CommercialPrior AuthHigh impact
Evolent Musculoskeletal Program Updates: Effective November 3, 2026
Ambetter·IL · Orthopedics, General Surgery·Prior Authorization
Effective date
Nov 3, 2026
We identified it
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.
Action Required
By November 3, 2026: Billing and authorization teams must implement the following changes for Ambetter of Illinois claims: (1) Update prior authorization request workflows to require providers to select site-of-care (inpatient/outpatient) for shoulder, hip, knee, and spine surgeries at intake; (2) Train 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; (3) Update authorization templates and encounter forms to include site-of-care selection fields; (4) Coordinate with Evolent during the authorization process to understand allowable exceptions for hospital-based settings; (5) Communicate with ordering providers that final authorizations will now include both procedure AND site-of-care determinations. Failure to comply may result in authorization denials or delayed determinations. Contact Ambetter Health Provider Services at 855-745-5507 (TTY: 844-517-3431) for implementation questions.