Tag: Prior Authorization
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.
Humana
TIPS, TRICKS AND HELPS
PREAUTHORIZATON LISTS (PAL):
Lists of services and medications effective July 1, 2025, that may required preauthorization for members with Medicaid, Medicare Advantage, and dual Medicare-Medicaid coverage are now available.
Easily determine if a prior authorization is required with Humana’s search tool. Search by Current Procedural Terminology (CPT®) codes, procedures or generic drug name(s). Remember to verify benefit coverage in Availity Essentials
Availity Essentials Introduces Check Claim Status Feature:
Availity has enhanced its Eligibility and Benefits (E/B) page by adding a Check Claim Status feature.
What you can expect:
- Improved efficiency and accuracy: The check Claim Status tool pre-populates your patient’s information, ensuring accuracy.
- Time savings: You can access claim status with one click- saving time and effort
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