Prior authorization and notification list — Humana Dual Fully Integrated (HMO D-SNP) Virginia
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Governs prior authorization and notification requirements for medications and certain services for Humana Dual Fully Integrated (HMO D-SNP) Virginia plans; affects participating providers delivering office/clinic/outpatient/home-administered medications and related services.
No material clinical or coverage changes in this revision.
Coverage and Authorization Requirements
General coverage stance
Coverage requires medical necessity and adherence to Medicare/CMS guidelines; investigational or experimental procedures/devices are generally not covered.
ALL of the following
- Service or medication must be medically necessary and provided according to Medicare/CMS coverage guidelines (refer to CMS).
- Prior authorization is required for medications listed in this document when delivered in the provider's office, clinic, outpatient or home setting; providers must obtain advance approval from the plan to determine coverage.
- Investigational and experimental procedures and devices usually are not covered; consult the member's Evidence of Coverage or Humana for confirmation of coverage.
Prior authorization / notification medication list (partial)
Partial extract of the prior authorization/notification medication list; entries below show medication name, generic equivalent and associated billing code(s).
Examples from the partial list
Medications requiring prior authorization/notification (partial list)
Partial entries illustrating medications that require prior authorization/notification and notation conventions (see operational notes for symbols).
Partial medication entries
Prior authorization/notification medication list (partial)
Additional partial list entries; some medications are annotated for step therapy, NDC billing requirements, or transplant review.
Sample entries and annotations
Operational and billing criteria
Operational and billing rules that apply to entries in the prior authorization/notification list.
ALL of the following
- All shared HCPCS codes and not otherwise classified (NOC) codes require a corresponding National Drug Code (NDC) to be billed on all claims (‡).
- Items flagged with '**' require step therapy through a Humana-preferred drug as part of preauthorization.
- Items flagged with '††' are reviewed by the Humana National Transplant Network; transplant preauthorization requests can be submitted by fax to 502-508-9300, by phone to 866-421-5663 (Mon–Fri, 7 a.m.–7 p.m. CT), or by email to transplant@humana.com.
Billing Codes and Coding Rules
How Providers Request Authorization & Submission Channels
How to request prior authorization
Prior authorization is required for listed medications administered in provider/clinic/outpatient/home settings. Requests may be initiated via CoverMyMeds, by phone at 866-461-7273 (TTY: 711), or by fax at 888-447-3430; request forms are available on Humana's prior authorization for professionally administered drugs website.
- Online: CoverMyMeds
- Phone: 866-461-7273 (TTY: 711), Mon–Fri, 8 a.m.–11 p.m. ET
- Fax: 888-447-3430 (request forms on Humana website)
Denial risk / financial penalty
Failure to obtain required prior authorization may result in financial penalties to the practice and reduced benefits for the patient; services or medications provided without prior authorization may be subject to retrospective medical necessity review.
- Penalties and reduced member benefits may apply per provider contract and member Evidence of Coverage
- Services provided without authorization may be reviewed retrospectively for medical necessity
Required documentation for prior authorization request
Include the following information when submitting a prior authorization request: patient identifiers, date of service, HCPCS codes and diagnosis codes (up to 6), service location, facility and provider TIN/NPI, caller contact, and relevant clinical information; providing complete clinical information upfront expedites determination.
- Patient name, DOB, Humana member ID
- Date of service or admission
- HCPCS codes and up to 6 diagnosis codes
- Service location and facility/provider TIN & NPI
- Caller/requester name and phone number and attending provider phone
- Relevant clinical information
Step therapy for Medicare Part B medications
Step therapy may apply to Medicare Part B medications; Humana maintains a Medicare Part B Step Therapy Preferred Drug List and some strategies may require trials across Part B and Part D benefits.
- Review Humana's Part B Step Therapy PDL and coverage policies for specific requirements
- Preferred status does not guarantee exemption from step therapy
Transplant preauthorization routing
Certain transplant-related preauthorization requests are reviewed by the Humana National Transplant Network and have separate submission contacts.
