All PlansPrior AuthMedium impact
Important Prior Authorization Updates: Effective October 1, 2026
Ambetter·IN · Genetics, ENT (Ear, Nose & Throat), General Surgery +1 more·Prior Authorization
Effective date
Oct 1, 2026
We identified it
Aug 26, 2026
Summary
Ambetter Health is updating prior authorization (PA) requirements effective October 1, 2026, removing PA requirements for genetic testing, home services, and transplant services while adding PA requirements for specific sinus surgery procedures. These changes aim to reduce administrative burden and create uniform PA requirements across markets and lines of business.
Action Required
By September 30, 2026: Billing team must update prior authorization rules in billing software and claim submission systems for Ambetter Health plans. REMOVE prior auth requirements for genetic testing codes (86812, 86813, 86817), home visit codes (S9211, S9213, S9214), and transplant code (38208). ADD prior auth requirements for sinus surgery codes (31276, 31296, 31297, 31298). Update encounter forms and provider workflows to reflect these changes. Communicate changes to clinical and administrative staff. Verify changes are live before October 1, 2026 to prevent claim denials or unnecessary authorization requests.