Humana contracted with the Kentucky Cabinet for Health and Family Services to provide services to Medicaid enrollees through Humana Health Plan. Medicaid provides healthcare coverage for income-eligible children, seniors, disabled adults, pregnant women and other eligible adults. It is funded by both the state and federal governments.
Humana Medical Coverage Policies are available on Humana.com. Humana uses nationally recognized medical necessity guidelines of Milliman Clinical Guidance (MCG) and American Society of Addiction Medicine (ASAM) criteria. Criteria are readily available for review by DMS, practitioners, the public or members upon request at no cost. MCG is available either verbally or in writing for DMS, practitioners, the public or members upon request. For providers and practitioners, the process to obtain criteria is communicated annually in the provider newsletter and in the provider manual.
These documents apply to all counties in Kentucky.
Below are several helpful resources that may provide additional guidance and information.
Continuity of Care Provisions
A prior authorization (PA) shall be honored by the Humana Health Plan for 90 days or until the recipient or provider is contacted by the Humana Health Plan regarding the PA. If the recipient and provider are not contacted by Humana Health Plan, the existing Medicaid PA shall be honored until expired.
How to request preauthorization
Except where noted preauthorization requests for medical services may be initiated:
- Online via Availity.com (registration required)
- By calling Humana’s interactive voice response (IVR) line at 1-800-444-9137 (available Monday through Friday, 8 a.m. to 8 p.m. Eastern time)
Please note: Online preauthorization requests are encouraged.
- By calling our authorization intake team directly at 1-888-285-1114
- Additionally, clinical information for a medical service preauthorization request may be faxed to 1-833-974-0059 using , PDF opens new window or , PDF opens new window.
Except where noted, preauthorization requests for professionally administered medications may be initiated:
- By sending a fax to 1-888-447-3430 (request forms are available at Humana.com/medpa
- By calling 1-866-461-7273 (available Monday through Friday, 6 a.m. to 8 p.m. Eastern time)
Except where noted, preauthorization requests for pharmacy medications may be initiated:
- Logging into , opens new window
- By sending a fax to 1-877-486-2621 using , PDF opens new window
- Call Humana Pharmacy Clinical Review (HCPR) at
Submitting pharmacy claims
Starting Jan. 1, 2020, Humana Pharmacy Solutions began managing the pharmacy network for Humana’s Medicaid managed care plan in Kentucky. See the notification for updates.
Provider Relations Representative Assignments
New Horizon Kentucky Medicaid Provider Newsletter
Annual compliance training materials for healthcare providers
The Centers for Medicare & Medicaid Services (CMS) and state Medicaid contracts mandate that all Humana-contracted physicians and other healthcare providers complete compliance program requirements. Healthcare providers can complete this requirement online at the Availity Web Portal (registration required). Please refer to the following for more information: