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Evolent Musculoskeletal Program Updates Effective Dec 5, 2026
Act
by Dec 5, 2026
Effective date
Dec 5, 2026
Identified
Sep 29, 2026
Summary
Effective December 5, 2026, Evolent/Ambetter from Meridian is implementing a new site-of-care selection requirement for shoulder, hip, knee, and spine surgeries. Providers must now select a preferred outpatient or inpatient site during prior authorization requests; if hospital-based care is chosen for procedures eligible for outpatient settings, providers must justify with clinical documentation or select from allowable exceptions. Final authorizations will reflect determinations for both the procedure and site of care.
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What to do
by Dec 5, 2026 · 5 steps
01Billing and prior authorization team must update workflows to incorporate site-of-care selection into the authorization request process for shoulder, hip, knee, and spine surgeries for Ambetter from Meridian members.
02Providers submitting authorization requests must be educated to select preferred site of care (outpatient vs. inpatient) during intake; educate clinical staff on new requirements via team briefing.
03Update authorization templates and submission forms to include site-of-care selection fields and decision trees for exception documentation.
04Clinical staff must be prepared to document medical justification if hospital-based settings are selected for procedures eligible for outpatient performance.
05Obtain and review Evolent Place of Service Policy 1773 in RadMD and integrate guidance into internal protocols.
If missed: Failure to comply will result in authorization denials or delays.
Original notice
Evolent Musculoskeletal Program Updates Effective Dec 5, 2026
ambetterhealth.com · Always check the source before changing claims.
Related changes
See all Ambetter changes →Effective December 5, 2026: Prior Authorization Updates for Musculoskeletal Surgical ProceduresHighEffective Dec 5, 2026 · Prior AuthorizationEvolent 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 December 5, 2026 (PDF)HighEffective Dec 5, 2026 · Quality MeasuresBrowse every Ambetter change in the policy list