Pilot

What changed

Every change to a Hawaiʻi plan's prior authorization rules that we have confirmed, with the plan's own document. Newest first.

Plan

Service category

Coming up

1 November 2026alohacareohana

Community Care Services moves to AlohaCare statewide

Before: ʻOhana Health Plan served Community Care Services (CCS) members.
Now: Med-QUEST awarded AlohaCare the statewide CCS contract for the QUEST Integration population, effective 1 November 2026. CCS covers intensive behavioral health services for adults with serious mental illness.
What to do: Check eligibility and authorizations for CCS patients against AlohaCare from 1 November 2026.

Med-QUEST memo QI-2621 / CCS-2605, 25 September 2026

DIRECTConfirmed 18 October 2026

31 December 2026ohana

ʻOhana Health Plan leaves QUEST on 31 December 2026

Before: ʻOhana Health Plan was one of five QUEST Integration plans.
Now: ʻOhana's QUEST Integration plan ends on 31 December 2026, and members' new QUEST plans start on 1 January 2027. Members who did not choose a plan by 20 October 2026 are assigned one by Med-QUEST. Under Med-QUEST's transition-of-care rules, the new plan must continue ongoing medically necessary services and honor existing prior authorizations, including prescriptions, without any prior approval, in or out of network, for at least 45 days, or at least 90 days for members with special health care needs or long-term services and supports. Claims for services through 31 December 2026 are due to ʻOhana by 31 December 2027.
What to do: Confirm each ʻOhana patient's 2027 plan at the first January visit, request the new plan's authorizations before the transition period ends, and send ʻOhana claims for 2026 services by 31 December 2027. See the ʻOhana transition kit at /ohana.

ʻOhana Health Plan provider information letter on the QUEST exit, approved 14 August 2026

DIRECTConfirmed 18 October 2026

31 December 2026ohana

Wellcare By ʻOhana Medicare Advantage is not renewing for 2027

Before: Wellcare By ʻOhana offered a Medicare Advantage plan in Hawaiʻi.
Now: Wellcare's notice says the plan will not renew in 2027 and coverage ends 31 December 2026. Members can choose another Medicare Advantage plan by 7 December 2026, or through the end of February 2027 under a special enrollment period; otherwise they return to Original Medicare.
What to do: Help affected patients choose before 7 December. 1-800-MEDICARE can help.

Wellcare plan non-renewal notice, Hawaiʻi, updated 1 October 2026

DIRECTConfirmed 18 October 2026

1 January 2027

Plans must run prior authorization interfaces from 1 January 2027

Before: Plans accept prior authorization requests through their own portals, fax, phone, and vendors.
Now: Medicare Advantage, Medicaid and CHIP, and federal Marketplace plans must run a Prior Authorization API from 1 January 2027 (for managed care, rating periods starting on or after that date). This does not change the rules for what needs approval.
What to do: Ask your EHR vendor when it will connect to each plan's interface. Keep using today's channels until it does.

CMS fact sheet: CMS Interoperability and Prior Authorization Final Rule (CMS-0057-F)

DIRECTConfirmed 18 October 2026

September 2026

8 September 2026va-ccn

VA Community Care ends its separate precertification step

Before: Some services under VA Community Care needed a precertification ID from the VA Precertification Portal.
Now: VA ended the precertification requirement on 8 September 2026 and took the portal offline. Care still needs an approved VA referral, and added services still need a Request for Services before care begins. TriWest's precertification page still warns of denials from 25 September; VA's newer notice controls.
What to do: Stop requesting precertification IDs. Keep sending a Request for Services to the authorizing VA medical center for anything outside the referral, and confirm with TriWest if a claim is denied for a missing precertification ID.

VA Community Care: Precertification Requirements, updated 9 September 2026

DIRECTConfirmed 18 October 2026

April 2026

1 April 2026hmsa

Evolent stops reviewing 13 HMSA imaging codes; 60 still need approval

Before: Evolent reviewed these 13 primary imaging codes and their billed groups for HMSA, including extremity CT and MRI, breast MRI, cardiac MRI and CT, and bone density CT.
Now: Evolent no longer reviews those 13 primary codes and their billed groups, 34 codes in all. Sixty primary imaging codes still need Evolent prior authorization, including CT, MRI, PET, myocardial perfusion, and coronary CT angiography. Low-dose CT lung screening (71271) is not on the April 2026 matrix.
What to do: Look up the code in the finder before you request. If the code is not on Evolent's current HMSA matrix, Evolent review is not required under that matrix. HMSA's own rules for a code can still apply.

HMSA Commercial and Medicaid Utilization Review Matrix 2026, dated 1 April 2026 (Evolent)

DIRECTConfirmed 18 October 2026

1 April 2026hmsa

HMSA ends the imaging Fast Pass

Before: Providers who held an HMSA imaging Fast Pass had a shortcut for in-scope advanced imaging.
Now: Imaging Fast Passes ended on 1 April 2026. Every provider requests Evolent authorization for every in-scope imaging study. HMSA says a performance-based Fast Pass will follow; none had been announced as of 18 October 2026. The physical therapy Fast Pass continues.
What to do: If your office used a Fast Pass, request authorization for every in-scope study through Evolent RadMD.

HMSA Provider Education Presentation, Cardiac and Advanced Imaging, April 2026 (Evolent)

DIRECTConfirmed 18 October 2026

1 April 2026hmsa

HMSA occupational therapy and chiropractic lose their eight unmanaged visits

Before: The first eight occupational therapy visits, and the first eight chiropractic visits on select commercial plans, did not need Evolent review.
Now: Occupational therapy and chiropractic need Evolent prior authorization after the initial evaluation on the first date of service. Physical therapy still needs Evolent prior authorization after the first date of service, and its Fast Pass continues. Speech therapy stays with HMSA, not Evolent.
What to do: Request Evolent authorization before the second OT or chiropractic visit. Evolent backdates physical medicine requests submitted within 10 calendar days of the date of service.

HMSA Provider Education Presentation, Physical Medicine, April 2026 (Evolent)

DIRECTConfirmed 18 October 2026

January 2026

1 January 2026hmsakaiseralohacareohanauhchumanadevotedmedquest-ffs

One federal clock for QUEST, Med-QUEST, and Medicare Advantage: 7 days standard, 72 hours expedited

Before: QUEST plans and Medicare Advantage plans had up to 14 calendar days for a standard decision. Med-QUEST fee-for-service followed the Hawaiʻi rule: 30 calendar days non-urgent, 2 working days urgent.
Now: Since 1 January 2026, prior authorization decisions on items and services are due within 7 calendar days for a standard request and 72 hours for an expedited one. Drugs have their own clocks. Extensions are allowed only on limited grounds.
What to do: Note the date and time a complete request reached the plan. Use the decision clock calculator to see the legal deadline.

eCFR 42 CFR 438.210, 440.230, and 422.568, as amended by CMS-0057-F

DIRECTConfirmed 18 October 2026

How this works

Every Monday we check 153 public documents automatically and 31 by hand, because some plan sites block automated reading. A person reads every flagged change before it appears here. Last check: 18 October 2026.

Noticed a change we missed?

This tells you what the plan publishes. It does not guarantee coverage or payment. Confirm with the plan.