12/16/2025

Health Alliance Plan

Health Alliance Plan Managed Care Committee Member

April Danish, CHONC - Newland Medical Associates

Effective January 1, 2026

New Online Prior Authorization Platform - Users Need to Verify Identity Read details HERE

Prior Authorization for J9334 and J1305 Read details HERE

Formulary and Prior Authorization Changes in 2026 Read details HERE

New Plans and Plan Changes in 2026 Read detail HERE

Peer-to-Peer Guidelines for HAP Medicare Advantage Patients
In alignment with industry standards, once an adverse determination is made for an inpatient admission, any peer-to-peer requests must follow our appeals process. You can find this process online. Just log in at www.hap.org and select Provider Manual under Quick Links.

Peer-to-peer discussions are allowed prior to HAP rendering a final decision.

This affects your HAP Medicare Advantage patients.

Coordination of Benefits - Secondary Claim Payment Calculations
Secondary claims will be processed using the lower allowable amount between the two plans. This change is designed to create consistency in secondary claim calculations and help providers anticipate payment amounts more accurately.

Process Change When Providers Appeal On Behalf of a Member
You might appeal a decision on behalf of your HAP Commercial patient, which could include attending a hearing to present the rationale on why we should overturn a denied decision.

Hearings for second-level appeals for HAP Commercial members will no longer be offered as part of our appeals process. This change will not affect your right to submit a second-level appeal, nor will it change the criteria or timelines for filing.

We will continue to send letters to members and providers when a provider is appealing on behalf of a member. The letter contains appropriate instructions on our process.