All PlansPrior AuthMedium impact
Important Prior Authorization Updates: Effective October 1, 2026
Ambetter·Genetics, General Surgery, Transplant Surgery +1 more·Prior Authorization
Effective date
Oct 1, 2026
We identified it
Aug 26, 2026
Summary
Ambetter Health is streamlining prior authorization (PA) requirements effective October 1, 2026, by removing PA requirements for genetic testing, home services, and transplant services, while adding PA requirements for specific sinus surgery procedures. This change simplifies PA processes across markets and aims to reduce administrative burden while maintaining appropriate clinical review.
Action Required
By October 1, 2026: Billing team must update billing system rules to remove PA requirements for genetic testing codes (86812, 86813, 86817), home visit codes (S9211, S9213, S9214), and transplant code (38208). Simultaneously, update system to require PA for sinus procedure codes 31297 and 31298. Remove PA request workflows for the eliminated codes and add PA requirement triggers for the new codes (31297, 31298) in the billing system. Update encounter forms and provider reminders to reflect these changes. Contact your local Ambetter Provider Engagement representative if clarification is needed on any specific codes. Failure to align with these requirements may result in claim processing delays or denials.