Medicare AdvantagePrior AuthMedium impact
Important Prior Authorization Updates: Effective October 1, 2026
Ambetter·NH · Genetics, ENT (Ear, Nose & Throat), Transplant Surgery +1 more·Prior Authorization
Effective date
Oct 1, 2026
We identified it
Aug 26, 2026
Summary
Ambetter from NH Healthy Families is eliminating prior authorization requirements for genetic testing (CPT 86812, 86813, 86817), home visit services (HCPCS S9211, S9213, S9214), and transplant services (CPT 38208), while adding new PA requirements for sinus surgery procedures (CPT 31276, 31296, 31297, 31298). These changes take effect October 1, 2026, and aim to reduce administrative burden and streamline approval processes.
Action Required
By September 30, 2026: Billing team must update the billing system and prior authorization workflows for Ambetter NH plans. (1) Remove prior authorization requirement flags for genetic testing codes 86812, 86813, 86817 and home visit codes S9211, S9213, S9214 and transplant code 38208. (2) Add new prior authorization requirements for sinus surgery codes 31276, 31296, 31297, and 31298. (3) Update encounter templates and provider order entry systems to reflect these changes. (4) Communicate changes to all clinical staff and providers to prevent unnecessary authorization requests and delays. Billing team should contact local Ambetter Provider Engagement representative with questions about implementation. Failure to implement these changes may result in claim denials for newly required authorizations or unnecessary delays for services no longer requiring authorization.