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Upcoming Evolent Program Enhancements for Ambetter Health Providers: Effective December 2026
Act
by Nov 1, 2026
Effective date
Dec 1, 2026
Identified
Aug 26, 2026
Summary
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.
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What to do
by Nov 1, 2026 · 6 steps
01Billing and clinical teams must update oncology prior authorization workflows to recognize that Evolent will now issue direct denials rather than Recommended Adverse Determinations (RADs) effective December 1, 2026.
02Train providers to expect final determinations instead of advisory recommendations.
03By November 15, 2026: Update authorization request submission processes for orthopedic surgeries (shoulder, hip, knee, spine) to include mandatory site-of-care selection fields effective December 5, 2026.
04Billing team must prepare templates requiring providers to select preferred site of care and document clinical justification when hospital-based settings are chosen for outpatient-eligible procedures.
05Ensure all staff submitting MSK authorization requests understand that final determinations will evaluate both medical necessity AND site-of-care criteria.
06Contact Ambetter Health Provider Services (1-833-919-3213) or Evolent (1-888-999-7713) with any implementation questions.
If missed: Failure to comply with new authorization submission requirements may result in claim denials or processing delays.
Original notice
Upcoming Evolent Program Enhancements for Ambetter Health Providers: Effective December 2026
ambetterhealth.com · Always check the source before changing claims.
Related changes
See all Ambetter changes →Evolent Musculoskeletal Program Updates Effective Dec 5, 2026HighEffective Dec 5, 2026 · Provider BulletinEvolent Musculoskeletal Program Updates: Effective November 3, 2026HighEffective Nov 3, 2026 · Prior AuthorizationEvolent Oncology Program UpdatesMediumEffective Dec 1, 2026 · Provider BulletinEvolent Oncology Program Updates Effective October 1, 2026MediumEffective Oct 1, 2026 · Provider BulletinBrowse every Ambetter change in the policy list