Updated policy for advanced imaging
Beginning November 1, 2021, Humana will institute an updated policy for advanced imaging services. This policy will apply to fully insured and LFP commercial plans in select states (see below) for certain radiology services (i.e. computed tomography [CT] scan, magnetic resonance angiogram [MRA], magnetic resonance imaging [MRI], positron emission tomography [PET] scan).
Using an in-network freestanding facility, when appropriate, can help provide our plan members with access to cost-effective imaging services, without sacrificing quality.
This policy will follow a two-phase implementation process. Phase 1 will begin November 1, 2021, for Florida, Georgia, Ohio, and Tennessee. Phase 2 will be effective January 1, 2022, for Illinois, Indiana, Kansas, Louisiana, Missouri and Wisconsin.
As part of this change, providers have been notified and will be directed to use lower-cost (freestanding) imaging centers for the services listed above. This will occur as part of the preauthorization process with the provider, which means any member impact will occur only if the provider does not comply with the new policy and sends a member to a hospital location and not a freestanding facility when a hospital location is not medically necessary.
Answers to questions you may have:
•Why is Humana making this policy update? Humana remains committed to lowering overall cost of care, and we continue to work to find options that help keep our members’ costs as low as possible while maintaining a high quality of their care. One savings opportunity is routine imaging, which describes a variety of services that provide a view inside the body. Getting these procedures from outside a hospital can provide the same diagnostic results while helping control costs. Starting November 1, 2021, Humana may deny claims for these services if they are not medically necessary in a hospital setting. We’ve notified doctors in our network of this policy update. Savings opportunities like this are designed to help lower member out-of-pocket costs, and ultimately, control health plan premiums by helping reduce overall medical costs through lower imaging rates.
•Which radiology services on the current preauthorization list will now require a site-of-service review?
Computed Tomography (CT) Scan
Includes Computed Tomography Angiogram (CTA) Scan
Magnetic Resonance Angiogram (MRA)
Magnetic Resonance Imaging (MRI)
Positron Emission Tomography (PET) Scan
•Why did Humana decide to include these specific procedures? We conduct careful reviews to determine which procedures can be performed safely and effectively at a freestanding facility, consistent with the terms of our members’ benefit plans.
•What will happen if the provider does not follow this policy? As with all services on the Pre-Authorization List (PAL), providers are required to obtain the proper authorization prior to a member receiving services. If a provider disregards the preauthorization process and sends a member to a hospital setting when a free standing facility was appropriate and available, the member may be impacted and responsible for additional cost due to no authorization being on file. We are working to educate our providers to minimize any such impact to our members.
•Will there be exceptions to this policy? There may be certain circumstances where the member will be eligible to have the imaging services administered by a hospital (e.g. availability of nearby free standing imaging centers, a member’s specific medical needs, etc.). This criteria can be found in the Site of Service – Advanced Radiologic Imaging medical coverage policy, which is available on Humana.com.
If you have additional questions, please don’t hesitate to call your Humana sales representative. We continue to be committed to maintaining a high level of customer care and working with businesses like yours to offer health benefit solutions that address the unique needs of your employees.