Humana Announces Changes to Preclusion List

February 2019 ~

Humana states the payer will end affiliations with any providers on CMS’ preclusion list.

Announced in a notice in the insurer’s most recent provider newsletter, Humana will end association with healthcare providers who are affiliated with Tax Identification Numbers or National Provider Identifiers on the CMS preclusion list.

As seen in the announcement, the CMS preclusion list includes providers and prescribers who are prohibited from receiving payment for Medicare Advantage services or Part D drugs prescribed to Medicare beneficiaries.

Humana states that, according to the CMS preclusion list, those on the list include individuals or entities who:

  • “Are currently revoked from Medicare, are under an active reenrollment bar, and CMS has determined that the underlying conduct that led to the revocation is detrimental to the best interests of the Medicare program”1

Or

  • “Have engaged in behavior for which CMS could have revoked the individual or entity to the extent applicable if they had been enrolled in Medicare, and CMS determines that the underlying conduct that would have led to the revocation is detrimental to the best interests of the Medicare Program.”2

Beginning January 1, 2019, the preclusion list will be made available to Humana and other Part D sponsors and Medicare Advantage plans. The preclusion will take effect on April 1, 2019, and Humana will:

  • Reject a pharmacy claim (or deny a beneficiary request for reimbursement) for a Part D drug that is prescribed by a healthcare provider on the preclusion list.
  • Deny payment for a healthcare item or service furnished by a healthcare provider or entity on the preclusion list.
Source(s): Humana’s Your Practice Newsletter; CMS Preclusion List;

 

 

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