Humana Updates Preauthorization and Notification Lists for 2017

On Jan. 23, 2017, Humana will update preauthorization and notification lists for all commercial fully insured plans, Medicare Advantage (MA) plans, dual Medicare-Medicaid plans and Illinois Integrated Care Plan (ICP). Preauthorization is not required for MA private fee-for-service (PFFS) plans; notification is requested for these plans, but not required, as this helps coordinate care for our members. Health care 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.

Important note: The notification letter mailed to all participating physicians and health care providers included the following, “Preauthorization requirements are expanding to include decompression of peripheral nerve (i.e., carpal tunnel surgery) and nasal/sinus endoscopy for MA plans and dual Medicare-Medicaid plans.” The nasal/sinus endoscopy requirement has been revised to “surgical nasal/sinus endoscopic procedures (excludes diagnostic nasal/sinus endoscopies).”

Please note 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 health care 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 health care provider notifying Humana of the intent to provide an item or service. Humana does not require notification, but requests it, as this helps coordinate care for our members. This process is distinguished from preauthorization. Humana does not issue an approval or denial related to a notification.

Please note that urgent/emergent services do not require referrals or preauthorizations.

Updates to the lists include the following:

  1. Preauthorization for genetic/molecular testing is expanding to include HumanaOne (commercial individual) products.
  2. Preauthorization requirements are expanding to include decompression of peripheral nerve (i.e., carpal tunnel surgery) and surgical nasal/sinus endoscopic procedures (excludes diagnostic nasal/sinus endoscopies) for MA plans and dual Medicare-Medicaid plans.

    Physicians and labs have several options when submitting preauthorizations for genetic/molecular testing and peripheral nerve and nasal/sinus endoscopy:

    • Submit requests online via Humana’s secure provider portal at Humana.com/providers (registration required)
    • Submit requests online via Availity.com (registration required)
    • Submit requests by calling Humana’s Interactive Voice Response line at 1-800-523-0023

    Submit requests by fax (for genetic/molecular testing only) by downloading the genetic/molecular testing form on our website at https://www.humana.com/provider/medical-providers/education/referral/dna-preauth and faxing it to 1-877-561-1826.

  3. Preauthorization for behavioral health services is expanding to include transcranial magnetic stimulation (TMS) and electroconvulsive therapy (ECT) for commercial fully insured, Medicare and dual Medicare-Medicaid plans.
  4. Preauthorization for behavioral health services is expanding to include applied behavioral analysis (ABA) for commercial fully insured plans.

    Health care providers seeking preauthorization for TMS, ECT or ABA services need to call Humana Behavioral Health at 1-800-777-6330, and identify the type of service requested. Calls are routed to the appropriate clinical intake team to process the request. If clinical information necessary to process the request is not provided, you will be contacted to submit the specific information necessary to process the request.

  5. Preauthorization for cardiac devices is expanding to include loop recorder for arrhythmia management for commercial fully insured plans, MA plans and dual Medicare-Medicaid plans. Preauthorization requests are reviewed by HealthHelp, a nationally recognized specialty benefit management organization.
  6. Preauthorization for oncology surgery is expanding to include breast lumpectomy for commercial fully insured plans, MA plans and dual Medicare-Medicaid plans. Preauthorization requests are reviewed by HealthHelp.
  7. Preauthorization for screening/diagnostic imaging services is expanding to include breast cancer biopsy (excisional) for commercial fully insured plans, MA plans and dual Medicare-Medicaid plans. Preauthorization requests are reviewed by HealthHelp.

  8. Health care providers seeking preauthorization for loop recorder for arrhythmia management, breast lumpectomy or breast cancer biopsy from HealthHelp may initiate the request and submit required clinical information by logging on to the HealthHelp Consult website at www.healthhelp.com/humana or by calling 1-866-825-1550, Monday through Friday, 7 a.m. to 7 p.m. Central time, and Saturday, 9 a.m. to 4 p.m.

    The required clinical information may be provided via web at www.healthhelp.com/humana, fax to 1-888-863-4467 or telephone (IVR) at 1-866-825-1550. Questions regarding preauthorization of these services via HealthHelp may be directed to 1-866-825-1550, Monday through Friday, 7 a.m. to 7 p.m. Central time, and Saturday, 9 a.m. to 4 p.m.

  9. Medication preauthorization requirements are expanding to include Granix, Zarxio, Gelsyn-3 and all blood-clotting factors for commercial fully insured plans, MA plans and dual Medicare-Medicaid plans and the Illinois Medicaid plan.
  10. A payment policy for certain drugs and biologics is being added for commercial plans.
  11. There are certain drugs and biologics for which the dose, frequency and duration of therapy may differ from patient to patient due to factors such as the patient’s diagnosis, stage in therapy or weight. Humana will consider these additional elements when reviewing preauthorization requests. Humana also has established guidelines for review of injectable or infusible drugs and biologics to determine the appropriateness of the outpatient hospital site of care. Preauthorization requests will be reviewed utilizing an evidence-based medicine approach.

