For information on how to submit a preauthorization for frequently requested services/procedures for your patients with Humana follow the links below.
Tag: Humana
New Clinical Documentation Attachments Required for Prior Authorizations
Effective Jan. 1, 2026, the Centers for Medicare & Medicaid Services (CMS) requires prior authorization (PA) decisions within seven calendar days for standard (non-urgent) requests for medical items and services (See CMS Interoperability and Prior Authorization Final Rule – CMS-0057-F).
Below is From Humana
Humana is committed to maintaining the new streamlined time frame for PA decisions in accordance with this rule. To comply, all supporting clinical documentation must be submitted at the time of the PA request. Beginning May 16, 2026, providers submitting outpatient Medicare authorization requests for PA services via the Availity Essentials™ portal will be required to upload supporting clinical documentation. Exceptions may apply.
If you have other questions, please call 800-457-4708 (TTY: 711) Monday-Friday, 7 a.m. – 7 p.m., Eastern time.
CMS now requires impacted payers to send PA decisions to providers within 72 hours for expedited (urgent) requests and seven calendar days for standard (non-urgent) requests.
To streamline the PA process and comply with CMS Interoperability and Prior Authorization Final Rule – CMS-0057-F, supporting clinical documentation must be received with the authorization request. This ensures that Humana has the information necessary to promptly and accurately review requests.
This requirement applies to Medicare outpatient authorization requests for PA services submitted directly through Availity Essentials. It does not apply to home health services, inpatient services or Medicaid membership. This change does not impact submissions outside of Availity Essentials.
Availity Essentials will require clinical records to be attached before submission for outpatient PA services. If records are unavailable, your progress will be saved as a draft in the Authorization/Referral dashboard for up to 90 days. You may resume and submit once documentation is available. Please note, draft entries are not considered submissions; Humana will not receive your request until it is submitted with records attached.
Required information may include, but is not limited to, the items below:
• Patient details: Full name, date of birth and Humana policy ID number
• Referring and servicing provider details: Name, National Provider Identifier (NPI), Tax Identification Number (TIN), specialty and contact information (including fax)
• Diagnosis and procedure codes: Accurate International Classification of Diseases (ICD) diagnosis codes (up to six) and procedure codes (up to 10, as applicable) specific to the request
• Treatment details: Specific service, procedure, item or medication being requested, including planned date of service, service location, inpatient or outpatient status, quantity, medication dosage, frequency and duration
• Clinical rationale: Detailed explanation of medical necessity with supporting evidence from medical records. See Humana.com/CoveragePolicies for more information on clinical guidelines.
• Relevant medical history: Past medical conditions, current medications, allergies and significant laboratory results
• Supporting documentation: Imaging studies, laboratory reports, prior treatments or therapies, progress notes or other relevant clinical data that supports the medical necessity of the request
For additional details, please refer to the CMS Interoperability and Prior Authorization Final Rule – CMS0057-F and Humana coverage policies at Humana.com/CoveragePolicies.
Health Plan Representatives Updated 8/4/2025
The Health Plan Representatives List has been updated. This is a good tool to print and have close by when you have an issue.
The biggest change for claims issues will be HealthSpring (HCSC) formerly Cigna MA. Here is how:
- Email ALL claims issues to [email protected]
2. HealthSpring has supplied the spreadsheet that MUST be used. A link is provided below, or you may call POET, we will be glad to email you an electronic copy.
Only the columns with Red Lettering, need to be filled out by the Physician’s office.
4. Always feel free to copy [email protected] if you would like POET to be in the loop.
5. If you have a time sensitive, special, or just an issue you would like to discuss with POET, please call (936) 637-7638.
Humana
TIPS, TRICKS AND HELPS
PREAUTHORIZATON LISTS (PAL):
Lists of services and medications effective July 1, 2025, that may required preauthorization for members with Medicaid, Medicare Advantage, and dual Medicare-Medicaid coverage are now available.
Easily determine if a prior authorization is required with Humana’s search tool. Search by Current Procedural Terminology (CPT®) codes, procedures or generic drug name(s). Remember to verify benefit coverage in Availity Essentials
Availity Essentials Introduces Check Claim Status Feature:
Availity has enhanced its Eligibility and Benefits (E/B) page by adding a Check Claim Status feature.
What you can expect:
- Improved efficiency and accuracy: The check Claim Status tool pre-populates your patient’s information, ensuring accuracy.
- Time savings: You can access claim status with one click- saving time and effort
https://provider.humana.com/
Humana’s Contract Numbers
Knowing the Medicare Advantage (MA) Contract number of the plans your office has opt’ed into can be a big help.
Some may say what is a MA contract number? Or you may have heard it called an H number.
The Centers for Medicare and Medicaid Services (CMS) is responsible for identifying each Medicare Advantage C plan with a unique contract number. This number is assigned to the insurance company during the approval process. For local managed care contracts, the number begins with an ‘H’ or a ‘9″.
Below are your H numbers for the Humana-POET contract.
The next time you are in doubt about a Humana Card, look for one of these numbers on the front of the card.
Humana Gold Plus H0028-041 (HMO)
HumanaChoice Giveback H5216-358 (PPO)
Humana USAA Honor Giveback H5216-348-000-2025 (PP0) This is the only Humana Military card under the POET Contract.
This isn’t the best example of a Humana card, but you can see the H number in the bottom right hand corner.
Do not be confused: Tricare for life is a 2ndary Plan and does not need a contract.
New! Search Tool Helps Streamline Prior Auths
Prior authorizations are often cited as one of the top burdens for healthcare professionals. To help streamline your workflow and save time, Humana has launched a new prior authorization search tool.
Now you can search by CPT® code, procedure or drug name to determine if authorization is required. You also can find guidance on how to submit medical and pharmacy authorizations.
Humana Physician News Q2 2024 Newsletter
NEW! 2024 preauthorization lists (PAL) and notification requirements Lists of services and medications, effective July 1, 2024, that may require preauthorization for patients with Medicare Advantage, Medicaid, dual Medicare-Medicaid and commercial coverage are now available.
NEW! 2024 provider manuals Humana Medicare and Medicaid provider manuals, effective March 15, 2024, are now available.*
Quality and Stars learning series Humana provides educational webinars each month, covering Quality and Stars-related topics for both learning purposes and continuing education credits.
Humana News
Humana Physician News Q1 2023
Just to mention a few topics:
- Financial Assistance for patients
- Real-time Benefit check
- Medication reconciliation for reduced hospital readmission
Humana Physician News
A Wealth of Information Just Waiting for You.
- Humana’s Neighborhood Centers offer patients one on one health education.
- Value-based care reduces acute care.
- Earn CME by attending the CMS Statin Webinar.
- Complete your annual 2022 Compliance Training.
- Many Resources and Support.
Recent Comments