Upcoming Evolent Program Enhancements for Ambetter Health Providers: Effective December 2026

Date: 08/07/26

Ambetter Health is implementing two program enhancements in partnership with Evolent designed to improve efficiency, reducing administrative burden, support clinically appropriate care decisions, and enhance the provider experience.

Effective December 1, 2026

Oncology Prior Authorization Review Updates

Beginning December 1, 2026, Evolent will issue denial determinations for oncology authorization requests that do not meet clinical criteria.

For authorization requests received before December 1, 2026, Evolent will continue to issue Recommended Adverse Determinations (RADs) when clinical criteria are not met, with Ambetter Health making the final determination of the request.

Appeals and Grievance

There are no changes to the appeals process. Providers should continue to submit grievances and appeals to Ambetter Health.

Effective December 5, 2026

Musculoskeletal (MSK) Site-of-Care Review Enhancements

Beginning December 5, 2026, Evolent will introduce a site-of-care selection process for shoulder, hip, knee, and spine surgeries.

When submitting an authorization request, providers will be asked to select a preferred site of care. If a hospital-based setting is chosen for a procedure that may be performed in an outpatient setting, providers must either:

• Select an allowable exception, or
• Provide supporting clinical justification.

Before rendering a determination, Evolent clinical reviews will evaluate both:

• Medical necessity, and
• Site-of-care criteria

Final authorizations will include determinations for both procedure and site of care.

Questions?

For question regarding these programs, please contact:

• Ambetter Health Provider Services 1-833-919-3213, or
• Evolent 1-888-999-7713