What types of policy changes does Ambetter issue?

Ambetter regularly publishes coverage updates including prior authorization requirement changes, billing code additions or deletions, plan-type coverage modifications, and clinical policy revisions. PolicyChanges.app monitors these notices and summarizes the impact for providers.

How often does Ambetter update its policies?

Ambetter typically releases policy bulletins on a rolling basis throughout the year. Our system checks for new updates daily and adds them to this feed as soon as they are identified.

How many Ambetter policy changes are tracked here?

This page currently tracks 50 documented Ambetter policy changes. New items are added as they are identified.

What should I do when Ambetter changes a prior authorization policy?

Review each change's effective date and action-required notes. Update your billing and clinical workflows before the effective date to avoid claim denials. Each policy detail page on PolicyChanges.app includes a plain-English summary and action items.

PAYER POLICY CHANGES

Ambetter Policy Changes & Prior Auth Updates

We track 50 documented policy changes from Ambetter across AL, AR, AZ, CA, DE and 5 more states. Each entry includes an AI-generated plain-English summary, effective date, affected billing codes, and a direct link to the original Ambetter notice. Use the related links below to narrow results by specialty or state, or create a free alert to get new Ambetter updates by email (daily or weekly, your choice, on every plan).

Ambetter · Effective Nov 30, 2026High impact
Effective November 30, 2026: Clinical Policies
Effective November 30, 2026 at 12:00 AM, Ambetter Health and Superior HealthPlan updated several clinical policies for Medicaid (STAR, STAR Health, STAR Kids, STAR+PLUS), CHIP and Ambetter Health products. A new policy sets medical necessity criteria for skin and soft tissue substitutes for diabetic foot ulcers, venous leg ulcers and burns, covering up to four initial applications and continued treatment up to ten applications per wound per 12-week episode. Selective nerve root block criteria now apply to diagnostic purposes only, and all therapeutic indications were removed.
Ambetter · Effective Dec 1, 2026High impact
Upcoming Evolent Program Enhancements for Ambetter Health Providers: Effective December 2026
Ambetter Health is implementing two program enhancements effective December 2026: (1) Beginning December 1, Evolent will issue direct denial determinations for oncology prior authorizations that don't meet clinical criteria instead of issuing Recommended Adverse Determinations; (2) Beginning December 5, Evolent will require site-of-care selection for shoulder, hip, knee, and spine surgeries with clinical justification if hospital-based settings are chosen for outpatient-eligible procedures.
Ambetter · Effective Dec 2, 2026High impact
Revision to Payment Platform Transition from Payspan to Zelis
Centene is transitioning claims payment processing from Payspan to the Zelis platform, with phased conversions beginning December 2, 2026 (WellCare Medicare) and extending through February 5, 2027 (Iowa Total Care Medicaid and WellCare Dual Eligible). Practices must enroll in a Zelis payment method (ZAPP Edge, Virtual Card, ePayment Center, or Paper Check) before their line of business converts to avoid payment disruption or default to paper checks.
Ambetter · Effective Dec 5, 2026High impact
Evolent Musculoskeletal Program Updates: Effective December 5, 2026
Effective December 5, 2026, Ambetter from WellCare of Kentucky (through Evolent) is implementing site-of-care requirements for shoulder, hip, knee, and spine surgeries. Ordering providers must now select a preferred outpatient site when submitting authorization requests for procedures that can be performed in an outpatient setting; hospital-based site selection will require either an allowable exception or clinical justification. Prior authorizations will reflect determinations for both the procedure and site of care.
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.
Ambetter · Effective Dec 5, 2026High impact
Evolent Musculoskeletal Program Updates: Effective December 5, 2026
Effective December 5, 2026, Evolent will implement site-of-care selection requirements for shoulder, hip, knee, and spine surgeries for Ambetter from WellCare of New Jersey members. Ordering providers must now specify preferred outpatient or inpatient settings during authorization requests; hospital-based settings for outpatient-eligible procedures require either selection from allowable exceptions or clinical justification. Clinical reviewers will evaluate both medical necessity and site of care before authorization is finalized.
