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Evolent Musculoskeletal Program Updates: Effective December 5, 2026
Act
by Dec 5, 2026
Effective date
Dec 5, 2026
Identified
Nov 4, 2026
Summary
Effective December 5, 2026, Ambetter from WellCare of Kentucky (through Evolent) is implementing site-of-care requirements for shoulder, hip, knee, and spine surgeries. Ordering providers must now select a preferred outpatient site when submitting authorization requests for procedures that can be performed in an outpatient setting; hospital-based site selection will require either an allowable exception or clinical justification. Prior authorizations will reflect determinations for both the procedure and site of care.
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What to do
by Dec 5, 2026 · 5 steps
01Tell providers and front desk staff that prior authorization requests for shoulder, hip, knee, and spine surgeries for Ambetter from WellCare of Kentucky members must now include site-of-care selection, with preference for outpatient settings when clinically appropriate.
02Instruct providers that if they select a hospital-based setting for a procedure that can be performed in an outpatient setting, they must choose from Evolent's list of allowable exceptions or provide supporting clinical justification with the request.
03Update your prior authorization tracking and submission process to ensure requests for these procedures include the required site-of-care information before sending to Evolent; requests missing site-of-care selection or justification may be delayed or denied pending clarification.
04Coordinate with your provider relations team to communicate this requirement to all ordering providers who perform or refer for shoulder, hip, knee, and spine surgeries.
05For questions, direct providers to contact Ambetter from WellCare of Kentucky provider services at 1-833-705-2175.
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