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Effective 11/1/26: New Prior Authorization Requirement for Certain Genetic Testing Procedures
Act
by Oct 15, 2026
Effective date
Nov 1, 2026
Identified
Aug 26, 2026
Summary
Effective November 1, 2026, Superior HealthPlan will require prior authorization for 11 specific genetic testing procedures across Medicaid (STAR, STAR Health, STAR Kids, STAR+PLUS), CHIP, Ambetter from Superior HealthPlan, and Ambetter Health Solutions members. Billing teams must implement prior authorization workflows for these procedure codes before the effective date to avoid claim denials.
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What to do
by Oct 15, 2026 · 4 steps
01Billing team must update billing system and prior authorization workflows to require prior authorization for all 12 genetic testing procedure codes (0493U, 0540U, 81162, 81523, 0632U, 0648U, 0650U, 0651U, 0652U, 0657U, 0658U, 0659U) for applicable plan members.
02Update encounter forms and provider templates to alert staff that prior authorization is required before ordering these tests.
03Confirm staff knows to reference Evolent's Genetic Testing Policies webpage for medical necessity criteria.
04Train front desk and clinical staff to inform patients that these procedures require pre-authorization.
If missed: Failure to obtain prior authorization will result in claim denials for all affected plan types.
Codes mentioned
8116281523
Original notice
Effective 11/1/26: New Prior Authorization Requirement for Certain Genetic Testing Procedures
ambetterhealth.com · Always check the source before changing claims.