Pain Management

Pain management

Select pain management services are administered by OrthoNet, a utilization management company.

Preauthorization and notification requirements

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

  • Pain infusion pumps (back and neck pain only)
  • Spinal cord stimulator devices
  • Spinal fusion
  • Other decompression surgeries
  • Facet injections
  • Epidural injections (outpatient only)
  • Kyphoplasty
  • Vertebroplasty

Preauthorization is required for the following:

  • Humana commercial members
  • Medicare Advantage (MA) members
  • Select administrative-services-only members
  • Humana Integrated Care Program members (Illinois)
  • Humana Gold Plus® Integrated (Medicare-Medicaid) members (Illinois)
  • Humana Gold Plus® Integrated, a Commonwealth Coordinated Care Plan, members (Virginia)

OrthoNet will evaluate the medical necessity of the services and request needed medical records. An OrthoNet physician may contact the requesting physician to discuss the preauthorization request. Healthcare 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)
  • HumanaOne members
  • 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 members in Florida
  • Members in Puerto Rico

Submitting requests by fax or phone

The easiest way to submit a preauthorization request for pain management services is by faxing the request directly to OrthoNet at 1-888-605-5345. Request forms are available on OrthoNet’s website. Fax the completed form and this 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 and 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 (if multiple services and/or dates are requested)

To initiate a preauthorization request for pain management via telephone, you may call OrthoNet at 1-888-605-5344 from 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 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 pain management. 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 may also initiate a preauthorization request for pain management services 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.

Questions

Questions about this program may be directed to OrthoNet at 1-888-605-5344 from 8:30 a.m. to 5:30 p.m. local time, Monday through Friday.

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