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Foot surgeries

Preauthorization determinations for select foot surgeries are made by OrthoNet, a utilization management company.

Preauthorization and notification requirements

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

  • Bunionectomies
  • Hammertoe surgeries

Preauthorization is required for the following:

  • Commercial group members (including members with Humana individual products, effective Oct. 24, 2016)
  • Medicare Advantage (MA) members
  • 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 providers should submit requests with supporting clinical documentation 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.

Exclusions from the preauthorization requirement include:

  • MA private-fee-for-service (PFFS) members (notification is requested, but not required)
  • Commercial and MA health maintenance organization (HMO) members assigned to an independent physician association (IPA) that has a capitated or delegated arrangement with Humana
  • MA HMO members in Florida and Nevada
  • Atlanta MA HMO members
  • Some MA HMO members in California
  • Medicaid only members
  • Members in Hawaii and Puerto Rico

Submitting requests by fax or phone

The easiest way to submit a preauthorization request for foot surgery 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 undertaken, in detail, including duration and results
  • Relevant current imaging reports and other key diagnostic test results, including relevant angles (e.g., HVA, IMA, MTP)

To initiate a preauthorization request for foot surgery 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 authorization 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 foot surgery. 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 foot surgery 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; select markets only). 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 authorization requests in specific states:

Texas authorization request form

Physicians and other clinicians in Texas may use this form to submit authorization 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 authorization request form

Physicians and other clinicians in Indiana may use this form to submit authorization 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.