Pain Management

Pain management

Preauthorization requests for the following pain management services are reviewed by OrthoNet(link opens in new window), a utilization management company.

Pain Management

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

Musculoskeletal Surgery

  • Spinal fusion
  • Other decompression surgeries
  • Kyphoplasty
  • Vertebroplasty

OrthoNet will evaluate the medical necessity of the services and request needed medical records. An OrthoNet physician may contact the requesting physician to discuss the preauthorization request. Physicians and other health care providers should submit requests with supporting clinical documentation. OrthoNet responds to preauthorization requests within regulatory guidelines. Rarely is turnaround time greater than 72 hours after receiving complete supporting information.

Preauthorization requirement

OrthoNet manages pain management preauthorization requests for the following:

  • Patients with Humana commercial coverage (including patients with Humana individual coverage)
  • Patients with Humana Medicare Advantage (MA) coverage
  • Patients with select administrative services only (ASO) coverage
  • Patients with Humana Gold Plus® Integrated (Medicare-Medicaid) coverage (Illinois)

OrthoNet does not review preauthorization requests for the following, as physicians and other health care providers who participate in an independent practice association (IPA) or other risk network with delegated services need to refer to their IPA or risk network for guidance on processing preauthorization requests:

  • Patients with Humana Florida MA health maintenance organization (HMO) and Medicaid HMO coverage
  • Patients with Nevada and some California MA HMO coverage
  • Patients with Atlanta MA HMO coverage
  • Patients in Hawaii
  • Puerto Rico members

Please note:

  • For patients with MA Private Fee-for-Service (PFFS) coverage, preauthorization is not required. Notification is requested for these plans, as this helps coordinate care for your patients.
  • Preauthorization is not required for services provided by nonparticipating health care providers for patients with MA PPO coverage. Notification is requested as this helps coordinate care for your patients.

Submitting preauthorization requests

Preauthorization requests for pain management procedures can be submitted to Orthonet online, by phone or by fax.

Submit a request online

The easiest way to submit a preauthorization request for pain management services is via OrthoNet’s online portal. The secure web portal provides physicians and other health care professionals with the capability to submit authorization requests and check their status, as well as reprint copies of authorization letters.

To register for web portal access, visit www.orthonet-online.com(link opens in new window). Choose “Provider,” and then select “Humana” in the “Health Plan Contracts” box. Finally, choose “New User-Account Request Form” and submit your information.

Submit a request by phone

To initiate a preauthorization request for pain management services via telephone, you may call OrthoNet at 1-888-605-5344 for pain management services or 1-866-565-4733 for musculoskeletal surgery from 8:30 a.m. to 5:30 p.m. Eastern time, Monday through Friday.

Submit a request via fax

You can also fax authorization requests directly to OrthoNet at 1-888-605-5345. Request forms are available on OrthoNet’s website(link opens in new window). Fax a completed request form and the supporting clinical information listed below.

For patients in Puerto Rico

For Puerto Rico patients with commercial coverage, submit preauthorization requests by telephone at 1-888-605-5344 for pain management services or 1-866-565-4733 for musculoskeletal surgery, or by fax to 1-800-658-9457.

For Puerto Rico patients with MA coverage, submit preauthorization requests by telephone at 1-866-488-5995 or 1-866-773-5959, or by fax to 1-800-594-5309.

As you move through the preauthorization process, you will be prompted to provide the following clinical information, along with the name and identification number of the patient and the physician.

  • Patient diagnosis
  • Clinical information relevant to the procedure, such as:
    • Significant clinical history, including history of present illness, significant comorbidities, current medications, surgical history and history of any prior pain procedures and the outcomes achieved
    • Relevant current and historical imaging reports and other key diagnostic testing
    • Treatment plan with expected near-term outcomes (if multiple services and/or dates are requested)

    Following OrthoNet’s review of the submitted information, you will be given an authorization number, or you will be asked for additional information if the request is incomplete or does not meet evidence-based criteria for pain management.

    If OrthoNet requests medical records as a result of your preauthorization request, please return the information promptly to facilitate the timely processing of your request.

State-specific preauthorization forms

The following forms may be used for preauthorization requests in specific states:

Texas preauthorization request form

Physicians and other clinicians in Texas may use this form to submit preauthorization requests for their Humana-covered patients. Instructions are available here. Once complete, please fax it to OrthoNet at 1-888-605-5345. Include supporting clinical documentation (e.g., medical records, progress notes, lab reports, radiology studies, etc.) with your fax form.

Indiana preauthorization request form

Physicians and other clinicians in Indiana may use this form to submit preauthorization requests for their Humana-covered patients. Instructions are included on the form. Once complete, please fax it to OrthoNet at 1-888-605-5345. Include supporting clinical documentation (e.g., medical records, progress notes, lab reports, radiology studies, etc.) with your fax form.

Questions

Questions about this program may be directed to OrthoNet at 1-888-605-5344 (pain management services) or 1-866-565-4733 for musculoskeletal surgery from 8:30 a.m. to 5:30 p.m. Eastern time, Monday through Friday.

Additional resources

The OrthoNet website(link opens in new window) provides access to request forms, evaluation forms and other OrthoNet documents.