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Important Prior Authorization Updates
Act
by Mar 31, 2026
Effective date
Apr 1, 2026
Identified
Aug 26, 2026
Summary
Ambetter from Absolute Total Care is updating prior authorization (PA) requirements effective April 1, 2026, removing PA requirements for certain DME and diabetic supply codes (A9276, A9279, K0004, L5652) for in-network providers while maintaining PA requirements for surgery-musculoskeletal procedures (CPT 25111). The changes aim to reduce administrative burden and create uniform PA requirements across markets.
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What to do
by Mar 31, 2026 · 8 steps
01Billing team must update prior authorization system rules in billing software to reflect PA requirement changes for Ambetter plans.
02Remove PA requirement for HCPCS codes A9276 and A9279 (diabetic supplies) for PAR providers.
03Remove PA requirement for HCPCS code K0004 (wheelchairs) for PAR providers.
04Remove PA requirement for HCPCS code L5652 (orthotic/prosthetic) for PAR providers.
05Maintain PA requirement for CPT 25111 (surgery-musculoskeletal).
06Update claim scrubbing rules and denial prevention workflows in the system.
07Front desk and authorization staff should be notified of the changes to avoid requesting unnecessary PAs.
08Contact local Ambetter Provider Engagement representative with questions about specific codes or market-specific variations.
If missed: Failure to update system rules may result in delayed claim processing or incorrect PA denials.
Codes mentioned
A9276A9279K0004L565225111
Original notice
Important Prior Authorization Updates
ambetterhealth.com · Always check the source before changing claims.