Pain Management

Preauthorization and Notification for Pain Management Services

Humana requires that all preauthorization requests for pain infusion pumps (back and neck pain only), spinal cord stimulator devices, spinal fusion, other decompression surgeries, facet injections, epidural injections (outpatient only), kyphoplasty and vertebroplasty for Humana commercial and Medicare Advantage members be submitted to OrthoNet. OrthoNet will review medical necessity and may request medical records or conduct peer-to-peer discussions when necessary. Providers should submit requests at least four business days before the date of the service.

Please note that precertification, preadmission, preauthorization and notification requirements all refer to the same process of preauthorization.

Please note: Exclusions from this requirement include the following members and providers:

• Medicare Advantage (MA) Private-Fee-for-Service (PFFS) members
• HumanaOne members
• Commercial and MA HMO members assigned to an independent physician association (IPA) that has a capitated or delegated arrangement with Humana
• MA HMO members in Florida, California, and Nevada

Submitting Preauthorization Requests

To initiate a preauthorization request for pain management via the Web, you may log in to the secure provider area of Humana.com/providers (registration required) or www.availity.com (registration required, select markets only). Your request will be forwarded to OrthoNet for review.

To initiate a preauthorization request for pain management via telephone, you may call OrthoNet at 1-888-605-5344, 8:30 a.m. to 5:30 p.m. local time, Monday through Friday.

As you move through the authorization process, you will be prompted to provide the following information:

• Member name
• Member ID number
• Physician name
• Physician ID number
• Patient diagnosis
• Clinical information relevant to the procedure, such as the following:
  • Significant clinical history, including history of present illness (HPI), significant comorbidities, current medications, surgical history, history of any prior pain procedures and the outcomes achieved
  • Relevant current (and historical) imaging reports and other key diagnostic testing
  • Treatment plan with expected near-term outcomes

Following instant assessment, you will be given an authorization number, or you will be asked for additional information if the request is incomplete or does not meet evidence-based criteria for pain management. If OrthoNet requests medical records as a result of your preauthorization request, please return the information promptly. Your collaboration with Humana and OrthoNet will facilitate the timely processing of your preauthorization requests and claims.