All PlansPrior AuthMedium impact
Important Prior Authorization Updates: Effective October 1, 2026
Ambetter·IA · Genetics, ENT (Ear, Nose & Throat), Transplant Surgery +1 more·Prior Authorization
Effective date
Oct 1, 2026
We identified it
Aug 26, 2026
Summary
Ambetter Health is updating prior authorization requirements effective October 1, 2026. The changes remove PA requirements for genetic testing (86812, 86813, 86817), home services (S9211, S9213, S9214), and transplant services (38208), while adding PA requirements for sinus surgery procedures (31276, 31296, 31297, 31298). These changes aim to reduce administrative burden and create uniform PA requirements across markets.
Action Required
By September 30, 2026: Billing team must update billing software and internal PA tracking systems 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—claims for these services should no longer require PA submission. (2) ADD prior authorization requirements for sinus surgery codes 31276, 31296, 31297, 31298—these will now require PA before billing. Update encounter forms, provider templates, and front-desk PA checklists accordingly. (3) Notify providers and clinical staff of these changes. (4) Contact Ambetter Health Provider Engagement representative if questions arise about implementation. Failure to implement these changes may result in unnecessary claim delays or denials.