Medicare AdvantagePrior AuthMedium impact
Important Prior Authorization Updates: Effective October 1, 2026
Ambetter·AZ · Genetics, ENT (Ear, Nose & Throat), Transplant Surgery +1 more·Prior Authorization
Effective date
Oct 1, 2026
We identified it
Aug 26, 2026
Summary
Ambetter from Arizona Complete Health is removing prior authorization requirements for genetic testing (CPT 86812, 86813, 86817), home services (HCPCS S9211, S9213, S9214), and transplant services (CPT 38208), while adding prior authorization requirements for sinus surgery procedures (CPT 31276, 31296, 31297, 31298). These changes take effect October 1, 2026, and aim to reduce administrative burden and simplify the PA process across markets and lines of business.
Action Required
By October 1, 2026: Billing team must update authorization requirements in billing system. (1) REMOVE prior authorization requirements for CPT 86812, 86813, 86817 (genetic testing), HCPCS S9211, S9213, S9214 (home services), and CPT 38208 (transplant services)—claims for these codes should process without PA submission. (2) ADD prior authorization requirements for CPT 31276, 31296, 31297, 31298 (sinus surgery procedures)—PA must be obtained before billing these codes. Update encounter forms, charge entry screens, and any pre-visit verification workflows in the billing software to reflect these changes. Notify providers and front desk staff of the new sinus surgery PA requirement to prevent claim denials. Contact your local Ambetter Provider Engagement representative with questions about specific codes.