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Evolent Musculoskeletal Program Updates: Effective December 5, 2026
Act
by Dec 5, 2026
Effective date
Dec 5, 2026
Identified
Oct 21, 2026
Summary
Effective December 5, 2026, Evolent will implement site-of-care selection requirements for shoulder, hip, knee, and spine surgeries for Ambetter from WellCare of New Jersey members. Ordering providers must now specify preferred outpatient or inpatient settings during authorization requests; hospital-based settings for outpatient-eligible procedures require either selection from allowable exceptions or clinical justification. Clinical reviewers will evaluate both medical necessity and site of care before authorization is finalized.
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What to do
by Dec 5, 2026 · 5 steps
01Billing and authorization teams must implement workflow changes to require site-of-care selection (outpatient vs. inpatient) for shoulder, hip, knee, and spine surgery authorization requests submitted to Ambetter from WellCare of New Jersey.
02Update prior authorization submission processes to include a mandatory site-of-care field.
03Train ordering providers and authorization staff that hospital-based settings selected for procedures that can be performed in outpatient settings must be accompanied by either a selection from Evolent's allowable exceptions list or clinical justification documentation.
04Prepare clinical review protocols to evaluate both medical necessity and site-of-care criteria concurrently before authorization determination.
05Contact Ambetter from WellCare of New Jersey provider services at 1-844-606-1926 (TTY 711) for clarification on allowable exceptions and submission requirements.
If missed: Failure to comply may result in authorization delays or denials.
Original notice
Evolent Musculoskeletal Program Updates: Effective December 5, 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, 2026 (PDF)HighEffective Dec 5, 2026 · MarketplaceEvolent Musculoskeletal Program Updates Effective 12/05/2026HighEffective Dec 5, 2026 · Quality MeasuresBrowse every Ambetter change in the policy list