Evolent Musculoskeletal Program Updates: Effective November 3, 2026

Date: 07/01/26

Effective November 3, 2026, Evolent will guide ordering providers, during intake of an authorization request for Ambetter of Illinois members, to select a preferred site-of-care.

Ambetter of Illinois in collaboration with Evolent, will update how musculoskeletal services are reviewed and administered. These changes reflect a shared commitment to improving the quality of care, reducing administrative burden, efficiency, and supporting timely, clinically appropriate care decisions.

What’s Changing: Site-of-care selection for shoulder, hip, knee, and spine surgeries

Advances in surgical care have enabled many procedures that once required inpatient stays to be safely performed in outpatient settings.

Effective November 3, 2026, Evolent will guide ordering providers, during intake of an authorization request for Ambetter of Illinois members, to select a preferred site-of-care. If a hospital-based setting is selected for a procedure that can be performed in an outpatient setting, providers will be required to either choose from a list of allowable exceptions or provide supporting clinical justification.

Clinical reviewers will evaluate medical necessity and site-of-care criteria before rendering a determination. After the authorization request is complete, the final authorization will reflect determinations for both the procedure and the site-of-care.

For questions or additional information, please contact Ambetter Health, Provider Services at 855-745-5507, TTY: 844-517-3431 for assistance.