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AmbetterExchange · Prior Auth · Prior Authorization · SC · Genetics, General Surgery, ENT (Ear, Nose & Throat) +1 moreMedium impact

Important Prior Authorization Updates: Effective October 1, 2026

Act
by Oct 1, 2026
Effective date
Oct 1, 2026
Identified
Aug 26, 2026

Summary

Ambetter from Absolute Total Care is removing prior authorization requirements for genetic testing, home services, and transplant services effective October 1, 2026, while adding prior authorization requirements for specific sinus surgery procedures. These changes aim to reduce administrative burden and streamline the PA process across markets and lines of business.

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What to do

by Oct 1, 2026 · 9 steps
01Billing team must update prior authorization requirements in the billing system and provider workflows.
02REMOVE prior auth requirement for genetic testing codes 86812, 86813, 86817 - these services no longer require PA.
03REMOVE prior auth requirement for home services codes S9211, S9213, S9214 - these visits no longer require PA.
04REMOVE prior auth requirement for transplant services code 38208 - transplants no longer require PA.
05ADD prior auth requirement for sinus surgery procedures 31276, 31296, 31297, 31298 - these now require PA.
06Update billing system rules, encounter forms, and provider communication materials.
07Notify providers of the changes immediately.
08Billing team should verify all system updates are complete before the effective date to avoid claim denials or processing delays.
09Contact Ambetter Provider Services or your Provider Engagement Account Manager with questions.

Codes mentioned

868128681386817S9211S9213S92143127631296312973129838208

Original notice

Important Prior Authorization Updates: Effective October 1, 2026
ambetterhealth.com · Always check the source before changing claims.
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Related policy hubs

Ambetter policiesSC policy changesGeneticsGeneral SurgeryENT (Ear, Nose & Throat)Transplant SurgeryCode 86812Code 86813Code 86817Code S9211Code S9213Code S9214Code 31276Code 31296Code 31297Code 31298Code 38208

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