicaid updated enrollment requirements for behavioral health providers under the Innovations Waiver Program and Community Intervention Services (CIS), effective July 12 and August 23, 2026. Changes include new accrediting body options (Council on Quality and Leadership), new service types (Outpatient Behavioral Health Service, Facility-based Crisis Service for Children & Adolescents), and new national accreditation requirements for specific services within one year of enrollment.

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Obstructive and Central Sleep Apnea Treatment (for North Carolina Only)

Molecular Oncology Testing for Solid Tumor Cancer Diagnosis, Prognosis, and Treatment Decisions (for North Carolina Only)

October 2026 Provider Newsletter

NC Integrated Care for Kids Closeout and Related Billing Code Changes

New oncology prior authorization code updates

August Provider Newsletter

June 2026 Newsletter

Ambetter of North Carolina Inc. Billing Code Update for various HCPC H Codes: Effective 01/01/2027

Transition to American Medical Association Maternity Current Procedural Terminology 2027 Code Changes Effective Jan. 1, 2027

Reminder: Innovations Waiver Provider Services Updates

Transarterial Radioembolization (TARE)/Selective Internal Radiation Therapy (SIRT) for the Treatment of Malignant Cancers of the Liver (for North Carolina Only)

Cardiovascular Disease Risk Tests (for North Carolina Only)

Breast Imaging for Screening and Diagnosing Cancer (for North Carolina Only)

Treatment of Temporomandibular Joint Disorders (for North Carolina Only)

Surgery of the Knee (for North Carolina Only)

Outpatient Surgical Procedures – Site of Service (for North Carolina Only)

Bariatric Surgery (for North Carolina Only)

Update on Care Coordination for High-Risk Pregnant Women and At-Risk Children

Termination of Taxonomy 251S00000X for Records Without a Service Effective Nov. 2, 2026

Quarterly Provider Update – Summer 2026

Spinal Fusion and Decompression (for North Carolina Only)

Action Required: Drug Enforcement Administration Certification Required for Prescribing Controlled Substances

Extracorporeal Shock Wave Therapy (ESWT) for Musculoskeletal Conditions and Soft Tissue Indications (for North Carolina Only)

Electric Tumor Treatment Field Therapy (for North Carolina Only)

Bronchial Thermoplasty (for North Carolina Only)

Molecular Biomarkers for Prostate Cancer Risk Stratification - Medicare Advantage (Revised)

Bariatric Surgery - Medicare Advantage (Revised)

ICD-10 Update Effective Oct. 1, 2026

Updated 1915(i) Assessment and Companion Guide Now Available

Deadline Extended to Oct. 1, 2026, for 251S00000X Providers With No Services Selected

Leveling of Care: Emergency Department Evaluation and Management Overcoding for Facility Services

Amendment to Clinical Coverage Policy 8G Peer Support Services

Spinal Fusion Surgery - Medicare Advantage (Revised)

Benign Prostatic Hyperplasia Treatments - Medicare Advantage (Revised)

Ambulatory Cardiac Monitoring Devices - Medicare Advantage (Revised)

Provider Categorical Risk Level Adjustment

Neuroablative Techniques for Chronic Pain - Medicare Advantage (Revised)

Neuroablative Techniques for Chronic Pain - Medicare Advantage (Revised)

Medical Policy Updates August 5, 2026

Genetic Testing for Hereditary Cancer - Medicare Advantage (Revised)

Breast Reconstruction - Medicare Advantage (Revised)

Benign Prostatic Hyperplasia Treatments - Medicare Advantage (Revised)

Updated Reminder: Requirements for Research-Based Behavioral Health Treatment Service Delivery – Aug. 31, 2026

Intraoperative Neurophysiologic Monitoring (IONM) Update: Effective 8/1/26

Updated Reminder: Requirements for Research-Based Behavioral Health Treatment Service Delivery – Aug. 5, 2026

Updates to Rate Increase for Personal Care Services and the Community Alternatives Program

Rate Increase for Personal Care Services and the Community Alternatives Program

Update to North Carolina Medicaid Due Process/Appeals Unit Fax Number for Claim Review

Medical Policy Update July 15, 2026

Recent Behavioral Health Enrollment Updates for Organizations