MedicaidAdministrativeMedium impact
Medical Necessity Determinations (Revised)
Humana·IN·Medicaid
Effective date
Jul 1, 2024
We identified it
Jun 24, 2026
Summary
Humana Indiana Medicaid has revised their Medical Necessity Determinations policy, establishing a hierarchical framework for reviewing medical and pharmacy coverage requests. The policy clarifies that medical necessity reviews must follow federal law, Indiana Code, state plan requirements, and national clinical guidelines in that order.
Action Required
By July 17, 2025 (review date): Billing and authorization teams must ensure all Humana Indiana Medicaid prior authorization requests follow the established criteria hierarchy - federal law, Indiana Code, state plan, Indiana Administrative Code, then national clinical guidelines (InterQual or MCG). Update internal prior auth workflows to reference this hierarchy when appealing denials or submitting documentation.