Medicare AdvantagePrior AuthHigh impact
[Texas] Evolent Prior Authorization Updates Effective January 1, 2027 (PDF)
WellCare·TX · Cardiology, Vascular Surgery, General Surgery·Provider Bulletin
Effective date
Jan 1, 2027
We identified it
Sep 11, 2026
Summary
Effective January 1, 2027, Superior HealthPlan, Ambetter, and Wellcare will require prior authorization for 28 specific cardiac vascular revascularization procedures (CPT codes 37254, 37256, 37258, 37260, 37263, 37265, 37267, 37269, 37271, 37273, 37275, 37277, 37280, 37282, 37284, 37286, 37288, and others). Prior authorization requests must be submitted to Evolent Specialty Services, Inc. through their provider portal, phone, or fax. Exception: Medicaid members under 21 and Ambetter members under 18 are exempt from this requirement.
Action Required
By December 15, 2026: Billing team must update billing software and provider workflows to require prior authorization from Evolent Specialty Services for all 17 affected cardiac revascularization CPT codes (37254, 37256, 37258, 37260, 37263, 37265, 37267, 37269, 37271, 37273, 37275, 37277, 37280, 37282, 37284, 37286, 37288). Update encounter forms and clinical documentation templates to prompt providers to request prior authorization before scheduling procedures for Superior HealthPlan, Ambetter, and Wellcare members. Configure system to exclude Medicaid (STAR, STAR Health, STAR Kids, STAR+PLUS) members under age 21 and Ambetter members under age 18 from prior authorization requirements. Providers must submit all prior authorization requests via Evolent's provider portal (www1.RadMD.com), phone (1-800-642-7554), or fax (1-800-784-6864). Claims submitted without prior authorization for eligible members will be denied. Contact Evolent or your local Provider Engagement Representative for questions about specific requirements and access to Evolent's Cardiology Clinical Guidelines.