ExchangePrior AuthHigh impact
Evolent Prior Authorization Updates Effective January 1, 2027
Ambetter·TN · Cardiology, Vascular Surgery·Prior Authorization
Effective date
Jan 1, 2027
We identified it
Aug 26, 2026
Summary
Effective January 1, 2027, Evolent is adding 24 cardiology procedure codes related to endovascular revascularization to its prior authorization requirements for Ambetter of Tennessee Marketplace plans. These codes cover iliac, femoral, popliteal, and tibial/peroneal vascular territory procedures with angioplasty, stent placement, and/or atherectomy. All prior authorizations for these codes will be managed by Evolent Specialty Services.
Action Required
By December 15, 2026: Billing team must update the billing system to require prior authorization through Evolent Specialty Services for all 18 cardiology CPT codes (37254, 37256, 37258, 37260, 37263, 37265, 37267, 37269, 37271, 37273, 37275, 37277, 37280, 37282, 37284, 37286, 37288, 37290) when billed to Ambetter of Tennessee Marketplace plans. Update encounter forms and provider templates to flag these procedures as requiring prior auth. Train clinical and billing staff on the new requirement. Contact local Provider Engagement representative with questions. Failure to obtain prior authorization for these codes will result in claim denials for Ambetter Tennessee members effective January 1, 2027.