Ambetter · Effective Dec 5, 2026High impact
Evolent Musculoskeletal Program Updates Effective December 5, 2026 (PDF)
Effective December 5, 2026, Evolent is implementing new site-of-care selection requirements for shoulder, hip, knee, and spine surgeries across its Medicaid, Marketplace, and Medicare plans. Ordering providers must now select a preferred outpatient or inpatient site during prior authorization intake; if hospital-based settings are chosen for procedures safely performed in outpatient settings, providers must document clinical justification or select from allowable exceptions. Clinical reviewers will evaluate both medical necessity and site of care before rendering authorization determinations.
Ambetter · Effective Dec 5, 2026High impact
Evolent Musculoskeletal Program Updates Effective 12/05/2026
Effective December 5, 2026, Evolent (on behalf of Sunflower) is implementing new site-of-care selection requirements for shoulder, hip, knee, and spine surgeries. Ordering providers must now select a preferred outpatient or inpatient site during authorization requests; if hospital-based settings are chosen for procedures that can be performed outpatient, providers must justify the selection or select from allowable exceptions. Clinical reviewers will evaluate both medical necessity and site-of-care criteria before authorization.
Ambetter · Effective Dec 5, 2026High impact
Effective December 5, 2026: Prior Authorization Updates for Musculoskeletal Surgical Procedures
Beginning December 5, 2026, Superior HealthPlan and Ambetter Health will require prior authorization requests for musculoskeletal surgeries (shoulder, hip, knee, spine) to specify a preferred site of care. Providers selecting hospital-based settings for procedures that can be performed in outpatient settings must either choose from allowable exceptions or provide clinical justification. Clinical reviewers will evaluate both medical necessity and site-of-care criteria before rendering authorization determinations.
Ambetter · Effective Dec 5, 2026High impact
Evolent Musculoskeletal Program Updates Effective 12.5.26
Effective December 5, 2026, Evolent will implement new site-of-care selection requirements for shoulder, hip, knee, and spine surgeries for Ambetter Marketplace members. Providers must select outpatient settings when clinically appropriate; if hospital-based settings are chosen for procedures that can be performed outpatient, providers must document allowable exceptions or provide clinical justification. Clinical reviewers will evaluate both medical necessity and site of care before authorization.
Ambetter · Effective Dec 5, 2026High impact
Evolent Musculoskeletal Program Updates Effective Dec 5, 2026
Effective December 5, 2026, Evolent/Ambetter from Meridian is implementing a new site-of-care selection requirement for shoulder, hip, knee, and spine surgeries. Providers must now select a preferred outpatient or inpatient site during prior authorization requests; if hospital-based care is chosen for procedures eligible for outpatient settings, providers must justify with clinical documentation or select from allowable exceptions. Final authorizations will reflect determinations for both the procedure and site of care.
Ambetter · Effective Dec 5, 2026High impact
Evolent Musculoskeletal Program Updates Effective December 5, 2026 (PDF)
Effective December 5, 2026, Evolent is implementing mandatory site-of-care selection for shoulder, hip, knee, and spine surgeries for Home State Health, Show Me Healthy Kids, and Ambetter from Home State Health members. Providers must justify hospital-based settings for procedures that can be safely performed in outpatient settings, or select from allowable exceptions. Clinical reviewers will evaluate both medical necessity and site of care before issuing final authorization.
Ambetter · Effective Dec 6, 2026High impact
Leveling for Facility Claims
Ambetter from WellCare of Kentucky will apply national CPT guidelines to the coding of outpatient emergency department E&M levels for facility claims beginning 12/06/2026. Under the payer's comparative peer risk adjustment process, E&M claim lines will be recoded to the corrected level, with reimbursement at the highest level whose criteria are met, based on facility resources such as nursing time, clinical staff effort, supplies, equipment, and overhead rather than provider cognitive work. The payer's policy CC.PP.80 replaces the previous Optum EDC Analyzer.
