Medicare AdvantagePrior AuthHigh impact
Prior Authorization Changes Effective Oct. 1 and Nov. 1, 2026
HealthSpring·Oncology, Allergy & Immunology·Prior Authorization
Effective date
Oct 1, 2026
We identified it
Sep 11, 2026
Summary
HealthSpring Medicare Advantage is changing prior authorization requirements for HealthSpring and EviCore, effective in two phases: Oct. 1, 2026 (removal/replacement of oncology codes, removal of immunology and molecular diagnostic codes from HealthSpring review) and Nov. 1, 2026 (addition of oncology drug codes to EviCore review). Billing teams must verify current prior authorization requirements through Availity Essentials before rendering services, as claims without required prior auth will be denied.
Action Required
By Sept. 30, 2026: Billing team must update all workflows to reflect the Oct. 1 prior authorization changes. Action items: (1) In billing system and Availity Essentials: Remove prior authorization requirement for the immunology code and molecular diagnostic code previously requiring HealthSpring review; (2) Update or replace oncology codes in system to reflect new prior authorization requirements through HealthSpring; (3) Train all billing and front-desk staff to verify prior authorization requirements through Availity Essentials or preferred vendor BEFORE rendering ANY services for HealthSpring Medicare Advantage members. By Oct. 31, 2026: Update billing system to add oncology drug codes requiring EviCore review, effective Nov. 1, 2026. Communicate new requirements to providers and clinical staff. Failure to obtain required prior authorization will result in claim denials, and providers may not seek reimbursement from members.