Effective December 5, 2026: Prior Authorization Updates for Musculoskeletal Surgical Procedures

Date: 10/05/26

Superior HealthPlan and Ambetter Health are collaborating with their contracted Utilization Review Agent (URA), Evolent Specialty Services, Inc., URA #1777359 (Evolent), to implement updates to how Musculoskeletal services are reviewed and administered to enhance the member and provider experience for our Medicaid (STAR, STAR+PLUS, STAR Kids, STAR Health), CHIP, Marketplace and ICHRA Programs. These changes reflect a shared commitment to improving quality of care, efficiency, reducing administrative burden, and supporting timely, clinically appropriate care decisions.

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. Beginning December 5, 2026, Evolent will guide ordering providers, during intake of a preauthorization request 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 both medical necessity of the requested procedure and site of care criteria prior to rendering a determination. Once the processing of the authorization request is complete, medical necessity determinations for both the procedure and the site of care will be provided. The policy proposed for implementation on December 5, 2026, can be accessed at the following link: Place of Service Policy for Musculoskeletal Surgery.

For questions or additional information, please contact your Provider Representative.