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Fast Facts Newsletter - August (Special Edition) 2026
HealthPartners·MN · Chiropractic, Pharmacy, Oncology +6 more·Pharmacy
Effective date
Jul 1, 2026
We identified it
Aug 1, 2026
Summary
HealthPartners issued a comprehensive policy update affecting pharmacy formularies, medical coverage criteria, and administrative operations. Key changes include: (1) Chiropractic claims routing transition from Fulcrum Health to direct HealthPartners submission effective July 1, 2026; (2) SUD billing requirements alignment with Minnesota DHS Behavioral Health Fund Grid effective September 1, 2026; (3) Multiple drug formulary and pharmacy policy updates favoring biosimilars (Avtozma over Actemra, Mvasi/Vegzelma over Avastin); (4) Medical policy revisions for TMD diagnostics, wheelchair codes, and Cohere coverage criteria effective October 1, 2026.
Action Required
IMMEDIATE ACTIONS: (1) By July 17, 2026: Billing team must stop submitting chiropractic claims to Fulcrum Health and redirect ALL chiropractic claims directly to HealthPartners for processing. Any claims received by Fulcrum after July 17 will not be processed. Establish electronic claims submission through HealthPartners-approved clearinghouses. Verify your practice is enrolled in the HealthPartners provider system before clearinghouse enrollment. Update billing software routing rules and staff workflows. (2) By September 1, 2026: Billing team must update SUD service billing practices to comply with Minnesota DHS Behavioral Health Fund Billing Grid. Review and implement correct modifier combinations and billing requirements per DHS guidelines (reference: edocs.dhs.state.mn.us/lfserver/Public/DHS-7612-ENG). Train billing staff on new requirements. (3) By October 1, 2026: Billing team must update systems to require prior authorization for power wheelchair codes K0830 and K0831 per revised DME policy. Add these codes to Group 1/Group 2 wheelchair authorization criteria in billing software. ONGOING: Pharmacy team must implement formulary changes immediately upon October 1 posting: update billing system drug preference lists to favor Avtozma (over Actemra), Mvasi/Vegzelma (over Avastin), Epysqli (over Soliris/biosimilars), and Bildyos/Stoboclo (over Prolia). Remove Ziextenzo from preferred products. Update prior authorization rules for new biosimilar preferences. Medical coding team must remove diagnostic imaging (tomography, cone beam CT, arthrography, MRI) from non-surgical TMD treatment coverage—reclassify as requiring prior auth per revised policy.