CommercialPrior AuthMedium impact
Important Prior Authorization Updates: Effective October 1, 2026
Ambetter·DE · Genetics, ENT (Ear, Nose & Throat), General Surgery·Prior Authorization
Effective date
Oct 1, 2026
We identified it
Aug 26, 2026
Summary
Ambetter Health of Delaware is updating prior authorization (PA) requirements effective October 1, 2026. Genetic testing (CPT 86812, 86813, 86817) and home visit services (HCPCS S9211, S9213, S9214) are moving to NO PA REQUIRED, while sinus surgery procedures (CPT 31276, 31296, 31297, 31298) now require PA. Changes aim to reduce administrative burden and create uniform PA requirements across markets.
Action Required
By September 15, 2026: Billing team must update Ambetter Health of Delaware billing system rules: (1) REMOVE prior authorization requirements from genetic testing codes 86812, 86813, 86817 and home visit codes S9211, S9213, S9214 so claims process without PA; (2) ADD prior authorization requirement for sinus surgery codes 31276, 31296, 31297, 31298 so claims require PA before submission. Update encounter forms and provider documentation templates to reflect these changes. Communicate updates to all clinical staff ordering these services. Contact your local Ambetter Provider Engagement representative for clarification on any codes. Failure to implement these changes will result in incorrect claim denials or unnecessary PA submissions.