Medicare AdvantagePrior AuthMedium impact
Important Prior Authorization Updates: Effective October 1, 2026
Ambetter·MS · Genetics, Transplant Surgery, ENT (Ear, Nose & Throat) +1 more·Prior Authorization
Effective date
Oct 1, 2026
We identified it
Aug 26, 2026
Summary
Ambetter from Magnolia Health is removing prior authorization requirements for genetic testing (86812, 86813, 86817), home services (S9211, S9213, S9214), and transplant services (38208) effective October 1, 2026. Simultaneously, prior authorization is now required for sinus surgery (31297). These changes aim to reduce administrative burden and create uniform PA requirements across markets.
Action Required
By September 30, 2026: Billing team must update billing software and prior authorization requirements in Ambetter from Magnolia Health claims processing system. (1) REMOVE prior authorization requirements for genetic testing codes 86812, 86813, 86817; home service codes S9211, S9213, S9214; and transplant code 38208. (2) ADD prior authorization requirement for sinus surgery code 31297. Update encounter forms and provider workflows to reflect these changes. Communicate changes to all clinical staff and coders. Failure to implement by the effective date may result in claim denials (for newly required PA on 31297) or processing delays. Contact your local Ambetter Provider Engagement representative with questions about specific codes.