Evolent Musculoskeletal Program Updates Effective November 3, 2026

By November 3, 2026: (1) Billing and authorization staff must update prior authorization workflows to require explicit site of care selection during authorization requests for shoulder, hip, knee, and spine surgeries for all Ambetter/Evolent members. (2) Providers must be educated to select outpatient settings as the default option when clinically appropriate, or document specific clinical justification for hospital-based inpatient selection from the list of allowable exceptions. (3) Update authorization submission processes and internal checklists to ensure both procedure and site of care determinations are captured in final authorizations. (4) Train billing team to expect dual determinations (procedure + site of care) on authorizations and to deny claims if site of care conflicts with authorization. Contact Evolent at 1-888-999-7713 or practicesuccess@evolent.com with questions on allowable exceptions. Failure to comply may result in authorization denials or claim rejections.