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Evolent Musculoskeletal Program Updates Effective December 5, 2026 (PDF)
Act
by Dec 5, 2026
Effective date
Dec 5, 2026
Identified
Oct 20, 2026
Summary
Effective December 5, 2026, Evolent is implementing new site-of-care selection requirements for shoulder, hip, knee, and spine surgeries across its Medicaid, Marketplace, and Medicare plans. Ordering providers must now select a preferred outpatient or inpatient site during prior authorization intake; if hospital-based settings are chosen for procedures safely performed in outpatient settings, providers must document clinical justification or select from allowable exceptions. Clinical reviewers will evaluate both medical necessity and site of care before rendering authorization determinations.
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What to do
by Dec 5, 2026 · 7 steps
01Billing and authorization teams must implement workflow changes to accommodate Evolent's new site-of-care selection requirements.
02Update prior authorization request intake processes to require ordering providers to select a preferred site of care (outpatient or inpatient) for shoulder, hip, knee, and spine surgeries.
03Establish protocol for providers to document clinical justification or select from Evolent's list of allowable exceptions when hospital-based settings are chosen for procedures safely performed in outpatient settings.
04Train clinical reviewers and authorization staff to evaluate both medical necessity and site-of-care criteria before rendering determinations.
05Ensure final authorizations reflect determinations for both procedure and site of care.
06Contact Evolent Provider Services or your designated Provider Engagement Account Manager for specific details on allowable exceptions and updated authorization workflows.
07This change affects Absolute Total Care Medicaid, Ambetter from Absolute Total Care Marketplace, and Wellcare Medicare plans.
Original notice
Evolent Musculoskeletal Program Updates Effective December 5, 2026 (PDF)
ambetterhealth.com · Always check the source before changing claims.
Related changes
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