Humana:
Prior authorization with Humana was effective August 29th. This is the official announcement. The lack of notification left many of our doctors struggling to prepare.
Sheri Frost with Chiropractic Consultants of America shared the following information for additional guidance:
- Humana Chiropractic policy has changed as of 07/27/23. Read it in its entirety to understand what is required. There is an extremely rigid standard of care. Care that does not meet the standard of care per the payer is not reimbursable.
- Using Availity is the best way to stay compliant. If Availity says you don’t need the pre-auth, print it and keep it for when you get a denial. Attach that document and appeal any unpaid claims. Step by Step Guide.
- Manual faxable pre-auth form that can be used if you don’t have Availity. Keep in mind this is not the way you want to go for long. Faxing a form takes days to process. Availity should take minutes.
- Humana summary of medical pre-authorization code changes. You will notice the changes to primary services like manipulations and acupuncture. What you don’t find are the therapy codes. There is a search engine to check each and every code that you use for Humana. It allows you to choose the state where you live and then enter the codes you use to verify if pre-authorization is required. Suggest you do so!
- Keep track of the approvals. You will not want to go over the approved number of visits prior to requesting more. Use the policy document to show patients what Humana will and will not cover and invest them in advocating for change.
- When a payer rolls out something this big they often change it quickly, the call centers don’t know anything about it and you get really bad info all around. Try to be patient while they work out the kinks. There will be a lot of them.
Humana Announcement (see last page)
UnitedHealthcare:
UnitedHealthcare (through its Optum subsidiary) will now require prior authorization for chiropractic and other therapy services under Medicare Advantage plans.
UnitedHealthcare (Optum) announced providers must obtain approval for defined treatment plans (request a number of visits). This policy will apply to chiropractic manipulative therapy (CMT), physical therapy, occupational therapy, and other related services, excluding the initial evaluation. Although UHC initially stated the program would apply to “multi-disciplinary offices,” the updated version indicates that it could apply to all chiropractic practices.
Advocacy Response -Utilize the Patient Advocacy Flyer
This new requirement imposes an additional administrative burden on providers and could significantly delay patient care, particularly for Medicare Advantage patients, who have chosen these plans expecting streamlined access to conservative care options.
ChiroCongress is organizing a nationwide response, and the NC Chiropractic Association is participating with a letter directly to UnitedHealthcare, voicing our concerns. They have also created a patient advocacy flyer that we encourage you to share with your patients to make sure they are informed and empowered to protect their access to essential care.
Download the Patient Advocacy Flyer
This flyer includes vital information about the prior authorization changes and guidance on how patients can advocate for themselves by contacting their insurance providers directly.
It clearly instructs your patients on how to contact Humana and UnitedHealthcare directly. It encourages them to demand respect for the treatment plans you recommend and to urge their insurers to stop the prior authorization requirement for chiropractic and other physical therapy care.
We strongly urge you to share this flyer widely to ensure that patients are informed and empowered to protect their access to essential care.
BCBSNC
On July 29, 2024, Health Network Solutions notified providers via email that BCBSNC plans to require prior authorization for most physical therapy codes for its fully insured plans starting October 1, 2024. HNS is advocating for HNS providers to be exempt from this change. Since then, the effective date has been moved to November 1, 2024. The NCCA is in communication with HNS to support their exemption efforts. We will alert the membership if and when additional steps, such as patient communication, would be impactful.