CommercialPrior AuthMedium impact
Important Prior Authorization Updates: Effective October 1, 2026
Ambetter·NV · 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 SilverSummit Healthplan is removing prior authorization requirements for genetic testing, home services, and transplant services effective October 1, 2026, while adding PA requirements for specific sinus and facial/cranial procedures. This streamlines the authorization process across markets and lines of business to reduce administrative burden and improve claim processing speed.
Action Required
By September 30, 2026: Billing team must update the billing system and prior authorization workflows to reflect these changes: (1) REMOVE prior authorization requirements for genetic testing codes 86812, 86813, 86817; home visit codes S9211, S9213, S9214; and transplant code 38208 — these should now process without PA; (2) ADD prior authorization requirements for sinus procedures 31296, 31297 and facial/cranial/TMJ procedure 41899 — these now require PA before claim submission. Update encounter forms, EMR templates, and provider communication materials. Flag these code changes in billing software rules. Contact your local Provider Engagement representative with questions about how these changes affect your specific practice. Failure to comply may result in claim denials for procedures submitted without required authorization or unnecessary delays for procedures that no longer require PA.