Ambetter · Effective Dec 15, 2026High impact
Evolent Musculoskeletal Program Updates Effective Dec 15, 2026
Effective December 15, 2026, Evolent (for Ambetter from Meridian members) is implementing mandatory site-of-care selection for shoulder, hip, knee, and spine surgeries. Providers must now choose outpatient settings for procedures that can be safely performed outside hospitals, or provide clinical justification for inpatient admission. Both procedure medical necessity and site of care will be evaluated during authorization review.
Ambetter · Effective Dec 20, 2026High impact
New and Updated Clinical Payment Policies: December 20th, 2026 (PDF)
Home State Health Plan implemented seven clinical payment policy changes effective December 20, 2026, affecting behavioral health documentation requirements, burn surgery coverage, fetal surgery criteria, epidural injection frequency limits, therapy services language requirements, genetic testing, and gender-affirming procedures. The most operationally significant change is the Behavioral Health Treatment Documentation Requirements policy (HIM.CP.BH.500/CP.MP.500), which adds nine new documentation elements and modifies existing requirements for mental health claims. Billing teams must immediately review affected policies, update documentation templates and prior authorization workflows, and communicate requirements to providers.
Ambetter · Effective Jan 1, 2027High impact
Ambetter Health of Delaware Billing Code Update for various HCPC H Codes: Effective 01/01/2027
Effective January 1, 2027, Ambetter Health of Delaware will stop covering 45 HCPCS H codes (H0003–H0047, H1011, H2001–H2033) and will begin covering HCPCS code H0006. The practice must stop billing the discontinued codes to Ambetter Delaware members and update charge entry and claim submission processes to reflect coverage changes.
Ambetter · Effective Jan 1, 2027High impact
Effective January 1, 2027: Pharmacy and Biopharmacy Policies
Effective January 1, 2027, Superior HealthPlan and Ambetter plans are implementing comprehensive updates to 30+ pharmacy and biopharmacy policies, including new prior authorization criteria, preferred drug redirections, and line-of-business expansions across multiple medication classes (insulin, GLP-1 agonists, DMARDs, biologics, and others). Billing teams must verify which policies affect their patient population and update prior authorization workflows, formulary redirects, and claim processing rules to reflect the new medical necessity criteria and preferred agent requirements.
Ambetter · Effective Jan 1, 2027High impact
Ambetter Health Billing Code Update for various HCPC H Codes: Effective 01/01/2027
Effective 01/01/2027, Ambetter Health will discontinue coverage for 45 HCPC H codes (primarily behavioral health and community support services) and will begin covering HCPC code H0006. Billing teams must update coding practices and prior authorization workflows to reflect these coverage changes.
Ambetter · Effective Jan 1, 2027High impact
Upcoming Changes to Pharmacy Policies (PDF)
This pharmacy policy update effective 1/1/2027 makes extensive changes to medication coverage criteria across 25+ drugs, including preferred agent redirections (e.g., Stelara to Imuldosa for autoimmune conditions), updated GLP-1 step-through requirements, addition of new line-of-business coverage (HIM/ICHRA), and retirement of obsolete policies. The most clinically impactful changes affect GLP-1 receptor agonists, insulin products, DMARDs, and biologics used in endocrinology, rheumatology, oncology, and dermatology practices.
Ambetter · Effective Jan 1, 2027High impact
September 2026 Provider Notification
Ambetter from Arkansas Health & Wellness has implemented 24 policy amendments and retirements effective January 1, 2027, affecting pharmacy prior authorization, preferred drug designations, and coverage criteria across multiple lines of business (HIM, ICHRA, Commercial). Key changes include stricter GLP-1 agonist authorization requirements, removal of certain preferred drugs (Humatrope, Stelara), addition of generics with brand redirections, and updates to diabetes and specialty medication policies.
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 from Coordinated Care Corporation Billing Code Update for various HCPC H Codes: Effective 01/01/2027
