MedicaidDocumentationMedium impact
Medical Necessity Determinations (Revised)
Humana·SC·Medicaid
Effective date
Jul 1, 2024
We identified it
Jun 24, 2026
Summary
Humana updated their medical necessity determination criteria for Medicaid pharmacy coverage in South Carolina, establishing specific evaluation standards that licensed pharmacists or physicians must use when reviewing requests for services, procedures, or products.
Action Required
Immediately: Billing team and providers should review current prior authorization processes for Medicaid pharmacy requests to ensure compliance with updated medical necessity criteria. When submitting requests, ensure documentation addresses all five criteria areas: exclusion status, state/federal compliance, accepted medical standards, medical necessity per CFR definitions, and specific South Carolina drug criteria. Update internal checklists to reference the new evaluation standards.