Humana Physician News - February 2025

February 4, 2025

                      Humana Physician News - First Issue - February 2025

 

 Streamline your workflow: Availity Essentials adds IPA and delegated entities

Effective November 2024, Availity Essentials™ member profiles now include names and addresses of Independent Practice Associations (IPAs) and delegated entities associated with Humana members. This update ensures claims are correctly routed.

What you can expect:

  • Improved efficiency and accuracy: Reduce your administrative burden with improved accuracy of Humana member information to make informed decisions.
  • Better coordination: Coordinate care more effectively with detailed Humana member information.
  • Time savings: Access details in one place, saving time and effort.

Get started → 

 

 New rule improves prior authorization process

Effective Jan. 1, 2026, the Centers for Medicare & Medicaid Services (CMS) will require prior authorization decisions within 7 calendar days for standard (non-urgent) requests for medical items and services. To meet the streamlined time frame in advance of 2026, supporting clinical information must be submitted at the time of prior authorization requests for items or services. Otherwise, it may result in a delayed and/or adverse decision.

You can easily determine if a prior authorization is required with Humana’s search tool. Search by Current Procedural Terminology (CPT®) codes, procedures or generic drug name(s). Remember to verify benefit coverage in Availity Essentials.

Review details → 

 

 New study shows CenterWell Pharmacy benefits heart failure with reduced ejection fraction patients

CenterWell Pharmacy® mail order with 90-day fills is associated with higher proportion of days covered, reduced hospitalizations and allowed medical spend, including for patients with heart failure with reduced ejection fraction (HFrEF).

Recent research confirmed HFrEF patients who take more medications on guideline-directed medical therapy have better health outcomes, regardless of pharmacy. In addition, those who filled with CenterWell had higher adherence and fewer admits compared with patients who fill elsewhere.*

Review research findings →

 

 Artificial intelligence adoption in the
value-based era 

Is artificial intelligence (AI) accelerating the shift to value or just making healthcare better at fee-for-service practices?

The Medical Group Management Association and Humana recently surveyed healthcare leaders about their perceptions and implementation of AI solutions in their organizations, including motivations for and barriers to AI adoption, governance and important factors for organizational buy-in.

Review research findings →

 

NEW! Watch the Stars condition  management overview video

According to the Centers for Disease Control and Prevention, 38 million Americans have diabetes and an additional 27 million, age 65 or older, have pre-diabetes. Effective diabetes management is vital to the health and well-being of your patients and an important component of meeting Medicare quality goals.
Ensure you have the information to best support your diabetic patients and understand CMS guidelines to meet Stars requirements, including those introduced in 2024.

Watch overview video →

 

Compliance reminders:

Complete your required 2025 training

CMS requires that training be completed annually by healthcare providers who participate in Humana MA Special Needs Plans (SNPs); Humana Healthy Horizons® Medicaid plans in 1 or more applicable states; and/or a Humana Medicare-Medicaid dual plan in Illinois. Review what training applies to your practice.

Access training →

 

Care for Older Adults—Medication Review measure

To ensure compliance, healthcare providers should perform the Care for Older Adults-Medication Review (COA-MDR) at least annually with 2 codes submitted at the same date of service:

  • 1159F Medication list documented in medical record
  • 1160F Review of all medications (prescriptions, over the counter, supplements) conducted and documented by prescribing practitioner

Review the COA measure →

 

NEW! Go365 provider toolkit puts patient well-being front and center

Go365 by Humana® well-being and rewards program can support your Humana-covered patients’ health outside the office. Offering guidance and tools to positively impact their nutrition, sleep, exercise and more, this toolkit features 2025 rewards, CPT codes and links to downloadable patient resources.

Access provider toolkit →

 

The holidays and substance use disorders

For many, the holidays were more than a time of celebration. According to the American Psychological Association, 38% of people reported increased stress, which can be especially troubling for those with a history of a substance use disorder. In fact, 27% of Americans admitted to drinking more over the holidays. Learn about managing substance use disorders.

Review guidelines →

 

Additional Humana links:

Prior authorization and notification lists →

Important policy reminders →

Claims payment policies →

Claims processing edits →

Medical and Pharmacy Coverage Policies →

Moving to value-based care →

Making It Easier: Series about doing business with Humana →

Clinical practice guidelines →

Behavioral health credentialing and resources →

Medicare/Medicaid annual compliance training →

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