CommercialPrior AuthMedium impact
Important Prior Authorization Updates: Effective October 1, 2026
Ambetter·TN · Genetics, General Surgery, ENT (Ear, Nose & Throat) +1 more·Prior Authorization
Effective date
Oct 1, 2026
We identified it
Aug 26, 2026
Summary
Ambetter of Tennessee is updating prior authorization (PA) requirements effective October 1, 2026, removing PA requirements for genetic testing, home services, and medical transportation, while adding PA requirement for sinus surgery (CPT 31297). These changes aim to reduce administrative burden and create uniform PA requirements across markets.
Action Required
By October 1, 2026: Billing team must update billing system and prior authorization workflow as follows: (1) Remove PA requirement flags for genetic testing codes 86812, 86813, 86817; home visit codes S9213, S9214, S9211; and medical transportation code 38208 in the prior auth system. (2) Add PA requirement flag for sinus surgery CPT 31297. (3) Update encounter forms, billing software rules, and provider documentation templates to reflect these changes. (4) Notify clinical staff and providers of the new requirements to prevent submission delays. Contact your local Ambetter Provider Engagement representative with questions about specific code applicability.