CommercialPrior AuthMedium impact
Important Prior Authorization Updates: Effective October 1, 2026
Ambetter·WA · 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 Coordinated Care Corporation is updating prior authorization requirements effective October 1, 2026. Key changes include removing PA requirements for genetic testing (86812, 86813, 86817), home services (S9211, S9213, S9214), and transplant services (38208), while maintaining PA requirements for sinus surgery procedures (31276, 31296, 31297, 31298). These changes aim to reduce administrative burden and create uniform PA requirements across markets.
Action Required
By September 30, 2026: Billing team must update prior authorization requirements in billing software and clinical workflows for Ambetter plans. REMOVE PA requirements for: genetic testing codes 86812, 86813, 86817; home service codes S9211, S9213, S9214; and transplant service code 38208. MAINTAIN PA requirements for sinus surgery codes 31276, 31296, 31297, 31298. Update internal PA submission protocols and provider education materials. Notify clinical staff to stop requesting prior authorization for the removed-requirement codes to avoid processing delays. Contact local Provider Engagement if questions arise about specific codes or market-specific variations.