Tag: Availity
New Clinical Documentation Attachments Required for Prior Authorizations
Effective Jan. 1, 2026, the Centers for Medicare & Medicaid Services (CMS) requires prior authorization (PA) decisions within seven calendar days for standard (non-urgent) requests for medical items and services (See CMS Interoperability and Prior Authorization Final Rule – CMS-0057-F).
Below is From Humana
Humana is committed to maintaining the new streamlined time frame for PA decisions in accordance with this rule. To comply, all supporting clinical documentation must be submitted at the time of the PA request. Beginning May 16, 2026, providers submitting outpatient Medicare authorization requests for PA services via the Availity Essentials™ portal will be required to upload supporting clinical documentation. Exceptions may apply.
If you have other questions, please call 800-457-4708 (TTY: 711) Monday-Friday, 7 a.m. – 7 p.m., Eastern time.
CMS now requires impacted payers to send PA decisions to providers within 72 hours for expedited (urgent) requests and seven calendar days for standard (non-urgent) requests.
To streamline the PA process and comply with CMS Interoperability and Prior Authorization Final Rule – CMS-0057-F, supporting clinical documentation must be received with the authorization request. This ensures that Humana has the information necessary to promptly and accurately review requests.
This requirement applies to Medicare outpatient authorization requests for PA services submitted directly through Availity Essentials. It does not apply to home health services, inpatient services or Medicaid membership. This change does not impact submissions outside of Availity Essentials.
Availity Essentials will require clinical records to be attached before submission for outpatient PA services. If records are unavailable, your progress will be saved as a draft in the Authorization/Referral dashboard for up to 90 days. You may resume and submit once documentation is available. Please note, draft entries are not considered submissions; Humana will not receive your request until it is submitted with records attached.
Required information may include, but is not limited to, the items below:
• Patient details: Full name, date of birth and Humana policy ID number
• Referring and servicing provider details: Name, National Provider Identifier (NPI), Tax Identification Number (TIN), specialty and contact information (including fax)
• Diagnosis and procedure codes: Accurate International Classification of Diseases (ICD) diagnosis codes (up to six) and procedure codes (up to 10, as applicable) specific to the request
• Treatment details: Specific service, procedure, item or medication being requested, including planned date of service, service location, inpatient or outpatient status, quantity, medication dosage, frequency and duration
• Clinical rationale: Detailed explanation of medical necessity with supporting evidence from medical records. See Humana.com/CoveragePolicies for more information on clinical guidelines.
• Relevant medical history: Past medical conditions, current medications, allergies and significant laboratory results
• Supporting documentation: Imaging studies, laboratory reports, prior treatments or therapies, progress notes or other relevant clinical data that supports the medical necessity of the request
For additional details, please refer to the CMS Interoperability and Prior Authorization Final Rule – CMS0057-F and Humana coverage policies at Humana.com/CoveragePolicies.
BCBS CIR Cheat Sheet
“The Claim Inquiry Resolution (CIR) tool within the Electronic Refund Management (eRM) portal accessed via Availity® Essentials only accepts inquiry submissions related to High-Dollar, Pre-Pay Review requests for most Host (BlueCard® out-of-area) claims (Medical Records and/or Itemized Bills). The other inquiry options that were available via CIR have transitioned to the Availity Claim Status Tool’s Dispute Claim or Message This Payer features.” Per BCBS Provider Education.
WHAT CAN BE DOWNLOADED TO eRM?
See Example Below —
Highlights for Aetna OfficeLink Updates
Claim and Code Review Program (CCRP) update
Starting December 1, you might see new claim edits
This update applies to both our commercial and Medicare members.
Beginning December 1, 2025, you may see new claim edits. These are part of our CCRP. These edits support our continuing effort to process claims accurately for our commercial, Medicare and Student Health members. You can view these edits on our provider portal on Availity.
