Reminder: 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.