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Effective December 5, 2026: Prior Authorization Updates for Musculoskeletal Surgical Procedures
Act
by Dec 5, 2026
Effective date
Dec 5, 2026
Identified
Oct 6, 2026
Summary
Beginning December 5, 2026, Superior HealthPlan and Ambetter Health will require prior authorization requests for musculoskeletal surgeries (shoulder, hip, knee, spine) to specify a preferred site of care. Providers selecting hospital-based settings for procedures that can be performed in outpatient settings must either choose from allowable exceptions or provide clinical justification. Clinical reviewers will evaluate both medical necessity and site-of-care criteria before rendering authorization determinations.
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What to do
by Dec 5, 2026 · 7 steps
01Billing and prior authorization staff must implement workflow changes to comply with Evolent Specialty Services' updated site-of-care guidance for musculoskeletal surgical procedures.
02Update prior authorization submission processes to require providers to select a preferred site of care (outpatient vs. hospital-based) during preauthorization intake for shoulder, hip, knee, and spine surgeries.
03Establish internal protocols to document clinical justification or select from allowable exceptions when hospital-based settings are requested for procedures eligible for outpatient performance.
04Train billing and authorization personnel on the new site-of-care evaluation criteria, as clinical reviewers will now render determinations on both medical necessity AND site-of-care appropriateness.
05Reference the Place of Service Policy for Musculoskeletal Surgery (linked in source) for detailed criteria.
06Failure to comply may result in authorization denials or delays.
07Contact your Superior HealthPlan/Ambetter Health Provider Representative for additional clarification.
Original notice
Effective December 5, 2026: Prior Authorization Updates for Musculoskeletal Surgical Procedures
ambetterhealth.com · Always check the source before changing claims.
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 November 3, 2026HighEffective Nov 3, 2026 · Prior AuthorizationBrowse every Ambetter change in the policy list