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New Prior Authorization Requirements for Medicare Advantage Plans

Humana and UnitedHealthcare recently alerted providers that they are implementing new prior authorization requirements for chiropractic services under their Medicare Advantage plans. They claim that these changes are part of a broader effort to ensure the appropriate use of healthcare resources.

Key Points:

Effective Dates:

Humana Medicare – August 29, 2024

United Healthcare Medicare - September 1, 2024

Affected Services:

Humana Medicare - 98940, 98941, 98942, 98943
United Healthcare Medicare - 98940, 98941, 98942 (when billed with the AT modifier) and select physical medicine codes (if covered under the plan)

Exclusions: This requirement does not apply to Evaluation and Management (E/M) services, which do not require prior authorization. Your office may need to adjust protocols accordingly. This may involve conducting the E/M on the initial date of service, submitting the preauthorization request, and scheduling the chiropractic treatments only after the authorization has been approved.

Impact on Providers: Providers must submit a prior authorization request for the treatment plan after the initial evaluation. Failure to obtain authorization may result in claim denial, and providers will not be able to balance bill patients for these services.

Resources for Providers:

Humana Providers: Visit the Humana Provider Coverage & Claims page for information on Preauthorization and Notifications.

UnitedHealthcare Providers: For guidance on submitting a prior authorization request, please visit the UnitedHealthcare Notification. UHC has delegated the review process to Optum Health Solutions.

We encourage all providers to familiarize themselves with these changes and ensure that prior authorizations are obtained promptly to avoid disruptions in patient care.

The MAC is currently exploring ways we can work with the national organizations to fight these changes. Stay tuned for more information as it becomes available.