Effective January 1, 2027, Ambetter from Coordinated Care Corporation will discontinue coverage for 42 HCPCS H codes (primarily behavioral health and social services codes) while simultaneously adding coverage for H0006. Billing teams must identify all claims currently using the discontinued codes and transition to alternative coding or request prior authorization to determine covered alternatives.
Ambetter · Effective Jan 1, 2027High impact
Ambetter of Illinois Billing Code Update for various HCPC H Codes: Effective 01/01/2027
Effective January 1, 2027, Ambetter of Illinois will discontinue coverage for 46 HCPCS H codes (behavioral health and social services codes) while adding coverage for H0006. Billing teams must identify all claims currently using the non-covered codes and implement workflow changes to prevent claim denials after the effective date.
Ambetter · Effective Jan 1, 2027High impact
Ambetter Health Billing Code Update for various HCPC H Codes: Effective 01/01/2027
Effective 01/01/2027, Ambetter Health is discontinuing coverage for 52 HCPCS H codes related to alcohol/drug treatment, behavioral health services, and mental health support. Simultaneously, H0006 (Alcohol/drug service, case management) will become newly covered. The billing team must immediately identify affected claims in the system and implement denial protocols for non-covered codes starting January 1, 2027.
Ambetter · Effective Jan 1, 2027High impact
Ambetter from Buckeye Health Plan Billing Code Update for various HCPC H Codes: Effective 01/01/2027
Effective January 1, 2027, Ambetter from Buckeye Health Plan will discontinue coverage for 45 HCPCS H codes commonly used for behavioral health and community support services. Simultaneously, H0006 coverage will begin. The practice must identify all affected claims and implement billing workflow changes to avoid denials.
Ambetter · Effective Jan 1, 2027High impact
Ambetter of Tennessee Billing Code Update for various HCPC H Codes: Effective 01/01/2027
Effective January 1, 2027, Ambetter of Tennessee will discontinue coverage for 46 HCPCS H codes (primarily behavioral health and social services codes) while adding coverage for H0006. The billing team must identify all claims currently using the non-covered codes and transition to alternative billing codes or obtain clarification on approved alternatives before the effective date.
Ambetter · Effective Jan 1, 2027High impact
Ambetter from Absolute Total Care Billing Code Update for various HCPC H Codes: Effective 01/01/2027
Effective January 1, 2027, Ambetter from Absolute Total Care will discontinue coverage for 45 HCPCS H codes (primarily behavioral health and substance abuse treatment services) while adding coverage for H0006. Billing teams must identify all claims using discontinued codes and transition to alternative codes or obtain patient verification of coverage changes.
Ambetter · Effective Jan 1, 2027High impact
Ambetter of Oklahoma Billing Code Update for various HCPC H Codes: Effective 01/01/2027
Effective January 1, 2027, Ambetter of Oklahoma will discontinue coverage for 46 HCPCS H codes commonly used for behavioral health, substance abuse treatment, and related services. Simultaneously, H0006 coverage begins on the same date. The billing team must identify all affected claims and establish processes to deny or redirect these codes for Ambetter Oklahoma members.
Ambetter · Effective Jan 1, 2027High impact
Ambetter from SilverSummit Healthplan Billing Code Update for various HCPC H Codes: Effective 01/01/2027
Effective January 1, 2027, Ambetter from SilverSummit Healthplan will discontinue coverage for 45 HCPCS H codes (primarily behavioral health and support services) while adding coverage for H0006. Billing teams must identify all claims using the discontinued codes and implement alternative billing strategies or obtain patient financial responsibility agreements.
Ambetter · Effective Jan 1, 2027High impact
Ambetter from WellCare of New Jersey Billing Code Update for various HCPC H Codes: Effective 01/01/2027
Effective January 1, 2027, Ambetter from WellCare of New Jersey will discontinue coverage for 45 HCPCS H codes (behavioral health and substance abuse treatment services) while adding coverage for H0006. Billing teams must identify all claims using the discontinued codes and implement alternative billing strategies or prior authorization processes before the effective date.
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.
Ambetter · Effective Jan 1, 2027High impact
Ambetter from Magnolia Health Billing Code Update for various HCPC H Codes: Effective 01/01/2027
