Evolent Musculoskeletal Program Updates Effective 12.5.26

Fecha: 05/10/26

Ambetter Health in collaboration with Evolent is implementing updates to how Musculoskeletal services are reviewed and administered to enhance the member and provider experience. These changes reflect a shared commitment to improving quality of care, efficiency, reducing administrative burden, 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.

Beginning December 5, 2026, Evolent will guide ordering providers, during intake of an authorization request for Marketplace 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 both medical necessity and site of care criteria prior to rendering 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 provider services at 1-866-595-8133.