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Prior Authorization Changes Effective Jan. 1, 2027
Act
by Dec 31, 2026
Effective date
Jan 1, 2027
Identified
Sep 25, 2026
Summary
HealthSpring Medicare Advantage is expanding prior authorization requirements effective Jan. 1, 2027, adding nine new service categories (oncology, hematology, orthotics, prosthetics, wound care, DME, chronic care, nuclear medicine, diabetes supplies, cardiology, and miscellaneous codes) that will require prior auth review through HealthSpring or EviCore. Billing teams must verify prior auth requirements through Availity before rendering services, as claims without required authorization may be denied and providers cannot bill members.
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What to do
by Dec 31, 2026 · 6 steps
01Billing team and clinical staff must update all workflows to require prior authorization verification for HealthSpring Medicare Advantage members in nine new service categories: oncology, hematology, orthotics, prosthetics, wound care, durable medical equipment, chronic care, nuclear medicine/diagnostics, diabetes supplies, and cardiology.
02Before rendering any service to HealthSpring MA members, staff must check eligibility and prior auth requirements through Availity Essentials or preferred vendor to determine if HealthSpring or EviCore is the reviewing entity.
03Update encounter forms, billing software rules, and provider education materials to reflect these new requirements.
04Train front desk staff to flag these service types at check-in and verify prior auth status.
05Inform providers that services performed without required prior authorization will result in claim denials and providers cannot seek reimbursement from members.
06Reference the detailed prior authorization requirements list on HealthSpring's provider portal for specific codes in each category.
Original notice
Prior Authorization Changes Effective Jan. 1, 2027
healthspring.com · Always check the source before changing claims.