Effective 01/01/2027, Ambetter from Magnolia Health will discontinue coverage for 45 HCPCS H codes (behavioral health and substance abuse treatment services) while adding coverage for H0006. Billing teams must immediately identify affected services, update claim submission logic, and prepare providers for coverage gaps to avoid claim denials.
Ambetter · Effective Jan 1, 2027High impact
Ambetter from Home State Health Billing Code Update for various HCPC H Codes: Effective 01/01/2027
Effective January 1, 2027, Ambetter from Home State Health will discontinue coverage for 45 HCPCS H codes (behavioral health and social services codes) while adding coverage for H0006. Billing teams must identify all claims currently using the non-covered codes and develop transition plans, as continued billing of these codes will result in denials.
Ambetter · Effective Jan 1, 2027High impact
Ambetter from Meridian Billing Code Update for various HCPC H Codes: Effective 01/01/2027
Effective January 1, 2027, Ambetter from Meridian will no longer cover 45 HCPCS H codes (behavioral health and social services codes), while H0006 will begin coverage on that same date. Billing teams must identify all claims using the discontinued codes and implement alternative billing strategies or have claims denied.
Ambetter · Effective Jan 1, 2027High impact
Ambetter from Louisiana Healthcare Connections Billing Code Update for various HCPC H Codes: Effective 01/01/2027
Effective January 1, 2027, Ambetter from Louisiana Healthcare Connections will discontinue coverage for 45 HCPCS H codes (behavioral health and social services) while adding coverage for H0006. Billing teams must identify affected claims, update system edits, and establish alternative coding or prior authorization protocols before the effective date.
Ambetter · Effective Jan 1, 2027High impact
Ambetter from WellCare of Kentucky Billing Code Update for various HCPC H Codes: Effective 01/01/2027
Effective January 1, 2027, Ambetter from WellCare of Kentucky will discontinue coverage for 46 HCPCS H codes (behavioral health and social services codes), while simultaneously activating coverage for H0006. Billing teams must identify all claims currently using the discontinued codes and establish alternative billing strategies or obtain prior authorization requirements before the effective date.
Ambetter · Effective Jan 1, 2027High impact
Ambetter from Peach State Health Plan Billing Code Update for various HCPC H Codes: Effective 01/01/2027
Effective January 1, 2027, Ambetter from Peach State Health Plan will discontinue coverage for 45 HCPC H codes (H0003-H0047, H1011, H2001-H2033) commonly used for behavioral health, substance abuse treatment, and support services. Simultaneously, H0006 coverage will be newly activated. Practices must identify affected claims, update billing systems, and establish alternative coding or coverage verification processes before the effective date.
Ambetter · Effective Jan 1, 2027High impact
Ambetter Health Billing Code Update for various HCPC H Codes: Effective 01/01/2027
Effective January 1, 2027, Ambetter Health will discontinue coverage for 45 HCPCS H codes (primarily behavioral health and substance abuse treatment codes) while simultaneously adding coverage for H0006. Billing teams must immediately identify affected services, audit current patient encounters, and prepare to transition claims to alternative coding or halt billing for these services by the effective date.
Ambetter · Effective Jan 1, 2027High impact
Ambetter from Arizona Complete Health Billing Code Update for various HCPC H Codes: Effective 01/01/2027
Effective January 1, 2027, Ambetter from Arizona Complete Health will discontinue coverage for 45 HCPCS H codes (primarily behavioral health and social services codes) while adding coverage for H0006. Billing teams must identify all claims using the discontinued codes and implement alternative billing strategies to avoid claim denials.
Ambetter · Effective Jan 1, 2027High impact
Ambetter from Arkansas Health & Wellness Billing Code Update for various HCPC H Codes: Effective 01/01/2027
Effective January 1, 2027, Ambetter from Arkansas Health & Wellness will discontinue coverage for 45 HCPCS H codes (primarily behavioral health and substance abuse treatment services) while adding coverage for H0006. Billing teams must identify all claims using the discontinued codes and establish alternative coding or prior authorization strategies to avoid claim denials.
Ambetter · Effective Jan 1, 2027High impact
Ambetter of Alabama Billing Code Update for various HCPC H Codes: Effective 01/01/2027
