All PlansPrior AuthMedium impact
Important Prior Authorization Updates (Effective October 1, 2026)
Ambetter·Genetics, General Surgery, ENT (Ear, Nose & Throat) +1 more·Prior Authorization
Effective date
Oct 1, 2026
We identified it
Aug 26, 2026
Summary
Ambetter Health is simplifying prior authorization requirements effective October 1, 2026, by removing PA requirements for genetic testing, home services, and transplant services, while adding PA requirements for specific sinus surgery procedures (31296, 31297). This change aims to reduce administrative burden and create uniform PA requirements across all markets and lines of business.
Action Required
By September 15, 2026: Billing team must update the billing system to reflect the following PA requirement changes for Ambetter Health plans: (1) Remove prior authorization requirements for genetic testing codes 86812, 86813, 86817; home visit codes S9211, S9213, S9214; and transplant code 38208; (2) Add prior authorization requirements for sinus surgery codes 31296 and 31297. Update encounter forms, billing software rules, and staff training materials to reflect these changes. Verify changes are live in the system at least 2 weeks before the October 1 effective date to prevent claim processing delays. Contact your Ambetter Health local Provider Engagement representative if clarification is needed on specific codes.