Medicare AdvantagePrior AuthHigh impact
Prior Authorization Changes Effective Oct. 1, 2026
HealthSpring·Oncology, Genetics·Prior Authorization
Effective date
Oct 1, 2026
We identified it
Aug 13, 2026
Summary
HealthSpring Medicare Advantage is expanding prior authorization requirements effective October 1, 2026 to include four new service categories: oncology codes, specialty infusion drug codes, molecular and genetic diagnostic codes, and miscellaneous codes. These will be reviewed by HealthSpring or EviCore healthcare. Billing teams must verify prior authorization requirements before rendering services or face claim denials and payment recovery restrictions.
Action Required
By September 30, 2026: Billing team must update all eligibility verification workflows in Availity Essentials and preferred vendor systems to screen for prior authorization requirements for oncology services, specialty infusion drugs, molecular/genetic diagnostics, and miscellaneous codes for HealthSpring Medicare Advantage members. Providers must obtain prior authorization from HealthSpring or EviCore healthcare BEFORE rendering these services. Update encounter forms and clinical workflows to prompt providers to confirm prior authorization status. Document that services rendered without required prior authorization will result in claim denials and providers cannot balance-bill members. Train front desk, clinical, and billing staff on the new requirements. Establish a process to flag claims for these service categories for pre-submission prior authorization verification.