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Evolent Musculoskeletal Program Updates Effective Dec 15, 2026
Effective date
Dec 15, 2026
Identified
Aug 29, 2026
Summary
Effective December 15, 2026, Evolent (for Ambetter from Meridian members) is implementing mandatory site-of-care selection for shoulder, hip, knee, and spine surgeries. Providers must now choose outpatient settings for procedures that can be safely performed outside hospitals, or provide clinical justification for inpatient admission. Both procedure medical necessity and site of care will be evaluated during authorization review.
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What to do
Action · 7 steps
01Before December 15, 2026: Billing and authorization staff must update workflows to comply with Evolent's mandatory site-of-care selection process.
02Train all ordering providers and authorization requesters on the new requirement to select preferred site of care (outpatient vs. inpatient) when submitting authorization requests for shoulder, hip, knee, and spine surgeries for Ambetter from Meridian members.
03Update authorization submission procedures to require site-of-care selection at intake; if inpatient is selected for procedures appropriate for outpatient, providers must either choose from allowable exceptions or submit clinical justification documentation.
04Notify providers to reference RadMD for Evolent Place of Service Policy 1773 Musculoskeletal Surgery.
05Configure billing system to flag authorizations for these procedures and ensure final authorization documentation includes both procedure and site-of-care determinations before claims submission.
06Failure to follow site-of-care guidance may result in authorization denials or claim rejections.
07Contact your Provider Engagement representative for questions.
Original notice
Evolent Musculoskeletal Program Updates Effective Dec 15, 2026
ambetterhealth.com · Always check the source before changing claims.
Related changes
See all Ambetter changes →Evolent Musculoskeletal Program Updates Effective 12.5.26HighEffective Dec 5, 2026 · Quality MeasuresEvolent Musculoskeletal Program Updates Effective November 3, 2026HighEffective Nov 3, 2026 · Provider BulletinEvolent Musculoskeletal Program Updates Effective Dec 5, 2026HighEffective Dec 5, 2026 · Provider BulletinEvolent Musculoskeletal Program Updates Effective December 5, 2026 (PDF)HighEffective Dec 5, 2026 · Quality MeasuresBrowse every Ambetter change in the policy list