Humana's Your Practice

Humana Updates Preauthorization
and Notification List

As of January 15, an updated Preauthorization and Notification list for commercial fully insured plans (e.g., HMO, PPO, POS and EPO) has been implemented. The updated list provides higher visibility for the medical services and medications requiring preauthorization (precertification, preadmission, preauthorization and notification requirements all refer to the same process of preauthorization). Refer to your provider agreement for additional information or requirements concerning preauthorization.

The list is available on Humana's Web site. Visit Humana.com and select "Providers," then "Tools & Resources." Next, click on "Provider Tools" and "Clinical & Healthcare Resources." The current Preauthorization and Notification List is under the "Download & Print" heading. Humana will update the list when new preauthorization or notification requirements are added, and when new drugs or technology enter the market. Office staff can also call the phone number on the back of the member's ID card to determine if a service requires preauthorization.

Important Notes:

Humana Medicare Advantage: This notification does not affect Humana Medicare Advantage plans.
HMO Members: The preauthorization requirements do apply to Humana HMO members. In addition, HMO members may require referrals for care received outside of the primary care physician's office. Physicians and other health care providers should continue to contact Humana to determine if a referral is needed for services not included on this list.
HumanaOne® Individual Major Medical Members: The outpatient therapy authorization requirements (physical, occupational and speech therapy) do not apply for HumanaOne members. Please check the member's ID card to verify if the member is enrolled in a HumanaOne plan.
Administrative Services Only (ASO) Groups: It is important to note that some employer groups for whom Humana provides administrative services only (self-insured, employer-sponsored programs) may customize their plans with different requirements.

Failure to obtain preauthorization for a service or medication listed could result in financial penalties for you and the member, based on your contract and the member's Certificate of Coverage. If a provider doesn't request authorization for a service indicated on the updated Preauthorization and Notification list, the claim may not be paid. If a provider does not request preauthorization, but the service or medication is considered medically necessary, then the provider or the member may be assessed the preauthorization penalty described in your contract or the member's Certificate of Coverage. An authorization does not guarantee payment, and any payment or coverage determination will be based upon all of the provisions of the member's Certificate or Evidence of Coverage (benefit plan document), which is in effect at the time a service is performed.

Humana recommends that an individual practitioner making a specific request for services or medications verify benefits and authorization requirements before providing services.

For more information, contact Humana customer service at 1-800-4HUMANA.