Preauthorization Processing Software Update to Close Gaps
Humana will be updating its preauthorization processing software soon, which may affect how health care providers’ claims are paid. Humana recently found some gaps in its application of its 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, Medicare Advantage (MA) plans and dual Medicare-Medicaid plans. Please note that the terms prior authorization, precertification, preadmission, preauthorization and notification all are used to refer to the preauthorization process. The software update will close these gaps; so, if a health care provider does not obtain preauthorization for a service, it may result in the claim not being paid.
- If a health care provider does not 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 health care provider does not request preauthorization, but the service or medication is considered medically necessary, then the health care provider or the member (excluding Medicare members) may be assessed the preauthorization penalty described in the health care provider's contract or the member's certificate or evidence 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.
- Health care providers may view the preauthorization and notification lists and find information about the changes to these lists by visiting Humana’s provider website at Humana.com/provider. Choose “Humana for physicians & hospitals.” Under “Key resources,” select “Authorizations/referrals.” Then, choose “Preauthorization and notification lists” to find links to the current preauthorization and notification lists and other information.
- Humana will update the lists when new preauthorization or notification requirements are added and when new drugs or technology enter the market.
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 affiliated health care providers contracted via a capitated or delegated arrangement. Health care providers need to refer to their provider agreement for clarification or contact Humana/ChoiceCare Provider Relations at 1-800-626-2741, Monday through Friday, 8 a.m. to 5 p.m. Central time, for further details.