How to request prior authorization and behavioral health/medication contacts

Prior authorization requests for medical services may be initiated online via Availity.com (registration required), by calling Humana Healthy Horizons in South Carolina's IVR line at 800-523-0023, or by faxing the prior authorization form to 833-441-0950. Behavioral health prior authorization may be initiated by calling the Behavioral Health Crisis Line at 833-364-2274, via Availity, IVR 800-523-0023, or fax to 833-441-0950. Medication prior authorizations may be faxed to 888-447-3430 (request forms at Humana.com/medPA) or requested by calling 866-461-7273 (M–F 8 a.m.–11 p.m. ET).

• Medical PA: Availity.com, IVR 800-523-0023, fax 833-441-0950
• Behavioral health PA: Behavioral Health Crisis Line 833-364-2274, Availity, IVR 800-523-0023, fax 833-441-0950
• Medication PA: fax 888-447-3430 (forms at Humana.com/medPA) or call 866-461-7273 (M–F 8 a.m.–11 p.m. ET)

Notification vs prior authorization

Notification is a separate process where providers inform Humana Healthy Horizons of the intent to provide a service; Humana does not issue an approval or denial for notifications.

Urgent/emergent services

Urgent or emergent services do not require referrals, prior authorization, or notification.

Consequences of not obtaining prior authorization/notification

Services provided without required prior authorization or notification may result in financial penalties for the practice, reduced patient benefits per the provider contract and the patient's evidence of coverage, and may be subject to retrospective medical necessity review.

• Potential financial penalties to the practice
• Reduced benefits for the patient based on contract/EOC
• Subject to retrospective medical necessity review

Specialty drugs prior authorization

Prior authorization is required for the listed specialty drugs when delivered in the physician's office, clinic, outpatient or home setting. To request prior authorization or provide notification for specialty drugs, access the fax forms as directed in the PAL.

• Specialty drug PA applies when delivered in physician office, clinic, outpatient or home settings
• Request PA or provide notification via the fax forms referenced in the PAL

Obstetrical admission notification

Humana Healthy Horizons requests notification for obstetrical admissions that exceed 48 hours for vaginal deliveries or 96 hours for cesarean sections to allow concurrent review for care coordination and discharge planning.

• Notify when postpartum stay >48 hours for vaginal delivery
• Notify when postpartum stay >96 hours for cesarean section

PAL-listed services requiring authorization/notification

Numerous services and procedures listed on the PAL—including varicose vein treatments, pain management injections and devices, spinal surgeries, physical/occupational/speech therapy, CT/MRI/MRA/PET/nuclear medicine imaging, transplant and VADs, wound care (NPWT), bariatric surgeries, gender affirmation, cochlear/implantable hearing devices, neurostimulators and others—require prior authorization or notification as specified in the PAL.

• Varicose vein surgical treatment and sclerotherapy (e.g., 36465–36483, 37700, 37718, etc.)
• Pain management: epidural, facet, trigger point injections, pain pumps, spinal cord stimulators (codes listed)
• Spine procedures: fusion, decompression, kyphoplasty/vertebroplasty (codes listed)
• Physical/occupational/speech therapy codes and facility-based imaging (CT/MRI/MRA/PET/nuclear medicine)
• Transplant surgeries, VADs, wound care (NPWT), bariatric surgery, cochlear/implantable devices, gender affirmation, neurostimulators