How to request prior authorization

Prior authorization is required for certain services and medications. To request prior authorization for medications (except where otherwise noted), submit via one of the following methods: Online via CoverMyMeds (http://www.covermymeds.com/); Phone: 866-461-7273 (TTY: 711), Monday–Friday, 8 a.m. – 11 p.m., Eastern time; Fax: 888-447-3430. Request forms are available on Humana's prior authorization for professionally administered drugs website. For transplant-related preauthorization requests, see the separate transplant network submission guidance below.

• Online: CoverMyMeds (http://www.covermymeds.com/)
• Phone: 866-461-7273 (TTY: 711), Monday–Friday, 8 a.m. – 11 p.m., Eastern time
• Fax: 888-447-3430 (Request forms available on Humana's prior authorization for professionally administered drugs website)

Advance coverage determination (ACD)

Humana may permit an Advance Coverage Determination (ACD) for investigational, experimental, or limited-benefit services or to determine coverage before providing a service. ACDs for medications on the list can be initiated by submitting a fax or phone request. You may be contacted if additional information is needed to complete the review.

Urgent services and new member active treatment provision

Urgent or emergent services do not require prior authorization. Additionally, 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. Humana may review services furnished during an active course of treatment when determining payment; include the appropriate modifier per Humana's Medicare Advantage Payment Policy or submit medical records showing the member is in an active course of treatment.

• Urgent/emergent services are exempt from prior authorization
• New member provision: 90-day active-treatment grace for services initiated prior to enrollment

Denial and financial risk

Failure to obtain required prior authorization may result in financial penalties to the provider and reduced patient benefits. Services or medications provided without required prior authorization may be subject to retrospective medical necessity review. Providers are encouraged to verify benefits and prior authorization requirements before providing services.

• Not obtaining prior authorization may result in financial penalties and reduced patient benefits
• Services provided without prior authorization may be subject to retrospective medical necessity review

Required information for prior authorization or notification

When submitting a prior authorization request or notification, include all required information to expedite determination. Submitting complete clinical documentation at the time of request reduces delays; Humana will contact the requester if additional information is 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 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 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 documentation

Medication prior authorization entries and flags

Medication prior authorization entries in Humana's lists include brand and generic names, associated billing codes, and special flags. Flags indicate: new preauthorization requirement (*), new-to-market drug addition (†), shared HCPCS/NOC codes requiring an NDC on claims (‡), step therapy required through a Humana-preferred drug (**), and therapies reviewed by the Humana National Transplant Network (††). Providers must follow these flags when preparing PA requests and billing claims.

• * New preauthorization requirement
• † New-to-market drug addition
• ‡ Shared HCPCS/NOC codes require a corresponding NDC on claims
• ** Step therapy required through a Humana-preferred drug as part of preauthorization
• †† Preauthorization requests routed to Humana National Transplant Network

Prior authorization submission requirements and special flags

Prior authorization submission requirements and special billing rules to note: all shared HCPCS and NOC codes require the corresponding NDC to be billed on claims; step therapy indicators (**) mean a Humana-preferred drug trial is required per the PA criteria; providers who do not stock a preferred medication may obtain it from a pharmacy (specialty or mail-order) to administer. Include NDC when applicable and follow Humana's coding and claims guidance to ensure appropriate payment.

• All shared HCPCS/NOC codes require a corresponding NDC on claims
• Step therapy (**) requires trial of a Humana‑preferred drug as part of preauthorization
• If provider does not stock preferred medication, consider obtaining from a pharmacy (specialty or mail-order)
• Include appropriate modifiers per Humana Medicare Advantage Payment Policy when applicable

Transplant Network preauthorization submission

Preauthorization requests for transplant-related items and therapies are reviewed by the Humana National Transplant Network. Submit transplant preauthorization requests 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. The transplant network will review and direct appropriate routing for these requests.

• Fax: 502-508-9300
• Phone: 866-421-5663, Monday–Friday, 7 a.m. – 7 p.m., Central time
• Email: transplant@humana.com
• Transplant-related PAs will be reviewed by the Humana National Transplant Network

Medication-specific entry guidance

Many medication-specific entries in Humana's PA list name the brand, generic, and billing codes — for example, brand name and corresponding J‑ or Q‑codes — along with the flags described above. Providers should reference the PA list entry for the medication in question and include the listed billing codes and required NDC information when submitting the request.

• Medication entries include brand name, generic name, and billing codes (J‑codes/Q‑codes)
• Follow medication-specific entry flags and billing code requirements when submitting PA

General prior authorization request method and plan-specific forms

For plan- or region-specific prior authorization and notification forms (for example, H1036-280 Humana Fully Integrated Florida HMO D‑SNP), access the indicated prior authorization and notification list and associated fax forms to request preauthorization or provide notification. Use the plan-specific forms when applicable.

• Access plan-specific PA/notification lists and fax forms (e.g., H1036-280 Humana Fully Integrated Florida HMO D‑SNP) as indicated
• Use plan-specific forms when submitting PA or notification