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AmbetterExchange · Prior Auth · Quality Measures · LA · Orthopedics, General SurgeryHigh impact

Evolent Musculoskeletal Program Updates Effective 12.5.26

Act
by Dec 5, 2026
Effective date
Dec 5, 2026
Identified
Oct 6, 2026

Summary

Effective December 5, 2026, Evolent will implement new site-of-care selection requirements for shoulder, hip, knee, and spine surgeries for Ambetter Marketplace members. Providers must select outpatient settings when clinically appropriate; if hospital-based settings are chosen for procedures that can be performed outpatient, providers must document allowable exceptions or provide clinical justification. Clinical reviewers will evaluate both medical necessity and site of care before authorization.

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What to do

by Dec 5, 2026 · 4 steps
01Billing and authorization teams must prepare for Evolent's new site-of-care intake process for Marketplace members undergoing shoulder, hip, knee, and spine surgeries.
02Update authorization workflows to ensure providers select preferred site of care during request submission; instruct providers that hospital-based settings for procedures suitable for outpatient performance will require selection from allowable exceptions or clinical justification documentation.
03Train staff to expect final authorizations that reflect determinations for both procedure and site of care.
04Contact Evolent provider services at 1-866-595-8133 with implementation questions.

Original notice

Evolent Musculoskeletal Program Updates Effective 12.5.26
ambetterhealth.com · Always check the source before changing claims.
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Related changes

See all Ambetter changes →
Evolent Musculoskeletal Program Updates Effective November 3, 2026HighEffective Nov 3, 2026 · Provider BulletinEvolent Musculoskeletal Program Updates Effective Dec 5, 2026HighEffective Dec 5, 2026 · Provider BulletinEvolent Musculoskeletal Program Updates Effective December 5, 2026 (PDF)HighEffective Dec 5, 2026 · Quality MeasuresEvolent Musculoskeletal Program Updates Effective Dec 15, 2026HighEffective Dec 15, 2026 · Provider BulletinBrowse every Ambetter change in the policy list

Related policy hubs

Ambetter policiesLA policy changesOrthopedicsGeneral Surgery

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