Humana Medicare Advantage has updated its Psychiatric Inpatient Hospitalization policy (HUM-9000-004) effective September 1, 2026. The policy reinforces the two-midnight benchmark for admission coverage and clarifies that psychiatric inpatient care must meet medical necessity standards based on complex medical factors. Billing teams must ensure claims documentation supports the two-midnight requirement and align with applicable MAC Local Coverage Determinations by geographic jurisdiction.
Action Required
Action needed
By August 1, 2026: Billing team must review applicable MAC Local Coverage Determinations (LCDs) by geographic jurisdiction: L33624 (IL, MN, WI, CT, ME, MA, NH, NY, RI, VT), L34183 (KY, OH), L34570 (AL, GA, TN, NC, SC, VA, WV), and L33975 (FL, PR, US VI). For all psychiatric inpatient admission claims using revenue codes 0114, 0124, 0134, 0144, 0154, 0204, ensure medical record documentation clearly supports: (1) admitting physician's expectation that patient requires care crossing two midnights; (2) complex medical factors documented (medical history, severity of symptoms, medical predictability of adverse events, need for diagnostic studies, facility availability); and (3) that admission is not for social convenience or non-medical reasons. Update claim denial response templates to reference two-midnight benchmark and require corrected documentation. Failure to meet these requirements will result in claim denials and potential recovery actions. Providers must document medical necessity in admission orders and progress notes.