All PlansPrior AuthMedium impact
Important Prior Authorization Updates: Effective October 1, 2026
Ambetter·SC · Genetics, General Surgery, ENT (Ear, Nose & Throat) +1 more·Prior Authorization
Effective date
Oct 1, 2026
We identified it
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.
Action Required
By October 1, 2026: Billing team must update prior authorization requirements in the billing system and provider workflows. (1) REMOVE prior auth requirement for genetic testing codes 86812, 86813, 86817 - these services no longer require PA. (2) REMOVE prior auth requirement for home services codes S9211, S9213, S9214 - these visits no longer require PA. (3) REMOVE prior auth requirement for transplant services code 38208 - transplants no longer require PA. (4) ADD prior auth requirement for sinus surgery procedures 31276, 31296, 31297, 31298 - these now require PA. Update billing system rules, encounter forms, and provider communication materials. Notify providers of the changes immediately. Billing team should verify all system updates are complete before the effective date to avoid claim denials or processing delays. Contact Ambetter Provider Services or your Provider Engagement Account Manager with questions.