CurrentHumanaPolicy N/A

Puerto Rico Medicare Advantage and Dual Medicare-Medicaid Plans Preauthorization and Notification List

Governs preauthorization and notification requirements for Humana Puerto Rico Medicare Advantage (MA) and Dual Eligible Special Needs plans, describing which services and medications require prior approval or notification and how providers should request them.

Policy Summary

PayerHumana

PolicyPuerto Rico Medicare Advantage and Dual Medicare-Medicaid Plans Preauthorization and Notification List

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionSubmit preauthorization requests online, by phone (866-488-5995), fax (800-594-5309) or email (citfaxpr@humana.com); urgent/emergent services do not require preauthorization.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

866-488-5995phone for preauthorizations

800-594-5309fax for requests

citfaxpr@humana.comACD/email

90 daysgrace period (active treatment)

Preauthorization and Advance Coverage Determinations

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Applicability, ACDs, and Medicare coverage requirement

Applicability by plan type and process for Advance Coverage Determination (ACD); services must meet Medicare medical necessity standards.

Applicability: The full list of preauthorization requirements applies to Humana Puerto Rico Medicare Advantage (MA) HMO, HMO POS, and MA PPO members; this list does not apply to Humana Medicare Supplement or Humana commercial plans.

ALL of the following

ACD submission methods (medical services): written mail to Humana PR Clinical Services Department, P.O. Box 195560, San Juan, PR (00919-5560); fax to 800-594-5309; email to citfaxpr@humana.com; or telephone at 866-773-5959.
ACD submission methods (medications): fax to 800-594-5309; email to citfaxpr@humana.com; or telephone at 866-773-5959.

Medicare coverage requirement: Services must be provided in accordance with Medicare coverage guidelines and be medically necessary as established by CMS.

Grace period for ongoing treatment: 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 those services against coverage criteria when determining payment.

Submission requirements and operational notes

Operational submission requirements, required information, and consequences for not obtaining preauthorization.

Urgent/emergent services: Urgent and emergent services do not require referrals or preauthorizations.

Consequences of no prior authorization: Failure to obtain required preauthorization may result in financial penalties for the practice, reduced patient benefits per the provider contract and Certificate of Coverage, and services provided without preauthorization may be subject to retrospective medical necessity review.

Required information for preauthorization or notification: Include member Humana ID number, member name and date of birth, date of actual service or hospital admission (or proposed procedure date if applicable), procedure codes, diagnosis codes (primary and secondary), place of service (inpatient/outpatient and specific setting), treatment facility TIN and NPI, performing provider TIN and NPI, caller/requestor name and telephone number, attending physician telephone number, and relevant clinical information.

Submission methods: Preauthorization requests and notifications can be submitted online, by telephone, by fax, or by email; online submission is encouraged. For Humana Puerto Rico specific channels, fax and email (including the contacts used for ACDs) are available.

Required Codes and Submission Data

Required coding and identifiersmixed

Procedure codes, Diagnosis codes (primary and secondary)

Providers must supply relevant procedure and diagnosis codes when requesting preauthorization.

Required information completeness

Member identifierMember's Humana ID number, name and date of birth

Service datesDate of actual service or hospital admission; date of proposed procedure (if applicable)

Clinical and coding detailsProcedure codes; diagnosis codes (primary and secondary); relevant clinical information

Place of servicePlace of service (inpatient, outpatient, telehealth, office, home, outpatient hospital, radiology facility, ambulatory surgery center)

Provider identifiersTax Identification Number (TIN) and National Provider Identifier (NPI) of treatment facility and provider performing the service

Requestor and attending contactsCaller/requestor's name and telephone number; attending physician's telephone number

What Providers Must Do

Prior Authorization

Definitions and scope of Preauthorization vs Notification

The term preauthorization (also called prior authorization, precertification, predetermination, or preadmission) is a process by which the physician or other healthcare provider must obtain advance approval from Humana as to whether an item or service will be covered. Preauthorization is required for the services and medications listed on Humana’s Puerto Rico Medicare Advantage and Dual Medicare-Medicaid preauthorization and notification lists and must be obtained prior to providing or administering the service or medication, except as noted elsewhere in this policy or list.

Preauthorization = advance approval from Humana that an item/service will be covered.
Notification = provider informs Humana of intent to provide an item/service; Humana does not issue approval/denial with notification; it facilitates care coordination.

Denial Risk

Urgent services and consequences of no prior authorization

Urgent or emergent services do not require referrals or preauthorizations and should be provided immediately to meet the patient’s clinical needs. However, for non-urgent services that require preauthorization, failure to obtain required prior authorization may lead to financial penalties for the practice, reduced benefits for the patient per the provider contract and the patient’s Certificate of Coverage, and retrospective medical necessity review of the services or medications provided without authorization. Providers should verify benefits and preauthorization requirements with Humana prior to providing services when the situation is not urgent.

Urgent/emergent services: no preauthorization required.
Consequences of no prior authorization: potential financial penalties to provider, reduced patient benefits, retrospective medical necessity review.

Note

Preauthorization submission methods

How to request preauthorization: Except where noted via links on the preauthorization/notification pages, requests for medical services can be initiated by the provider using any of the following methods. Online requests are encouraged. For medical services: - Online at https://humana.pr (registration required) - Call 866-488-5995 - Fax 800-594-5309 - Email citfaxpr@humana.com For medications (except where noted via links): - Fax 800-594-5309 (request forms available at Humana.com/Medpa) - Call 866-488-5995 - Email citfaxpr@humana.com This list and the contact methods may be updated; providers should follow the directions on the applicable Humana preauthorization/notification webpages and the downloadable lists for any service- or drug-specific submission requirements.

Online (preferred): https://humana.pr (registration required).
Phone: 866-488-5995.
Fax: 800-594-5309.
Email: citfaxpr@humana.com.
Medication forms: Humana.com/Medpa (fax form availability).

Key Definitions

Preauthorization

DefinitionProcess through which the physician or other healthcare provider must obtain advance approval from the plan as to whether an item or service will be covered.

When requiredUsed for services and medications listed on the preauthorization and notification list that must be approved prior to being provided or administered.

Relation to MedicareServices must meet Medicare coverage guidelines and be medically necessary per CMS standards.

Notification

DefinitionProcess by which the physician or other healthcare provider notifies Humana of the intent to provide an item or service; Humana does not issue an approval or denial for notifications.

PurposeHelps coordinate care for Humana-covered patients; is distinct from preauthorization.

ScopeApplies to items and services on the notification portion of the preauthorization and notification list.

Investigational/Experimental

DefinitionProcedures, devices or services considered investigational or experimental are generally not covered benefits.

Coverage actionConsult the patient's Evidence of Coverage or contact Humana for confirmation; certain services may not be covered under the member's plan.

ACD optionAdvance Coverage Determinations (ACDs) can be requested to determine whether Humana will pay for investigational/uncertain services (see submission methods in policy).