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Arthroscopy

Preauthorization requests for select arthroscopy services are reviewed by OrthoNet, a utilization management company.

Preauthorization and notification requirements

Humana requires preauthorization requests for the following services to be submitted to OrthoNet:

  • Hip arthroscopy
  • Knee arthroscopy
  • Shoulder arthroscopy

Preauthorization is required for the following:

  • Commercial members
  • Medicare Advantage (MA) members, unless otherwise noted below
  • Select administrative-services-only members
  • Humana Gold Plus® Integrated (Medicare-Medicaid) members (Illinois)
  • Humana Gold Plus® Integrated, Commonwealth Coordinated Care Plan (Medicare-Medicaid) members (Virginia)

OrthoNet will evaluate the medical necessity of the service and request needed medical records. An OrthoNet physician may contact the requesting physician to discuss the preauthorization request. Health care professionals should submit requests with supporting clinical documentation at least four business days before the date of the service.

OrthoNet does not review preauthorization requests for the following, as health care providers who participate in an independent practice association (IPA) or other risk network with delegated services need to refer to their IPA or risk network for guidance on processing preauthorization requests:

  • Florida MA health maintenance organization (HMO) and Medicaid HMO members
  • Nevada and some California MA HMO members
  • Atlanta MA HMO members
  • Hawaii members

Other important information

  • For Puerto Rico commercial members, submit preauthorization request by telephone at 1-800-611-1474, or by fax to 1-800-658-9457.
  • For Puerto Rico MA members, submit preauthorization request by telephone at 1-866-488-5995 or 1-866-773-5959, or by fax to 1-800-594-5309.
  • For Illinois Humana Integrated Care Program members, preauthorization requests may be submitted using Humana's Interactive Voice Response system (IVR) at 1-800-523-0023. If needed, representatives are available from 8 a.m. to 8 p.m. Eastern time, Monday through Friday.
  • For MA Private Fee-for-Service (PFFS) members, preauthorization is not required. Notification is requested for these plans, but not required, as this helps coordinate care for our members.
  • Preauthorization is not required for services provided by nonparticipating health care providers for MA PPO members. Notification is requested, but not required, as this helps coordinate care for our members.

The terms prior authorization, precertification, preadmission and preauthorization are all used to refer to the preauthorization process.

Submitting requests by fax or phone

The easiest way to submit a preauthorization request for arthroscopy is by faxing the request directly to OrthoNet at 1-888-605-5345. Fax the request and the following supporting clinical information:

  • Member diagnosis
  • Clinical information relevant to the procedure, such as:
  • Significant clinical history, including history of present illness, significant comorbidities, current medications, surgical history, key clinical exam findings and the results of conservative therapy
  • Relevant current imaging reports and other key diagnostic test results

To initiate a preauthorization request for arthroscopy via telephone, you may call OrthoNet at 1-866-565-4733, from 8:30 a.m. to 5:30 p.m. Eastern time, Monday through Friday.

As you move through the preauthorization process, you will be prompted to provide the information above, along with the name and identification number of the member and the physician.

Following OrthoNet’s review of the submitted information, 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 arthroscopy. If OrthoNet requests medical records as a result of your preauthorization request, please return the information promptly to facilitate the timely processing of your request.

Submitting requests online

You also may initiate a preauthorization request for arthroscopy via the web by logging in to the secure provider self-service area of Humana.com/providers (registration required) or the secure provider section of Availity.com (registration required). Your request will be forwarded to OrthoNet for review; then, OrthoNet will contact you to obtain supporting clinical information so that a determination of medical necessity can be made.

The following forms may be used for preauthorization requests in specific states:

Texas preauthorization request form

Physicians and other clinicians in Texas may use this form to submit preauthorization requests for their Humana-covered patients. Instructions are available here. Once complete, please fax it to OrthoNet at 1-888-605-5345. Include supporting clinical documentation (e.g., medical records, progress notes, lab reports, radiology studies, etc.) with your fax form.

Indiana preauthorization request form

Physicians and other clinicians in Indiana may use this form to submit preauthorization requests for their Humana-covered patients. Instructions are included on the form. Once complete, please fax it to OrthoNet at 1-888-605-5345. Include supporting clinical documentation (e.g., medical records, progress notes, lab reports, radiology studies, etc.) with your fax form.

Questions

Questions about this program may be directed to OrthoNet at 1-866-565-4733 from 8:30 a.m. to 5:30 p.m. Eastern time, Monday through Friday.

The OrthoNet website provides access to request forms, evaluation forms and other OrthoNet documents.