Medicare AdvantagePrior AuthHigh impact
New Prior Authorization Requirement for Certain Procedures: Effective January 1, 2027
Ambetter·TX · Vascular Surgery, Cardiology, Radiology·Prior Authorization
Effective date
Jan 1, 2027
We identified it
Sep 11, 2026
Summary
Superior HealthPlan, Ambetter from Superior HealthPlan, Ambetter Health, and Wellcare By Superior HealthPlan Dual Align are adding prior authorization requirements for 18 vascular revascularization procedure codes (iliac, femoral, popliteal, tibial, and peroneal territories) effective January 1, 2027. Prior authorization requests must be submitted to Evolent Specialty Services, Inc. through their provider portal, phone, or fax. Age-based exemptions apply for Medicaid (STAR programs) members under 21 and Ambetter members under 18.
Action Required
By December 31, 2026: Billing team must update billing system to require prior authorization through Evolent Specialty Services for all 18 affected vascular revascularization CPT codes (37254, 37256, 37258, 37260, 37263, 37265, 37267, 37269, 37271, 37273, 37275, 37277, 37280, 37282, 37284, 37286, 37288) for Superior HealthPlan, Ambetter from Superior HealthPlan, Ambetter Health, and Wellcare By Superior HealthPlan Dual Align plans. Configure system to EXEMPT Medicaid (STAR, STAR Health, STAR Kids, STAR+PLUS) members under age 21 and Ambetter members under age 18 from prior authorization requirements. Prior authorization must be submitted via Evolent's provider portal at www1.RadMD.com, phone 1-800-642-7554, or fax 1-800-784-6864. Update encounter templates and provider communication to alert providers these procedures now require prior authorization and must reference Evolent's Cardiology Clinical Guidelines. Establish workflow to submit prior authorization requests before scheduling or performing procedures. Claims submitted without required prior authorization will be denied. Contact local Provider Engagement Representative with questions about practice-specific implementation.