MedicaidPrior AuthHigh impact
Medical Necessity Determinations (Revised)
Humana·FL · Pharmacy·Medicaid
Effective date
Oct 15, 2025
We identified it
Jun 25, 2026
Summary
Humana has revised its Medical Necessity Determinations policy for Medicaid in Florida (effective October 15, 2025). This guidance clarifies the five-point criteria required to establish medical necessity for pharmacy and medical services under Florida Medicaid rules 59G-1.010, including requirements that services be covered benefits, meet state/federal regulations, be medically acceptable, align with professional standards, and represent the most conservative available treatment. Billing teams must ensure all prior authorization requests and claim submissions document compliance with these specific criteria.
Action Required
By October 15, 2025: Billing team and prior authorization staff must implement the revised five-point medical necessity criteria for all Humana Medicaid-Florida pharmacy and medical service requests. REQUIREMENTS: (1) Update preauthorization templates and checklists to require documentation of all five criteria: covered benefit status, state/federal regulatory compliance, medically acceptable per 59G-1.010 definition, professional medical standard alignment, and confirmation that no equally effective/less costly alternative exists statewide. (2) Train prior auth reviewers and billing staff on the specific language of Florida AHCA Rule 59G-1.010 medical acceptability standards. (3) Audit claim denials to ensure rejections cite specific criteria not met. (4) Instruct providers submitting requests to reference www.humana.com/PAL for applicable preauthorization codes and requirements. (5) Update internal denial reason codes to map to the five medical necessity criteria. Failure to implement these criteria will result in claim denials and prior authorization request rejections for Humana Medicaid-Florida members.