All PlansPrior AuthMedium impact
Important Prior Authorization Updates: Effective October 1, 2026
Ambetter·MI · 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 Meridian is eliminating prior authorization requirements for genetic testing, home visit services, and transplant services effective October 1, 2026, while adding PA requirements for sinus surgery procedures. The changes aim to reduce administrative burden and create uniform PA requirements across markets and lines of business.
Action Required
By September 30, 2026: Billing team must update authorization workflows in the billing system for Ambetter from Meridian members. (1) Remove prior authorization requirements for CPT codes 86812, 86813, 86817 (genetic testing), HCPCS codes S9211, S9213, S9214 (home visit services), and CPT code 38208 (transplant services) — claims for these services should no longer require PA before submission. (2) Add prior authorization requirements for CPT codes 31296, 31297, 31298 (sinus surgery procedures) — PA must now be obtained before billing these procedures. Update encounter forms, billing software rules, and provider reminders accordingly. Coordinate with providers and front desk staff to ensure PA requests are submitted for newly-required sinus procedures. Failure to obtain PA for newly-required codes will result in claim denials. Contact local Provider Engagement representative for clarification on code-specific requirements.