CommercialPrior AuthMedium impact
Important Prior Authorization Updates: Effective October 1, 2026
Ambetter·AL · Genetics, Transplant Surgery, ENT (Ear, Nose & Throat) +1 more·Prior Authorization
Effective date
Oct 1, 2026
We identified it
Aug 26, 2026
Summary
Ambetter of Alabama is updating prior authorization (PA) requirements effective October 1, 2026, removing PA requirements for genetic testing (CPT 86812, 86813, 86817) and transplant services (CPT 38208), while adding PA requirements for sinus surgery procedures (CPT 31296, 31297). These changes aim to reduce administrative burden and standardize PA processes across markets.
Action Required
By September 15, 2026: Billing team must update the billing system and prior authorization workflows for Ambetter of Alabama plans to reflect these changes: (1) REMOVE prior authorization requirements for genetic testing codes 86812, 86813, 86817 and transplant code 38208—these services may now be billed directly without PA; (2) ADD prior authorization requirements for sinus surgery codes 31296 and 31297—PA must be obtained before billing these procedures. Update encounter templates, billing rules, and provider communication materials. Contact your local Ambetter Provider Engagement representative with questions about code-specific implementation. Failure to implement these changes may result in claim denials or unnecessary PA delays.