Q3 2026 Provider Newsletter

REQUIREMENTS: By September 15, 2026: Billing team must update billing software to implement the following changes effective October 1, 2026: - REMOVE prior authorization requirement for genetic testing CPT codes 81378, 81379, 81380, 81381, 81382, 81383, 86812, 86813, and 86817. Update claim submission rules to allow these to process without prior auth. - ADD prior authorization requirement for sinus surgery CPT codes 31296 and 31297. Update authorization rules to require PA submission before billing. - REMOVE prior authorization requirement for transplant service CPT code 38208. Update claim rules to allow processing without PA. - Notify providers of the changes via internal communication and update provider-facing documentation. - Test billing system changes to ensure accurate claim routing and denial prevention. By November 15, 2026: Billing team must prepare for Evolent Musculoskeletal Program updates effective December 5, 2026: - Coordinate with authorization intake staff to implement site-of-care selection workflow for shoulder, hip, knee, and spine surgeries. - Update authorization request templates to require providers to select site of care (outpatient vs. hospital-based) during request submission. - Ensure clinical reviewers are trained to evaluate both medical necessity and site-of-care criteria before rendering authorization determinations. - Update authorization determination letters to reflect both procedure and site-of-care determinations. - Establish process for documenting clinical justification when hospital-based setting is selected for procedures that can be performed outpatient. ONGOING: Contact Provider Engagement representative with questions about specific prior authorization codes. Failure to implement these changes will result in incorrect claim denials for genetic testing and transplant services, and missing prior authorizations for sinus procedures.