MedicaidCoverageMedium impact
Clinical Trials - MEDICAID - LOUISIANA (Revised)
Humana·LA · Oncology, Cardiology, Pulmonology +4 more·Medicaid
Effective date
Jul 20, 2026
We identified it
Jul 21, 2026
Summary
This is a NEW Medicaid clinical trials coverage policy for Louisiana (Humana Healthy Horizons) effective 07/20/2026. The policy establishes coverage for items and services provided to members participating in qualifying clinical trials, with expedited 72-hour coverage determinations, no geographic/network restrictions, and specific criteria for trial qualification (NIH/CDC/CMS support, peer-reviewed, or investigational drug exemption status). Billing teams must understand coverage limitations: investigational items themselves are NOT covered, data collection-only services are NOT covered, and only services otherwise covered by the plan are eligible.
Action Required
By 07/20/2026: (1) Billing team must establish workflow to identify members enrolled in qualifying clinical trials and flag claims accordingly in billing system. (2) Providers must obtain and maintain attestation using the CMS-provided form (https://www.medicaid.gov/resources-for-states/downloads/medicaid-attest-form.docx) for all clinical trial participants prior to claim submission. (3) Update claim submission procedures to ensure coverage determinations are requested with 72-hour turnaround expectations; establish escalation process if determinations exceed 72 hours. (4) Configure billing system to DENY coverage for: investigational items/services (the trial intervention itself), data collection-only services not used in direct clinical management, and any services not otherwise covered by Humana Healthy Horizons. (5) Train billing and prior authorization staff on the three qualifying trial criteria (NIH/CDC/CMS/DoD/VA support; peer-reviewed by NIH standards; or investigational drug/biological exemption status). (6) Create internal documentation checklist to verify trial qualification before processing claims. Failure to properly identify qualifying vs. non-qualifying trials will result in inappropriate claim denials or coverage of non-covered services.