Prior Authorization Required

Providers must obtain prior authorization for medications and services listed for Humana Dual Integrated (HMO D-SNP) South Carolina members before administration, except where specific exceptions apply (for example, emergency care or active course of treatment protections described elsewhere). Failure to obtain required prior authorization may result in financial penalties to the practice, reduced benefits to the patient per the provider contract and Evidence of Coverage, and retrospective medical necessity review and claim denials.

• Prior authorization methods: Online via CoverMyMeds (http://www.covermymeds.com/), by phone at 866-461-7273 (TTY: 711), Monday–Friday, 8 a.m.–11 p.m. Eastern time, or by fax to 888-447-3430. Request forms are available on Humana's prior authorization for professionally administered drugs website.
• Advance coverage determinations (ACDs) for investigational or limited-benefit services or medications may be requested by phone at 866-461-7273 (TTY: 711) or by fax to 888-447-3430 to confirm payment prior to providing the service.
• Transplant-related preauthorization requests are reviewed by the Humana National Transplant Network and may be submitted by fax to 502-508-9300, by phone at 866-421-5663, Monday–Friday, 7 a.m.–7 p.m. Central time, or by email to transplant@humana.com.
• To prevent disruption of care, Humana does not require prior authorization for basic Medicare benefits during the first 90 days of a new member's enrollment for active courses of treatment that started prior to enrollment. Include appropriate modifier per Humana's Medicare Advantage Payment Policy (CP2023011) or medical records showing active course of treatment when submitting claims.
• All shared HCPCS and not otherwise classified (NOC) codes (marked ‡) require the corresponding NDC to be billed on all claims.

Documentation Requirements

When requesting prior authorization or an advance coverage determination, submit complete documentation to expedite the review. Humana may request additional clinical information if needed.

• Patient name, date of birth and Humana member ID number
• Date of actual service or hospital admission
• HCPCS code(s) and diagnosis codes (primary and secondary) — up to 6 diagnosis codes per authorization request
• Service location (inpatient: acute hospital, skilled nursing, hospice; outpatient: telehealth, office, home, off-campus outpatient hospital, on-campus outpatient hospital, ambulatory surgery center)
• Tax Identification Number (TIN) and National Provider Identifier (NPI) of the facility where service is rendered, and TIN and NPI of the provider performing the service
• Caller/requester name and phone number and attending provider's phone number
• Relevant clinical information and supporting medical records

Medication List Format and Legends

Medication list entries use a consistent format and legends so providers can identify the brand name, generic name, and required billing codes and note any special entry flags.

• Column 1: Brand medication name
• Column 2: Generic medication name
• Column 3: Billing codes (HCPCS/CPT/NDC guidance as applicable)
• Legend and entry symbols: see Annotation Key block for symbol meanings
• Each medication entry includes the identifiers necessary for submission (brand, generic, billing codes). For HCPCS/NOC entries marked with ‡, the corresponding NDC must be billed on all claims.

Prior Authorization Submission Methods

General submission methods and operational notes for prior authorization requests and notifications.

• Access fax forms to request preauthorization or provide notification via Humana's provider website (forms referenced throughout the medication list).
• Standard submission options: CoverMyMeds, phone 866-461-7273 (TTY: 711), or fax 888-447-3430.
• Include all required identifiers (see Documentation Requirements) with each request; submitting all relevant clinical information at initial request expedites determinations.
• Entries marked with step therapy indicator (**) will require documentation of trial and failure (or contraindication) of a Humana-preferred drug as part of the preauthorization.
• Services provided without required prior authorization may be subject to retrospective review and denial; always verify benefit and PA requirements prior to providing the service.

How to Request Prior Authorization / Notification (HMO D-SNP)

Specific submission guidance for Humana Dual Integrated (HMO D-SNP) South Carolina members and note on accessing forms.

• Humana Dual Integrated (HMO D-SNP) South Carolina: access the fax forms to request preauthorization or provide notification using links on Humana's provider site where indicated throughout the medication list.
• When submitting for HMO D-SNP members, include the plan/member identifiers and follow the same phone/fax/online channels listed above.

Annotation Key for List Entries

Annotation key — symbols used in the medication list and their meanings. Consolidated to avoid duplication and to ensure every symbol used in the list is defined.

• * New preauthorization requirement
• † New-to-market drug addition
• ‡ All shared HCPCS codes and not otherwise classified (NOC) codes require a corresponding National Drug Code (NDC) to be billed on all claims
• ** Step therapy required — prior authorization requires documentation of trial with a Humana-preferred drug (or documentation of contraindication/intolerance)
• †† Transplant review — preauthorization requests will be reviewed by the Humana National Transplant Network (fax: 502-508-9300; phone: 866-421-5663, Mon–Fri 7 a.m.–7 p.m. CT; email: transplant@humana.com)