Medicare AdvantagePrior AuthMedium impact
Important Prior Authorization Updates: Effective October 1, 2026
Ambetter·NC · Genetics, ENT (Ear, Nose & Throat), General Surgery +1 more·Prior Authorization
Effective date
Oct 1, 2026
We identified it
Aug 26, 2026
Summary
Ambetter of North Carolina is removing prior authorization requirements for genetic testing, home services, and transplant procedures effective October 1, 2026, while adding a new PA requirement for sinus surgery (CPT 31297). These changes aim to reduce administrative burden and streamline the PA process across markets.
Action Required
By September 30, 2026: Billing team must update Ambetter of North Carolina billing system rules to: (1) REMOVE prior authorization requirements for genetic testing codes 86812, 86813, 86817; home visit codes S9211, S9213, S9214; and transplant code 38208 — these services no longer require PA; (2) ADD new prior authorization requirement for CPT 31297 (sinus surgery) — this service now requires PA. Update claim scrubbing logic and provider encounter forms to reflect these changes. Communicate updates to clinical and front-desk staff. Failure to implement these changes may result in unnecessary claim denials or improper approvals. Contact local Provider Engagement representative at Ambetter NC for clarification on specific codes.