Humana's Prior Authorization Process for Medical Services and Medications

Humana requires prior authorization for certain medical services and medications to ensure coverage under health plans, especially for Medicare members. This process involves obtaining advanced approval from Humana before treatments or drugs are provided, excluding emergencies. Members are advised to consult their Evidence of Coverage or contact Humana directly to verify which services and prescriptions need prior authorization.

Requests for coverage decisions can be submitted by the member, their representative, or healthcare provider via phone, fax, or mail. Humana commits to responding within 14 days for standard requests, with expedited decisions available within 72 hours when health risks are significant. Extensions on decision timelines can be granted if additional information is needed or at the member’s request.

Members have rights to appeal coverage denials or delays, including filing fast complaints when decision extensions occur. Detailed instructions and support are provided for appeals, ensuring transparency in the coverage determination process. Humana employs a Clinical Pharmacy Review committee to establish criteria for high-risk or expensive medications requiring authorization, using clinical and regulatory guidelines.

Representation in the authorization or appeal process is permitted through valid authorization forms or legal documents. For Part D late enrollment penalties, members have the option to appeal with the Centers for Medicare & Medicaid Services under certain conditions. This structured authorization framework aims to maintain compliance and streamline coverage decisions while providing accountability and oversight for members and providers.