- Transplant reviews are handled by the Humana National Transplant Network
Requesting prior authorization — medication entries
Use the provided fax request forms to submit preauthorization or to provide notification for medications; each medication entry lists the applicable billing code(s) to include with the request.
Transplant preauthorization submission
Preauthorization requests that require transplant review can be submitted to the Humana National Transplant Network by fax, phone, or email: fax 502-508-9300, phone 866-421-5663 (Mon–Fri, 7 a.m.–7 p.m. CT), or email transplant@humana.com.
- Fax: 502-508-9300
- Phone: 866-421-5663 (Mon–Fri, 7 a.m.–7 p.m. CT)
- Email: transplant@humana.com
How to request prior authorization / submission channels
Except where noted, prior authorization may be initiated online via CoverMyMeds, by phone at 866-461-7273 (TTY: 711), or by fax at 888-447-3430; request forms are available on Humana's prior authorization for professionally administered drugs website.
- Online: CoverMyMeds
- Phone: 866-461-7273 (TTY: 711)
- Fax: 888-447-3430
Notation key for authorization requirements
Notation keys in the list indicate: * = new preauthorization requirement; † = new-to-market drug; ‡ = shared HCPCS/NOC codes require a corresponding NDC on all claims; ** = step therapy required through a Humana-preferred drug as part of preauthorization.
- * New preauthorization requirement
- † New-to-market drug addition
- ‡ Shared HCPCS/NOC codes require corresponding NDC on claims
- ** Step therapy required through a Humana-preferred drug as part of preauthorization
- †† Transplant-reviewed items (see transplant contacts)
Transplant review submission methods
Preauthorization requests that will be reviewed by the Humana National Transplant Network can be submitted by fax to 502-508-9300, by phone at 866-421-5663 (Mon–Fri, 7 a.m.–7 p.m. CT), or by email to transplant@humana.com.
- Fax: 502-508-9300
- Phone: 866-421-5663 (Mon–Fri, 7 a.m.–7 p.m. CT)
- Email: transplant@humana.com
How to request prior authorization / notification
Access and submit the Humana fax forms to request preauthorization or to provide notification for medications; the list provides medication names and billing codes to include in the submission.
- Medication entries include brand, generic name, and billing codes for authorization
How to request prior authorization (medication list segment)
For the medications in the list segment, use the fax forms to request prior authorization or provide notification and include the specified billing codes shown next to each medication entry.
Transplant preauthorization submission
Preauthorization requests for transplant-reviewed items will be reviewed by the Humana National Transplant Network and can be submitted by fax to 502-508-9300, phone 866-421-5663 (Mon–Fri, 7 a.m.–7 p.m. CT), or email transplant@humana.com.
- Transplant review contacts: fax 502-508-9300; phone 866-421-5663; email transplant@humana.com
How to request prior authorization
Prior authorization requests for listed medications are initiated by accessing the fax request forms on Humana's prior authorization website or via CoverMyMeds, phone (866-461-7273), or fax (888-447-3430).
- CoverMyMeds, phone 866-461-7273, or fax 888-447-3430
How to request prior authorization
Access Humana's fax forms to request preauthorization or provide notification for medications listed on the prior authorization list; the forms and instructions are on Humana's prior authorization for professionally administered drugs webpage.
- Use the listed billing codes with the fax forms when submitting requests
Transplant preauthorization submission instructions
Preauthorization requests for transplants are reviewed by the Humana National Transplant Network and can be submitted by fax to 502-508-9300, by phone at 866-421-5663 (Mon–Fri, 7 a.m.–7 p.m. CT), or by email to transplant@humana.com.
- Fax: 502-508-9300
- Phone: 866-421-5663 (Mon–Fri, 7 a.m.–7 p.m. CT)
- Email: transplant@humana.com
Definitions and Annotation Keys
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