  • A subset of the medications listed on the medication preauthorization lists for commercial plans, MA plans, dual Medicare-Medicaid plans and Medicaid plans will require additional information to allow Humana to complete a review to calculate dose, frequency of drug administration and stage of therapy.
  • A subset of the medications listed on the medication preauthorization lists for commercial plans, MA plans, dual Medicare-Medicaid plans and Medicaid plans will require additional information to allow Humana to consider approval for outpatient-hospital-based services with Centers for Medicare & Medicaid Services (CMS)/American Medical Association (AMA) place-of-service codes 19 (off-campus outpatient hospital) and 22 (on-campus outpatient hospital).
  • Upon completion of Humana’s review of the preauthorization request, the physician or health care provider will receive a determination outlining the approved dose, frequency, duration and site of care or the explanation of the denial.
  • If a health care provider does not obtain preauthorization or bills for units of a drug, frequency, duration of therapy or site of care outside of those authorized, it may result in claim denial. Any denial will follow Humana’s standard processes.

Reminder: Humana asks health care providers to submit claims for Healthcare Common Procedure Coding System (HCPCS) drug codes with the corresponding national drug code (NDC). Humana will reject claims for the following types of drug codes if submitted without an NDC:

  • Shared HCPCS codes
  • Not Otherwise Classified (NOC) codes

For up-to-date information about the specific drugs that must be submitted with NDCs, please refer to the most current version of Humana’s medication preauthorization lists found on Humana.com/PAL.

Questions regarding the NDC billing requirement may be directed to Humana Customer Service at 1-800-4HUMANA (1-800-448-6262).

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.

Important notes:

If a health care provider does not obtain preauthorization for a service, it could result in financial penalties for the practice and reduced benefits for the member, based on the health care provider’s contract and the member’s Certificate of Coverage. Services or medications provided without preauthorization may be subject to retrospective medical necessity review. We recommend that an individual practitioner making a specific request for services or medications verify benefits and authorization requirements with Humana prior to providing services.

  • Commercial HMO members: Health care providers who participate in an 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. Exclusions may change; refer to Humana.com/provider for the most up-to-date information. Choose “Authorizations & Referrals” and then the appropriate topic.
  • Humana Individual product members: The full list of Commercial Preauthorization and Notification List requirements applies to Humana Individual product members.
  • Humana MA HMO members: The full list of MA and Humana dual Medicare-Medicaid preauthorization requirements applies to Humana MA HMO and HMO-POS members. For MA HMO plans in Florida, specialists should direct all service and medication administration preauthorization requests to the member’s primary care physician for referral issuance. Health care providers who participate in an IPA or other risk network with delegated services are subject to the preauthorization list and should refer to their IPA or risk network for any questions or guidance processing their requests.
  • Humana MA PPO members:
  • The full list of MA and dual Medicare-Medicaid preauthorization requirements applies to Humana MA PPO members. Preauthorization is not required for services provided by nonparticipating health care providers for MA PPO members; notification is requested, but not required, as this helps coordinate care for our members.
  • Humana MA PFFS members: Preauthorization is not required for MA PFFS plans; notification is requested for these plans, but not required, as this helps coordinate care for our members. Physicians and health care providers may request an Advanced Coverage Determination (ACD) on behalf of the member for any service not on our preauthorization list for review and determination of coverage in advance of the services being provided.

ACDs for medical services may be initiated by submitting a written, fax or telephone request:

  • Send written requests to: Humana Correspondence, P.O. Box 14601, Lexington, KY 40512-4601
  • Submit by fax to 1-800-266-3022
  • Submit by telephone at 1-800-523-0023
  • All Humana MA members: For procedures or services that are investigational or experimental or may have limited benefit coverage, or for questions regarding whether Humana will pay for a service, physicians and health care providers may request an ACD on behalf of the member prior to providing the service. You may be contacted if additional information is needed.
  • ACDs for medical services may be initiated by submitting a written, fax or telephone request:

    • Send written requests to: Humana Correspondence, P.O. Box 14601, Lexington, KY 40512-4601
    • Submit by fax to 1-800-266-3022
    • Submit by telephone at 1-800-523-0023

    ACDs for medications on the list may be initiated by submitting a fax or telephone request:

    • Submit by fax to 1-888-447-3430
    • Submit by telephone at 1-866-461-7273
    • Administrative-services-only (ASO) groups: It is important to note that some employer groups for which Humana provides administrative services only (self-insured, employer-sponsored programs) may customize their plans with different requirements.
    • Humana Medicare Supplement plan: The MA and Dual Medicare-Medicaid Preauthorization and Notification List does not apply to policyholders of a Humana Medicare Supplement plan.

    For more information, contact Humana Customer Service at 1-800-4HUMANA (1-800-448-6262).