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Humana Physician News: Q4 2026
Act
by Jan 1, 2027
Effective date
Jan 1, 2027
Identified
Nov 4, 2026
Summary
Historical material: Humana's Q4 2026 physician newsletter (published October 1, 2026, first found by PolicyChanges on November 4, 2026) announces prior authorization and notification lists for Medicare Advantage and Dual Eligible Special Needs Plan patients that take effect January 1, 2027, plus Medicaid and Part D medication list changes and immunology biosimilar rules. The newsletter does not list individual codes, so the actual lists must be checked in Humana's PAL search tool; the rest of the newsletter is reminders on documentation, 100-day prescribing and claims payment policies.
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What to do
by Jan 1, 2027 · 8 steps
01Billing and prior authorization staff should use Humana's PAL search tool in Availity Essentials to look up each CPT code and drug the practice bills for Medicare Advantage and D-SNP patients, mark which ones will need prior authorization or notification starting January 1, 2027, and update the prior authorization tracker and scheduling notes.
02Verify benefit coverage in Availity Essentials before scheduling, because the newsletter says PA requirements do not confirm coverage.
03Pharmacy staff: for Humana Healthy Horizons Medicaid patients, review the updated medication lists for provider-administered drugs that may need PA and for preferred drug list and comprehensive drug list changes, and update formulary notes in the EHR.
04Also by January 1, 2027: check the Commonly Prescribed Drug List and the Part B step therapy list for MAPD and PDP patients and update drug defaults in e-prescribing.
05Infusion and prescribing staff: patients on select brand immunology products can switch to a preferred biosimilar for MAPD and PDP plans without a new PA, so update medication lists and tell providers.
06Providers and coders: document each chronic condition with specificity at every visit, since the newsletter says clear diagnosis documentation supports accurate coding, reduces claim denials and helps identify care gaps.
07Clinical staff: for the new Medicare Stars depression measure, screen with PHQ-2 or PHQ-9 and schedule follow-up within 30 days for positive screens.
08Billing team: review Humana's recently revised claims payment policies on modifier 62, DMEPOS proof of delivery documentation, home health notice of admission, automobile and workplace injuries, and urinary tumor markers for bladder cancer, and update charge entry and claim checklists to match.
Original notice
Humana Physician News: Q4 2026
assets.humana.com · Always check the source before changing claims.