Humana's Your Practice

Humana Updates Preauthorization
and Notification Lists

As of December 1, 2008, an updated Preauthorization and Notification list for all commercial fully insured plans (e.g., HMO, PPO, POS and EPO) has been implemented. A new Preauthorization and Notification list for Medicare Advantage (MA) plans also was implemented. Please note that precertification, preadmission, preauthorization and notification requirements all refer to the same process of preauthorization. For MA Private-Fee-for-Service (PFFS) plans, notification is requested, not required, as providers who choose to provide services to MA PFFS members may not have provider agreements. Providers may refer to their provider agreements for additional information or requirements concerning preauthorization.

The lists are available on Humana’s Web site. Visit Humana.com and click http://www.humana.com/providers/tools/provider_tools/clinical_healthcare.asp. The current Preauthorization and Notification lists are under the “Download & Print” heading. Humana will update the lists 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 identification (ID) card to determine if a service requires preauthorization.

Important Notes:

Commercial HMO Members: The preauthorization requirements 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.
Humana Medicare Advantage (MA) HMO Members: The full list of preauthorization requirements applies to Humana MA HMO members. In addition, Humana MA 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 follow the same process they follow today to request/submit referrals or contact Humana to determine if a referral is needed for services not included on this list.
Humana MA PPO Members: Preauthorization for a smaller list of services applies to Humana MA PPO members and notification is requested, but not required, for certain other services. Providers may be contacted if additional information is needed.
Humana MA PFFS Members: For Humana MA PFFS members, notification is requested, but not required, so that members may be referred to appropriate case management and disease management programs. Providers may be contacted if additional information is needed.
HumanaOne^® Individual Major Medical Members: The outpatient therapy authorization requirements (physical, occupational and speech therapy) do not apply to HumanaOne members. Providers may check the member’s identification 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 which Humana provides administrative services only (self-insured and employer-sponsored programs) may customize their plans with different requirements.

Failure to obtain preauthorization for a service or listed medication could result in financial penalties for the provider and the member, based on the provider’s 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 be subject to retrospective medical necessity review and may not be paid if it is determined not to be medically necessary. 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 the provider’s 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.