Effective January 1, 2027, Ambetter of Alabama will discontinue coverage for 45 HCPCS H codes (primarily behavioral health and support services codes) while adding coverage for H0006. Billing teams must immediately identify affected claims and update billing software to prevent denials for non-covered codes after the effective date.
Ambetter · Effective Jan 1, 2027High impact
Ambetter Health Billing Code Update for various HCPC H Codes Effective 01/01/2027
Effective January 1, 2027, Ambetter Health will discontinue coverage for 45 HCPCS H codes commonly used for behavioral health, substance abuse treatment, and related services. Simultaneously, HCPCS code H0006 will become newly covered. Billing teams must immediately identify affected claims and update billing logic to prevent denials.
Ambetter · Effective Jan 1, 2027High impact
Ambetter from Superior HealthPlan Billing Code Update for various HCPC H Codes Effective 01/01/2027
Ambetter from Superior HealthPlan is discontinuing coverage for 46 HCPCS H codes effective January 1, 2027, while adding coverage for H0006. Billing teams must identify claims currently using discontinued codes and establish alternative billing strategies or prior authorization workflows before the effective date.
Ambetter · Effective Jan 1, 2027High impact
Ambetter from Sunflower Health Plan Billing Code Update for various HCPC H Codes Effective 01/01/2027
Effective January 1, 2027, Ambetter from Sunflower Health Plan will discontinue coverage for 45 HCPCS H codes (primarily behavioral health and substance abuse treatment services) while adding coverage for H0006. Billing teams must identify all claims currently using discontinued codes and establish alternative billing strategies or obtain patient notification protocols before the effective date.
Ambetter · Effective Jan 1, 2027High impact
Evolent Prior Authorization Updates: Effective January 1, 2027
Evolent Specialty Services will require prior authorization for 23 cardiology codes covering angioplasty, stent placement and atherectomy in the iliac, femoral and popliteal, tibial and peroneal, and inframalleolar arteries, plus code 92930 for placement of intracoronary stents. The requirement begins January 1, 2027 for members of the Ambetter Health Marketplace and Wellcare Medicare health plans.
Ambetter · Effective Jan 1, 2027High impact
Evolent Prior Authorization Updates Effective January 1, 2027
Evolent Specialty Services will require prior authorization for 23 cardiology codes covering angioplasty, stent placement and atherectomy in the iliac, femoral and popliteal, tibial and peroneal, and inframalleolar arteries, plus code 92930 for placement of intracoronary stents. The requirement begins January 1, 2027 for members of the Ambetter Health Marketplace and Wellcare Medicare health plans.
Ambetter · Effective Feb 1, 2027High impact
30-Day Readmission Payment Policy Effective February 1, 2027
Home State Health and Ambetter from Home State Health are implementing a 30-Day Readmission Payment Policy effective February 1, 2027, which limits separate reimbursement for hospital readmissions occurring within 30 days of discharge when the readmission is clinically related and potentially preventable. Readmissions meeting these criteria will be treated as a continuation of the initial inpatient episode, with the Health Plan potentially denying separate payment. Billing teams must understand that Home State Health will review claims, medical records, and clinical documentation to make readmission determinations for reimbursement purposes.
Ambetter · Effective Dec 1, 2026Medium impact
Payspan Migration to Zelis (ZAPP)
Ambetter of Alabama is transitioning from PaySpan to Zelis (ZAPP) for claims and non-claims payments during December 2026 through early 2027. The practice must enroll in a Zelis payment method now to avoid disruption; if no enrollment occurs, payments will default to paper checks via USPS.
Ambetter · Effective Dec 1, 2026Medium impact
ASAM Criteria Changes for Adolescent and Transition-Aged Youth Substance Use Disorder Services: Effective December 1, 2026
Ambetter from WellCare of Kentucky is implementing ASAM 4th Edition Criteria for adolescent and transition-aged youth (TAY) substance use disorder services effective December 1, 2026. Changes include new admission and continued stay criteria, revised Levels of Care with new youth-specific levels, updated Six Dimensions assessment with a new Person-Centered Considerations dimension, and updated guidance for members aged 18-25. Providers must review and align internal assessments, documentation, and treatment-planning processes before the effective date.

