Tag: Prior Authorization
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.
HS
Updates for HealthSpring providers | |
We’re changing prior authorization requirements that may apply to some HealthSpring Medicare Advantage members. Changes are based on updates from utilization management prior authorization assessment, Current Procedural Terminology (CPT®) code changes released by the American Medical Association or Healthcare Common Procedure Coding System code changes from the Centers for Medicare & Medicaid Services. For some services and members, prior authorization may be required through HealthSpring utilization management, and related services for Medicare Advantage members will be reviewed by HealthSpring and EviCore healthcare. | |
These changes begin July 1, 2026: · Implementation of Part B Step Therapy Program · Addition of orthotic codes to be reviewed by HealthSpring · Addition of new Medicare Advantage Prescription Drug plan codes to be reviewed by HealthSpring | |
For more information, refer to the prior authorization requirements list on the clinical review page. Always check eligibility and benefits first through Availity® Essentials or your preferred vendor prior to rendering services. This step will confirm prior authorization requirements and utilization management vendors, if applicable. Checking eligibility and/or benefit information and/or obtaining prior authorization is not a guarantee of payment. Benefits will be determined once a claim is received and will be based upon, among other things, the member’s eligibility, and the terms of the member’s evidence of coverage. If you have any questions, call the number on the member’s ID card. Services performed without required prior authorization or that do not meet medical necessity criteria may be denied for payment, and the rendering provider may not seek reimbursement from the member. | |
Thank you for your partnership. | |
CPT copyright 2025 American Medical Association. All rights reserved. CPT is a registered trademark of the AMA. | |
HealthSpring products and services are provided exclusively by or through operating subsidiaries of Health Care Service Corporation, a Mutual Legal Reserve Company. PO Box 20002, Nashville, TN 37202 © Copyright 2026 Health Care Service Corporation. All Rights Reserved. |
HealthSpring Change in Prior Auths
Change in prior authorization administration for DME services, effective March 1, 2026 |
Effective March 1, 2026, HealthSpring will manage prior authorizations for durable medical equipment services, as well as orthotic and prosthetic codes. Lorem ipsum dolor sit amet, consectetur adipiscing elit. Ut elit tellus, luctus nec ullamcorper mattis, pulvinar dapibus leo.
EviCore healthcare will continue to manage prior authorizations for DME services through Feb. 28, 2026.
What this means to your patients through Feb. 28, 2026 · Submit prior authorization requests with dates of service before March 1, 2026, to EviCore as usual. · Continue to refer to EviCore for the most updated prior authorization code lists. · There are no changes to the claims submission or appeals processes.
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Key changes effective March 1, 2026 · DME providers will submit prior authorization requests directly to HealthSpring. · Submit prior authorization requests to HealthSpring for dates of services beginning March 1, 2026. Request prior authorization through Availity Essentials™, our provider portal. · A list of procedural codes requiring prior authorization is available on the clinical review page of our provider website, HealthSpring.com/Providers. · Any authorization issued prior to March 1 will remain valid for those dates and services. That means, any authorizations approved by EviCore before March 1 will remain effective with HealthSpring. You do not need to submit a new prior authorization request.
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How to request prior authorization Request prior authorization through our provider portal, Availity Essentials. This portal is the preferred and fastest method. Refer to Availity for instructions on setting up an account and navigating the portal. If you prefer, you can also call 1-800-914-8252 or fax 1-877-451-5541. |
BCBS Pharmacy Qtrly Updates for January 2026
Pharmacy Program Quarterly Update Changes Effective Jan. 1, 2026 – Part 1
UHC “Check by Member” Authorization Tool
UHC says they have a smarter way to check prior authorization requirements.
Our upgraded Check by Member tool is now the most accurate and reliable way to confirm prior authorization requirements.
- Personalized results based on member-specific data
- Same trusted source as our phone advocates
- Instant answers with no hold time
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.
Check Your Gold Card Eligibility
Last fall, UHC introduced the first national Gold Card program, reducing prior authorizations in favor of advance notification for provider groups consistently adhering to evidence-based care guidelines. They are happy to announce that in the 2nd year of the program, starting Oct. 1, 2025, additional provider groups will be eligible.
On Sept. 1, UHC will publish details on how to determine if your provider group has qualified for the program.
Check your Gold Card eligibility status starting Sept. 1
Provider groups can view their Gold Card program status in the UnitedHealthcare Provider Portal.
Renewing Oct. 1, 2025, the program simplifies the prior authorization process for qualifying providers and eligible services. Qualifying providers will need to submit advance notification, which confirms eligibility and network status, but no clinical information will be requested. We’ve updated the program protocol for the renewal period.
Visit our national Gold Card program page in September for detailed instructions on how to identify Gold Card status and access to an interactive guide that can help you navigate our resources.
Cigna Comm. Removes 96 Codes from Prior Auth. List.
To help reduce the paperwork and time providers (and patients) spend seeking approvals for more routine services, Cigna Healthcare will remove 96 codes from the list of services that require prior authorization for dates of service on and after May 31, 2025. These codes include commonly requested cardiology, otolaryngology (ENT), and other routine services.
Cigna Commercial REMOVING Multiple Services from Their Pre-Cert List.
Many services will no longer require prior authorization (i.e. Precertification) for Cigna Commercial, beginning May 31, 2025.
Please note, however, that removal from precertification is not a guarantee of payment. Codes may be subject to standard code editing, benefit plan exclusions, and post-service review for coverage.
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