On Jan. 1, 2019, Humana will update , opens new window for all commercial fully insured plans, Medicare Advantage (MA) plans and dual Medicare-Medicaid plans.*
Updates to the lists include the following:
- Preauthorization will be required for peripheral revascularization (atherectomy, angioplasty), ablation (bone, liver, kidney, prostate), thyroid surgeries (thyroidectomy and lobectomy) for commercial fully insured, MA and dual Medicare-Medicaid plans. Preauthorization requests will be reviewed by HealthHelp. To search services or procedures,
- Preauthorization will be required for capsule endoscopy and noninvasive home ventilators for commercial fully insured, MA and dual Medicare-Medicaid plans. Preauthorization requests will be reviewed by Humana.
- Preauthorization will be required for decompression of peripheral nerve (i.e., carpal tunnel surgery), EGD endoscopy (patients 59 and younger only, includes site-of-service evaluation) and gastric pacing for commercial fully insured plans. Preauthorization requests will be reviewed by Humana.
- Preauthorization for medications delivered in the physician’s office, clinic, outpatient or home setting is expanding to include all medications noted with an asterisk (*) on the preauthorization lists posted on Humana.com/PAL.
- The Centers for Medicare & Medicaid Services (CMS) rescinded its September 2012 memo “Prohibition on Imposing Mandatory Step Therapy for Access to Part B Drugs and Services,” which allows Medicare Advantage plans to apply step therapy for physician-administered and other Part B drugs. Due to this recent change, Humana will require review of some injectable drugs and biologics for step therapy requirements in addition to current review requirements. The affected drugs and biologics are indicated on Humana’s preauthorization and notification lists for Humana commercial, Medicare Advantage and dual Medicare-Medicaid plans with a (#) indicator.
- Urgent/emergent services do not require a referral or preauthorization.
- The term “preauthorization” (i.e., prior authorization, precertification, preadmission) when used in this communication is defined as a process through which the physician or other healthcare provider is required to obtain advance approval from the plan as to whether an item or service will be covered.
- “Notification” refers to the process of the physician or other healthcare provider notifying Humana of the intent to provide an item or service. Humana requests notification to help coordinate care for your patients. This process is distinguished from preauthorization. Humana does not issue an approval or denial related to a notification.
- Healthcare providers who participate in an independent practice association (IPA) or other risk network with delegated services are subject to the preauthorization list and should refer to their IPA or risk network for guidance on processing their requests.
- For additional information, refer to Humana.com/PAL.
*Affected plans include commercial fully insured plans, e.g., health maintenance organization (HMO), point of service (POS), preferred provider organization (PPO) and exclusive provider organization (EPO); Medicare Advantage (MA) plans, e.g., HMO, POS and PPO; dual Medicare-Medicaid plans, e.g., Illinois Medicare-Medicaid Alignment Initiative (MMAI); and Medicaid plans (Florida Managed Medical Assistance [MMA]). Preauthorization is not required for MA private fee-for-service (PFFS) plans; notification is requested for these plans, as this helps coordinate care for your patients.
For more information, contact Humana Customer Service at 1-800-4HUMANA (1-800-448-6262).