Medicare AdvantagePrior AuthMedium impact
Important Prior Authorization Updates
Ambetter·SC · PM&R (Physical Medicine & Rehab), Orthopedics, General Surgery +1 more·Prior Authorization
Effective date
Apr 1, 2026
We identified it
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.
Action Required
By March 31, 2026: Billing team must update prior authorization system rules in billing software to reflect PA requirement changes for Ambetter plans. Specifically: (1) Remove PA requirement for HCPCS codes A9276 and A9279 (diabetic supplies) for PAR providers; (2) Remove PA requirement for HCPCS code K0004 (wheelchairs) for PAR providers; (3) Remove PA requirement for HCPCS code L5652 (orthotic/prosthetic) for PAR providers; (4) Maintain PA requirement for CPT 25111 (surgery-musculoskeletal). Update claim scrubbing rules and denial prevention workflows in the system. Front desk and authorization staff should be notified of the changes to avoid requesting unnecessary PAs. Contact local Ambetter Provider Engagement representative with questions about specific codes or market-specific variations. Failure to update system rules may result in delayed claim processing or incorrect PA denials.