Humana Updates Preauthorization and Notification Lists for 2018

On Jan. 22, 2018, Humana will update preauthorization and notification lists for all commercial fully insured plans, Medicare Advantage (MA) plans and dual Medicare-Medicaid plans.*

Updates to the lists include the following:

  1. Preauthorization will be required for left atrial appendage closure (LAAC) device (e.g.; Watchman), lung biopsy and resection and simple mastectomy and gynecomastia surgery (excluding radical and modified) for comercial fully insured, MA and dual Medicare-Medicaid plans. Preauthorization requests will be reviewed by HealthHelp. For more details, refer to the following:
  2. Preauthorization for epidural injections will continue to be managed by OrthoNet for commercial fully insured, MA and dual Medicare-Medicaid plans. Refer to the applicable preauthorization and notification list at Humana.com/PAL for instructions on how to submit preauthorization requests for this service. (Please note: The notification letter mailed to all participating physicians and health care professionals indicated that Humana would begin reviewing these requests; however, the epidural injection requirement has been revised, and OrthoNet will retain management of epidural injections.)
  3. 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.
  4. Humana’s preferred viscosupplementals will be Monovisc and Orthovisc and will no longer require preauthorization. All other viscosupplementals will require preauthorization for commercial fully insured, MA and dual Medicare-Medicaid plans.

National Drug Code (NDC) Billing Requirement: For some Healthcare Common Procedure Coding System (HCPCS) drug codes, Humana requires all health care providers to submit each charge with the valid, corresponding NDC. For all other HCPCS drug codes, Humana asks prescribers to submit charges with valid, corresponding NDCs.

Humana may reject claims for the following types of drug codes if submitted without an NDC:

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

A rejected charge for a drug code that requires an NDC can be resubmitted, within timely guidelines, with an NDC for reconsideration of payment. For up-to-date information about the specific drugs that must be submitted with NDCs, please refer to the current version of Humana’s medication preauthorization lists on Humana.com/PAL.

Note: The requirement to bill an NDC applies to all professional and facility claims, except inpatient facility claims.

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

IMPORTANT NOTES

  • 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 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 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.
  • 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.
  • 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).