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Effective November 30, 2026: Clinical Policies

Upcoming Evolent Program Enhancements for Ambetter Health Providers: Effective December 2026

Revision to Payment Platform Transition from Payspan to Zelis

Evolent Musculoskeletal Program Updates: Effective December 5, 2026

October 2026 Provider Newsletter

Evolent Musculoskeletal Program Updates: Effective December 5, 2026

Evolent Musculoskeletal Program Updates Effective December 5, 2026 (PDF)

Evolent Musculoskeletal Program Updates Effective 12/05/2026

Effective December 5, 2026: Prior Authorization Updates for Musculoskeletal Surgical Procedures

Evolent Musculoskeletal Program Updates Effective 12.5.26

Evolent Musculoskeletal Program Updates Effective Dec 5, 2026

Evolent Musculoskeletal Program Updates Effective December 5, 2026 (PDF)

Leveling for Facility Claims

Evolent Musculoskeletal Program Updates Effective Dec 15, 2026

New and Updated Clinical Payment Policies: December 20th, 2026 (PDF)

Ambetter Health of Delaware Billing Code Update for various HCPC H Codes: Effective 01/01/2027

Effective January 1, 2027: Pharmacy and Biopharmacy Policies

Ambetter Health Billing Code Update for various HCPC H Codes: Effective 01/01/2027

Upcoming Changes to Pharmacy Policies (PDF)

September 2026 Provider Notification

August Provider Newsletter

June 2026 Newsletter

Ambetter from Coordinated Care Corporation Billing Code Update for various HCPC H Codes: Effective 01/01/2027

Ambetter of Illinois Billing Code Update for various HCPC H Codes: Effective 01/01/2027

Ambetter Health Billing Code Update for various HCPC H Codes: Effective 01/01/2027

Ambetter from Buckeye Health Plan Billing Code Update for various HCPC H Codes: Effective 01/01/2027

Ambetter of Tennessee Billing Code Update for various HCPC H Codes: Effective 01/01/2027

Ambetter from Absolute Total Care Billing Code Update for various HCPC H Codes: Effective 01/01/2027

Ambetter of Oklahoma Billing Code Update for various HCPC H Codes: Effective 01/01/2027

Ambetter from SilverSummit Healthplan Billing Code Update for various HCPC H Codes: Effective 01/01/2027

Ambetter from WellCare of New Jersey Billing Code Update for various HCPC H Codes: Effective 01/01/2027

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

Ambetter from Magnolia Health Billing Code Update for various HCPC H Codes: Effective 01/01/2027

Ambetter from Home State Health Billing Code Update for various HCPC H Codes: Effective 01/01/2027

Ambetter from Meridian Billing Code Update for various HCPC H Codes: Effective 01/01/2027

Ambetter from Louisiana Healthcare Connections Billing Code Update for various HCPC H Codes: Effective 01/01/2027

Ambetter from WellCare of Kentucky Billing Code Update for various HCPC H Codes: Effective 01/01/2027

Ambetter from Peach State Health Plan Billing Code Update for various HCPC H Codes: Effective 01/01/2027

Ambetter Health Billing Code Update for various HCPC H Codes: Effective 01/01/2027

Ambetter from Arizona Complete Health Billing Code Update for various HCPC H Codes: Effective 01/01/2027

Ambetter from Arkansas Health & Wellness Billing Code Update for various HCPC H Codes: Effective 01/01/2027

Ambetter of Alabama Billing Code Update for various HCPC H Codes: Effective 01/01/2027

Ambetter Health Billing Code Update for various HCPC H Codes Effective 01/01/2027

Ambetter from Superior HealthPlan Billing Code Update for various HCPC H Codes Effective 01/01/2027

Ambetter from Sunflower Health Plan Billing Code Update for various HCPC H Codes Effective 01/01/2027

Evolent Prior Authorization Updates: Effective January 1, 2027

Evolent Prior Authorization Updates Effective January 1, 2027

30-Day Readmission Payment Policy Effective February 1, 2027

Payspan Migration to Zelis (ZAPP)

ASAM Criteria Changes for Adolescent and Transition-Aged Youth Substance Use Disorder Services: Effective December 1, 2026