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Evolent Musculoskeletal Program Updates: Effective November 3, 2026
Act
by Nov 3, 2026
Effective date
Nov 3, 2026
Identified
Aug 26, 2026
Summary
Effective November 3, 2026, Evolent will require Ambetter of Illinois providers to select a preferred site-of-care (inpatient vs. outpatient) during prior authorization intake for shoulder, hip, knee, and spine surgeries. If a hospital-based setting is selected for procedures that can be safely performed outpatient, providers must either choose from allowable exceptions or provide clinical justification. Both procedure and site-of-care determinations will be reflected in the final authorization.
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What to do
by Nov 3, 2026 · 8 steps
01Billing and authorization teams must implement the following changes for Ambetter of Illinois claims.
02Update prior authorization request workflows to require providers to select site-of-care (inpatient/outpatient) for shoulder, hip, knee, and spine surgeries at intake.
03Train providers and clinical staff on the new site-of-care selection requirement and the process for documenting clinical justification when hospital-based settings are requested for outpatient-appropriate procedures.
04Update authorization templates and encounter forms to include site-of-care selection fields.
05Coordinate with Evolent during the authorization process to understand allowable exceptions for hospital-based settings.
06Communicate with ordering providers that final authorizations will now include both procedure AND site-of-care determinations.
07Failure to comply may result in authorization denials or delayed determinations.
08Contact Ambetter Health Provider Services at 855-745-5507 (TTY: 844-517-3431) for implementation questions.
Original notice
Evolent Musculoskeletal Program Updates: Effective November 3, 2026
ambetterhealth.com · Always check the source before changing claims.
Related changes
See all Ambetter changes →Effective December 5, 2026: Prior Authorization Updates for Musculoskeletal Surgical ProceduresHighEffective Dec 5, 2026 · Prior AuthorizationEvolent Musculoskeletal Program Updates Effective 12.5.26HighEffective Dec 5, 2026 · Quality MeasuresEvolent Musculoskeletal Program Updates Effective November 3, 2026HighEffective Nov 3, 2026 · Provider BulletinEvolent Musculoskeletal Program Updates Effective Dec 5, 2026HighEffective Dec 5, 2026 · Provider BulletinBrowse every Ambetter change in the policy list