For coding changes, go to Aetna Payer Spaces > Resources. In the search bar, search for “expanded claim edits.”
Except for Student Health, you’ll also have access to our code edit lookup tools. To find out if our new claim edits will apply to your claim, log in to Availity®. You’ll need to know your Aetna® provider ID number (PIN) to access our code edit lookup tools.
We may request medical records for certain claims, such as high-dollar claims, implant claims, anesthesia claims, and bundled services claims, to help confirm coding accuracy.
Changes to our National Precertification List (NPL)
These changes apply to our commercial and Medicare members, unless otherwise noted.
Effective January 1, 2026, we’ll require precertification for the following:
• Electrophysiological (EP) study (93654)
• Yondelis® (trabectedin, J9352)
• Docivyx™ (docetaxel, J9172) — Medicare members only
Check out the Original Publication, titles like:
- How to secure an authorization
- Urgent requests
- Changes to commercial drug lists begin on January 1
- And More
HealthSpring Rollout
■ Important Updates for Physician Offices-New Plans Coming in 2026
New benefit plans under the HealthSpring name will roll out January 2026. For now, you can find articles about these changes on: MedicareProviders.Cigna.com …and in the Provider Newsroom.
■ Claims Contact Information
Jim Denman will no longer handle claims.
For more information, please call POET
■ Goodbye HSConnect – Hello Availity Essentials
Cigna MA has partnered with Availity Essentials for enhanced online tools. HSConnect and Cigna for HCP are no longer needed.
■ Verify eligibility & benefits
■ Verify primary care provider
■ View customer ID cards
■ View maximum-out-of-pocket amounts
■ Submit professional & institutional claims
■ Check claim status
■ View remittance advice
■ Access Cigna MA links (including prior authorizations & resources) via the Payer Space page
Aetna Changes in NPL
Changes in National Precertification List
As of August 1, 2025, we require precertification for the following:
- Conexxence (denosumab-bnht, J3490, J3590, C9399)
- Bomyntra (denosumab-bnht, J3490, J3590, C9399)
- denosumab-bnht (biosimaliar Prolia, J3490, J3590, C9399)
- denosumab-bnht (biosimaliar Xgeva, J3490, J3590, C9399)
- Omlyclo (omalizumab-igec, J3490, J3590, C9399) (precertification includes the site of care)
- penpulimab-kcqx (J3490, J3590, C9399) (precertification includes the site of care)
- ustekinumab-stba (J3490, J3590, C9399)
- ustekinumab (J3490, J3590, C9399)
- Starjemza (ustekinumab-hmny, J3490, J3590, C9399)
Submitting precertification requests:
Submit precertification requests at least two weeks in advance and include the actual date of service in the request. To save time, request precertification online through our provider portal on Availity.* Doing so is fast, secure and simple.
You can also use your practice’s Electronic Medical Record (EMR) system if it’s set up for electronic precertification requests. Use our “Search by CPT® code” function on our Precertification Lists page to find out if the code requires precertification.***
If you need precertification for a specialty drug for a commercial or Medicare member, submit your request through Novologix®, which is also available on Availity®.
Note to Texas providers: Changes described in this article will be implemented for fully insured plans written in the state of Texas only if such changes are in accordance with applicable regulatory requirements. Changes for all other plans will be as outlined in this article.
Availity Portal Issues
It appears that Availity is having some issues.
If you have went in to Availity to complete an action, and it has your physician’s specialty wrong, this is an Availity issue. It seems to be across multiple insurances.
Please call Availity Customer Service (800) 282-4548.
POET is being told, it is not a credentialing or Healthplan issue.
Superior: New Availity Claim Features and Webinars.
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Change HealthCare!
Looking for answers? So is POET. We are looking for work-arounds. Hopefully we will have some up before closing today.
There is a New Player in the Game
EMI Health is proud to provide access to the Aetna network.
Each member will have a medical identification card with the EMI Health and Aetna logos.
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