Changes Coming to the Preclusion List

Humana will end association with healthcare providers who are affiliated with tax identification numbers or National Provider Identifier numbers (NPIs) on the Centers for Medicare & Medicaid Services (CMS) preclusion list.

The CMS preclusion list includes providers and prescribers who are prohibited from receiving payment for Medicare Advantage (MA) services or Part D drugs prescribed to Medicare beneficiaries. According to the CMS website (link opens in new window), 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.”

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.”

Beginning Jan. 1, 2019, the preclusion list will be made available to Humana and other Part D sponsors and MA plans. The preclusion will take effect 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.

For more information about the preclusion list and what it means for healthcare providers, including notification and appeal information, go to the CMS website (link opens in new window).