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AmbetterExchange · Prior Auth · Quality Measures · MO · Orthopedics, General Surgery, Sports MedicineHigh impact

Evolent Musculoskeletal Program Updates Effective December 5, 2026 (PDF)

Act
by Dec 5, 2026
Effective date
Dec 5, 2026
Identified
Sep 22, 2026

Summary

Effective December 5, 2026, Evolent is implementing mandatory site-of-care selection for shoulder, hip, knee, and spine surgeries for Home State Health, Show Me Healthy Kids, and Ambetter from Home State Health members. Providers must justify hospital-based settings for procedures that can be safely performed in outpatient settings, or select from allowable exceptions. Clinical reviewers will evaluate both medical necessity and site of care before issuing final authorization.

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What to do

by Dec 5, 2026 · 5 steps
01Billing and authorization teams must update prior authorization workflows to require site-of-care selection for shoulder, hip, knee, and spine surgical procedures.
02Providers submitting authorization requests must be trained to select appropriate site of care (outpatient vs. hospital-based) and provide clinical justification or select from allowable exceptions if hospital-based setting is requested.
03Update authorization submission forms, EMR templates, and provider communication materials.
04Educate ordering providers that authorizations will not be processed without complete site-of-care determinations.
05Claims may be denied or delayed if site-of-care justification is insufficient or missing.

Original notice

Evolent Musculoskeletal Program Updates Effective December 5, 2026 (PDF)
ambetterhealth.com · Always check the source before changing claims.
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Related changes

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Related policy hubs

Ambetter policiesMO policy changesOrthopedicsGeneral SurgerySports Medicine

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