MedicaidPrior AuthHigh impact
Medical Necessity Determinations (New)
Humana·VA·Medicaid
Effective date
Jul 1, 2025
We identified it
Jun 24, 2026
Summary
Humana has established new medical necessity determination criteria for Medicaid Virginia members, requiring services to meet federal regulations and evidence-based guidelines. Special EPSDT review processes are now mandatory for members under 21 years old.
Action Required
By July 1, 2025: Billing team must ensure all prior authorization requests for Medicaid Virginia members include documentation that services are not excluded benefits, meet state/federal regulations, and are evidence-based. For members under 21, ensure EPSDT criteria are documented and secondary physician review is available for denials. Update EMR templates to capture required medical necessity documentation.