Evolent Musculoskeletal Program Updates: Effective December 5, 2026

Date: 10/20/26

Ambetter from WellCare of New Jersey, in collaboration with Evolent, are implementing updates to the review and administration of musculoskeletal services to enhance the member and provider experience. These changes reflect a shared commitment to improving the quality and efficiency of care, reducing administrative burdens, 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 now allow many procedures that once required inpatient stays to be safely performed in outpatient settings.

Beginning December 5, 2026, Evolent will guide ordering providers to select a preferred site of care when submitting authorization requests for Ambetter from WellCare of New Jersey members. 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 both medical necessity and site of care criteria before making a determination. Once 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 from WellCare of New Jersey provider services at 1-844-606-1926 (TTY 711).