Humana Updates Preauthorization and Notification Lists for 2016

On Jan. 18, 2016, Humana will update preauthorization and notification lists for all commercial fully insured plans [e.g., health maintenance organization (HMO), point of service (POS), preferred provider organization (PPO) and exclusive provider organization (EPO)], Medicaid plans and Medicare Advantage (MA) and dual Medicare-Medicaid plans. Please note that prior authorization, precertification, preadmission, preauthorization and notification are all used to refer to the preauthorization process.

For MA Private Fee-for-Service (PFFS) plans, notification is requested, not required. In addition, certain services outlined in the preauthorization and notification lists may not be applicable for Chicago, Nevada or California health care providers affiliated with an independent physician association (IPA) via a capitated arrangement. Health care providers may refer to their provider agreements for additional information or requirements concerning preauthorization.

Updates to the lists include the following:

  1. The following services will be added to Humana’s commercial, Medicare Advantage and dual Medicare-Medicaid preauthorization lists:
    • Cardiac ablation
    • Transesophageal echocardiogram (TEE)
    • Cardiac computed tomographic angiography (CCTA)
    • Myocardial perfusion imaging single photon emission computed tomography (MPI SPECT)
    • Pulse volume recording
    • Transcatheter valve surgeries, including transcatheter aortic valve replacement (TAVR) and MitraClip
    • Electrophysiology study (EPS)
    • EPS with 3D mapping

    Preauthorization determinations for these services will be made by HealthHelp®, a nationally recognized specialty benefit management organization.

  2. The following services will be added to Humana’s commercial, Medicare Advantage and dual Medicare-Medicaid preauthorization lists:
    • Hip arthroscopy
    • Knee arthroscopy
    • Shoulder arthroscopy
    • Hammertoe surgery
    • Bunionectomy

    Preauthorization determinations for these services will be made by OrthoNet®, a utilization management company.

  3. Preauthorization requirements for pain management and spinal surgery services have been expanded to include Humana individual commercial products. (This preauthorization requirement has been effective for Humana’s commercial fully insured group and MA products since Jan. 24, 2010.).

    These preauthorization and notification requirements apply to the following services:

    Pain Management

    • Pain infusion pumps (back and neck pain only)
    • Spinal cord stimulator devices
    • Facet injections
    • Epidural injections (outpatient only)

    Spine Surgery

    • Spinal fusion
    • Other decompression surgeries
    • Kyphoplasty
    • Vertebroplasty

    The preauthorization determinations are made by OrthoNet.

    The lists are available here. Health care providers also may call the phone number on the back of the member's identification (ID) card to determine if a service requires preauthorization.

  4. The following updates will be made to Humana’s medication preauthorization lists:
    • The following drugs delivered in the physician’s office, clinic, outpatient or home setting have been added to the commercial medication preauthorization list: Aveed, Doxil, Neupogen, Orthovisc, Sylvant, Synvisc and Unituxin.
    • The following drugs delivered in the physician’s office, clinic, outpatient or home setting have been added to the Medicare and dual Medicare-Medicaid preauthorization list: Aveed, Gel-One, Monovisc, Neupogen, Orthovisc Sylvant, Synvisc and Unituxin.
    • The following drugs delivered in the physician’s office, clinic, outpatient or home setting have been added to the Medicaid medication preauthorization list for Illinois: Aveed, Doxil, Monovisc, Neupogen, Orthovisc, Gel-One, Synvisc and Unituxin.
    • Reminder: Humana asks health care providers to submit claims for Healthcare Common Procedure Coding System (HCPCS) drug codes with the corresponding national drug code (NDC). Humana will reject claims for the following types of drug codes if submitted without an NDC:

      – Shared HCPCS codes

      – Not Otherwise Classified (NOC) codes

Important Notes:

If a health care provider does not obtain preauthorization/notification for a service, it could result in financial penalties for the practice and reduced benefits for the member, based on the health care provider’s contract and the member’s Certificate or Evidence of Coverage (benefit plan document). If a health care provider doesn't obtain 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 (excluding Medicare members) 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, which is in effect at the time a service is performed.

There are exceptions to these lists. Not all procedures and medications are covered by all health plans. Since a single document cannot reflect all possible exceptions, we recommend that an individual practitioner making a specific request for services or medications verify benefits and authorization requirements with Humana prior to providing services.

  • Commercial HMO Members: Certain services outlined in the Commercial Preauthorization and Notification List may not be applicable for providers affiliated with an independent physician association (IPA) via a capitated or delegated arrangement. Health care providers should refer to their provider agreement for clarification. Exclusions may change; refer to Humana.com/providers for the most up-to-date information. Choose “Authorizations/Referrals” and then the appropriate topic.
  • Humana MA HMO Members: The full list of MA and Humana Medicare-Medicaid preauthorization requirements applies to Humana MA HMO and HMO-POS members. For HMO-POS plans, notification is requested, but not required, for covered services from nonparticipating providers. For MA HMO plans in Florida, specialists should direct all service and medication administration preauthorization requests to the member's primary care physician for referral issuance. In addition, certain services outlined in the Medicare Advantage Preauthorization and Notification List may not be applicable for providers affiliated with an independent practice association (IPA) via a capitated or delegated arrangement. For California MA HMO products, health care providers who participate in an IPA or other risk network with delegated services should refer to their IPA or risk network for further guidance on claims issues and policies. Please refer to your provider agreement for clarification. Exclusions may change; refer to Humana.com/providers for the most up-to-date information. Choose “Authorizations/Referrals” and then the appropriate topic.
  • Humana MA Preferred Provider Organization (PPO) Members: The full list of MA and Humana Medicare-Medicaid preauthorization requirements applies to Humana MA PPO members. Notification is requested, but not required, for covered services from nonparticipating providers.
  • 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.
  • Humana’s MA and Humana Medicare-Medicaid Medication Preauthorization Drug List: Humana requests, but does not require, that health care providers submit an Advance Coverage Determination (ACD) request for medications listed on the MA and Humana Medicare-Medicaid Medication Preauthorization List when requesting the medication for a Humana MA PFFS member. If a health care provider does not request an ACD for a medication for a Humana MA PFFS member, the claim may be reviewed for medical necessity, and the health care provider may be contacted for clinical information.

    ACDs for medications on the list may be initiated by submitting a fax or telephone request:

    - Submit by fax to 1-888-447-3430

    - Submit by telephone at 1-866-461-7273

  • Administrative Services Only (ASO) Groups: It is important to note that some employer groups for which Humana provides administrative services only (self-insured, employer-sponsored programs) may customize their plans with different requirements.
  • The MA and Humana Medicare-Medicaid list does not apply to policyholders of a Humana Medicare Supplement plan.

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 (1-800-448-6262).