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Evolent Musculoskeletal Program Updates Effective 12/05/2026
Act
by Dec 5, 2026
Effective date
Dec 5, 2026
Identified
Oct 14, 2026
Summary
Effective December 5, 2026, Evolent (on behalf of Sunflower) is implementing new site-of-care selection requirements for shoulder, hip, knee, and spine surgeries. Ordering providers must now select a preferred outpatient or inpatient site during authorization requests; if hospital-based settings are chosen for procedures that can be performed outpatient, providers must justify the selection or select from allowable exceptions. Clinical reviewers will evaluate both medical necessity and site-of-care criteria before authorization.
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What to do
by Dec 5, 2026 · 6 steps
01Billing and prior authorization teams must prepare to implement new site-of-care selection workflow in the authorization request process for Sunflower KanCare Medicaid and Ambetter from Sunflower Health Plan (Marketplace) members.
02Train ordering providers to select a preferred site of care (outpatient vs. inpatient) during authorization intake for shoulder, hip, knee, and spine surgeries.
03Establish processes for providers to document clinical justification or select from allowable exceptions if hospital-based settings are chosen for outpatient-eligible procedures.
04Coordinate with Evolent clinical reviewers to ensure authorization determinations reflect both procedure and site-of-care criteria.
05Update authorization request forms and provider guidance materials to reflect these requirements.
06Contact Sunflower Provider Relations (KanCare: 1-877-644-4623 or Ambetter Marketplace: 1-844-518-9505) with questions about implementation.
Original notice
Evolent Musculoskeletal Program Updates Effective 12/05/2026
ambetterhealth.com · Always check the source before changing claims.
Related changes
See all Ambetter changes →Evolent Musculoskeletal Program Updates: Effective December 5, 2026HighEffective Dec 5, 2026 · Provider BulletinEvolent Musculoskeletal Program Updates: Effective December 5, 2026HighEffective Dec 5, 2026 · Provider BulletinEvolent Musculoskeletal Program Updates Effective December 5, 2026 (PDF)HighEffective Dec 5, 2026 · MarketplaceBrowse every Ambetter change in the policy list