Definitions and required information for requests

Humana defines prior authorization as the process by which a healthcare provider must obtain advance approval from Humana Healthy Horizons for coverage of an item or service. Notification is the provider informing Humana of intent to provide an item or service; Humana does not approve or deny notifications. Required information for a prior authorization request or notification includes member name, Medicaid ID and DOB; date of service or hospital admission; procedure codes (up to 10 per request); diagnosis codes (up to 6 per request); date of proposed procedure; service location and inpatient/outpatient location; referral type; TIN and NPI of facility and provider performing the service; caller/requestor and attending provider contact numbers; relevant clinical information and discharge plans. Submitting all relevant clinical information at the time of request will help expedite determination.

• Prior authorization = advance approval from Humana Healthy Horizons (definition).
• Notification = provider notifies Humana; Humana does not issue approval/denial.
• Required request data: member name, Medicaid ID, DOB; date of service/admission; up to 10 procedure codes; up to 6 diagnosis codes; date of proposed procedure; service location and inpatient/outpatient location; referral type.
• Provider identifiers and contacts: TIN and NPI of facility and provider performing service; caller/requestor name & phone; attending provider phone.
• Clinical info: relevant clinical information and discharge plans; submit all relevant info to expedite determination.

How to request medical and behavioral health prior authorization

Request medical and behavioral health prior authorization through Availity Essentials, or call 844-881-4482 (Mon–Fri, 8:00 a.m.–8:00 p.m. ET). Medical prior auths may be faxed to Clinical Intake at 931-650-3709; behavioral health prior auths may be faxed to 931-650-3707. For Availity registration issues call Availity Client Services at 800-282-4548.

• Availity Essentials is the primary submission portal (unless otherwise noted).
• Phone for medical & behavioral health prior authorization: 844-881-4482 (Mon–Fri, 8 a.m.–8 p.m. ET).
• Fax numbers: medical — 931-650-3709; behavioral health — 931-650-3707.
• Availity registration help: 800-AVAILITY (282-4548).

How to request dental prior authorization

Submit dental prior authorization requests via the DentaQuest website or by calling Cardinal Care Smiles at 888-912-3456 (Mon–Fri, 8 a.m.–6 p.m. ET).

• DentaQuest website for online submission.
• Cardinal Care Smiles phone: 888-912-3456 (Mon–Fri, 8 a.m.–6 p.m. ET).

How to request vision prior authorization

Submit vision prior authorization requests via the EyeMed webpage or by calling Humana Healthy Horizons at 844-881-4482 (Mon–Fri, 8:00 a.m.–8:00 p.m. ET).

• EyeMed webpage for online submission.
• Phone for vision prior authorization: 844-881-4482 (Mon–Fri, 8 a.m.–8 p.m. ET).

Urgent/emergent services and consequences of missing prior authorization

Urgent and emergent services do not require prior authorization. Failure to obtain required prior authorization for nonurgent services may lead to financial penalties for the provider and reduced member benefits; services provided without prior authorization may be subject to retrospective medical necessity review.

• Urgent/emergent services: no referral or prior authorization required.
• Consequences for missing PA: provider financial penalties, reduced member benefits, and retrospective medical necessity review.

Prior authorization required (DME/supplies)

Durable medical equipment and supply HCPCS/L-codes listed on the PAL require prior authorization. Additionally, any service or supply that exceeds Virginia DMAS limits requires prior authorization — consult the DMAS DME webpage to determine limits.

• DME/L-code examples listed in the PAL (see code lists) require prior authorization.
• Services/supplies exceeding DMAS limits always require prior authorization; consult DMAS DME webpage.

Home health, home infusion and hospice

Home health and home infusion services have enumerated codes (for example: 99509, G0151–G0153, G0299–G0300, G0493–G0496, H2000, S5109, S5116, S9122, T1028) that are subject to the PAL. Hospice services require notification (notification only).

• Home health/home infusion example codes: 99509, G0151, G0152, G0153, G0299, G0300, G0493, G0494, G0495, G0496, H2000, S5109, S5116, S9122, T1028.
• Hospice services: notification required for all hospice services.

Molecular and genetic testing

Molecular diagnostic and genetic testing codes listed on the PAL require prior authorization. Example codes enumerated include 81105–81112, 81120–81121, 81161–81162 and many additional molecular/genetic CPT codes included in the PAL.

• Example molecular/genetic codes: 81105, 81106, 81107, 81108, 81109, 81110, 81111, 81112, 81120, 81121, 81161, 81162.
• The PAL contains an extensive list of molecular/genetic CPT and U-codes that require authorization.

Negative pressure wound therapy (NPWT)

Negative pressure wound therapy (NPWT) services and supplies listed on the PAL require prior authorization. Codes listed include 97605, 97606 and supplies HCPCS A6550 and E2402.

• NPWT procedure codes: 97605, 97606.
• NPWT supplies examples: A6550, E2402.

Nonemergent medical transportation (NEMT)

Nonemergent medical transportation (NEMT) services listed on the PAL are subject to the list; example HCPCS codes include A0130, A0380, A0422, A0425, A0426, A0428, T2001 and T2005.

• NEMT example codes: A0130, A0380, A0422, A0425, A0426, A0428, T2001, T2005.

Therapy prior authorization threshold

Prior authorization is required for physical, occupational and speech therapy after five visits. Codes affected include 97110, 97112, 97113, 97116, 97139, 92507, 92508, 97530, 97533 and 97535.

• Therapy PA threshold: prior authorization required after 5 visits.
• Example therapy codes listed: 97110, 97112, 97113, 97116, 97139, 92507, 92508, 97530, 97533, 97535.

Various procedures and devices requiring prior authorization or notification

The PAL lists numerous procedures, devices and service categories that require prior authorization or notification; examples include noninvasive home ventilators (E0465, E0466), spinal cord stimulators (63650, 63663, L8679 etc.), implantable cardiac and VAD procedures (codes such as 33221 series and 33975–33995), various surgical procedures (e.g., 43770–43775, 21085, 54405) and many DME/implant codes. Consult the PAL code lists for the complete enumerations.

• Noninvasive home ventilators: E0465, E0466.
• Spinal cord stimulators: 63650, 63663 and multiple HCPCS L/C codes (e.g., L8679).
• Ventricular assist devices and cardiac implant codes: examples include 33975–33995 and cardiac device series.
• Various surgical and implantable device codes listed throughout the PAL; refer to the PAL for full code detail.