Humana Prior Authorization for Procedures: Forms, Attachments, and Timelines
- Jamie P
- Sep 15
- 7 min read
Prior authorization (PA) for medical procedures is where many Humana claims live or die—often before the patient even reaches the operating room, scanner, or therapy bay. A clean, one-and-done submission can move an authorization from “received” to “approved” in days, while a messy packet can be pended multiple times, push you past scheduling windows, and leave patients frustrated. This guide translates Humana’s medical PA expectations into a practical playbook you can use today: which forms to use, what attachments reviewers actually need, and the timelines and follow-ups that keep cases moving.
You’ll also find templates, real-world examples, and simple operational tips for clinics, hospitals, and ambulatory centers that want approvals faster—without do-overs.
Medical vs. Pharmacy Prior Authorization: Know the Difference
Before you pick up a form, confirm whether your request is a medical or pharmacy benefit issue.
Medical PA applies to procedures, imaging, surgeries, DME, therapy services, and facility-rendered drugs billed on medical claims (CPT/HCPCS, UB-04/1500). Medical PAs are typically submitted through Humana’s provider portal workflow (e.g., via Availity) or a Humana PDF form when the portal flow isn’t available for that service line.
Pharmacy PA applies to retail or specialty prescriptions processed at a pharmacy (NDC), often initiated through a pharmacy ePA tool or the PBM’s portal.
This article focuses on medical PAs for procedures. If the order will be billed as a prescription fill (NDC at a pharmacy), you’re in the pharmacy lane—even if the drug is expensive.
What Usually Requires Humana Medical Prior Authorization
Humana publishes evolving lists of services that require PA by product type (Medicare Advantage, Medicaid, commercial). While the specifics change over time, common categories include:
Advanced Imaging: CT, CTA, MRI/MRA, PET, certain nuclear medicine studies
Cardiac Services and Devices: Echocardiography in certain contexts, ablations, pacers/ICDs
Orthopedic and Pain Procedures: Spine injections, stimulators, arthroscopy, certain joint surgeries
Oncology Care: Infusions, radiation therapy episodes, select biomarker testing
Sleep Studies: Facility-based polysomnography for adults
Molecular and Genetic Testing: Panels and non-routine diagnostics
DME/Orthotics/Prosthetics: Higher-cost items, custom devices, and rentals
Therapy Services: Certain PT/OT/ST thresholds or episodes in select plans
Site-of-Care Sensitive Services: Infusions and injections that may be redirected based on safety/cost
Because networks and benefit designs differ, always verify by plan and by CPT/HCPCS before scheduling.
Which Form or Channel to Use
Humana steers most medical PAs through its online authorization workflow (commonly accessed via Availity). The portal asks for structured data (member, provider, codes, place of service) and offers document upload for your clinical rationale. For service lines not supported in the portal, Humana provides downloadable PDF request forms (e.g., “Authorization/Referral Request”) that you can complete and submit with attachments through the indicated channel.
General rules of thumb:
Use the portal when available—it reduces missing fields and gives you a confirmation number to track.
Use the latest Humana form if the portal doesn’t support that request type or if the plan/product requires a PDF for your scenario.
Follow plan-specific instructions for state Medicaid or special programs (these may have unique forms or subcontracted reviewers).
The Clean Submission Blueprint: What Reviewers Expect
A reviewer’s job is to decide—quickly—whether your request meets medical necessity and policy. Make approval easy by standardizing your packet. Whether you’re entering details in the portal or attaching a PDF, your submission should include these six elements, in order:
Member and Coverage Details
Member name, DOB, Humana ID
Plan/product type (Medicare Advantage, Medicaid, commercial)
Referring and rendering provider names, NPIs, TIN, and contact numbers
Place of service (POS) and facility details (NPI, address)
Exact Service Requested
CPT/HCPCS codes and units (e.g., 27447 × 1 for total knee arthroplasty)
Laterality where relevant
Dates of service (or start date for an episode)
Site of care (e.g., outpatient hospital vs. ambulatory surgery center) with rationale if site-of-care is material
Diagnosis and Severity Snapshot
ICD-10 codes aligned to the request
One-paragraph functional severity summary (e.g., “Ambulation limited to <100 feet due to pain despite anti-inflammatories; frequent night pain; ADL limitations; failed conservative therapy.”)
Prior Conservative Treatment and Outcomes
Named interventions with dates/durations (medications, PT, injections, orthotics, activity modification)
Objective outcomes (e.g., WOMAC, Oswestry, AHI, EF% when relevant)
Adverse events or contraindications for alternatives
Imaging, Labs, and Consults
Relevant reports (not just orders): radiology impressions, sleep study summaries, echo reports, pathology, specialist notes
Any required baseline labs or screenings tied to the service
Medical Necessity Rationale and Monitoring
Point-by-point tie-back to common policy criteria (not a literature dump)
Risk management plan (peri-procedural, anesthesia considerations, discharge plan)
Follow-up and outcome tracking (what will you measure and when)
Formatting tip: Use bolded micro-headings (Diagnosis, Conservative Treatment, Imaging/Labs, Rationale, Risk/Follow-Up) in a one-page summary and attach reports separately. Reviewers read faster when your story is predictable.
Real-World Examples by Service Line
Advanced Imaging: Chest CT With Contrast
Codes: 71260
Why PA: Cost and appropriateness oversight; rule out duplicative or low-yield imaging
Attachments: Prior chest X-ray/ultrasound results, clinical notes (duration, red flags), relevant labs (if contrast safety is in question)
Rationale: Tie indication to accepted pathways (e.g., concerning symptoms + abnormal CXR), plus prior imaging dates
Facility-Based Sleep Study (PSG) for Adults
Codes: 95810/95811
Why PA: Frequent utilization management; home testing often preferred first
Attachments: Previous HSAT results if done; ESS score or sleep clinic note; comorbidity list (e.g., COPD, CHF, neuromuscular disease) showing why in-lab testing is indicated
Rationale: Safety/accuracy reasons for PSG vs. HSAT
Orthopedic Surgery: Arthroscopic Meniscectomy
Codes: 29881/29882
Why PA: Ensure conservative care attempted and imaging supports pathology
Attachments: MRI report showing tear characteristics; PT dates/outcomes; activity-limiting symptoms; failed injections or meds
Rationale: Persistent functional deficit despite conservative therapy; expected benefits and rehab plan
DME: Custom Knee Orthosis
Codes: L1846 or related
Why PA: Cost, customization, medical necessity
Attachments: Ortho note, measurements, functional impairment, prior off-the-shelf brace failure
Rationale: Objective gait/function improvement expected; skin integrity and safety considerations; fitting/education plan
Related: Decoding Medical Codes: The Beginner’s Guide to Healthcare Procedure Codes (ICD, CPT, HCPCS)
Timelines, Turnarounds, and Follow-Ups
Turnaround times vary by plan type, service, and whether the submission is complete. Electronic submissions through the portal typically move fastest, especially when you:
Submit a fully documented request on day one
Capture the confirmation number and posted turnaround expectation
Set a follow-up for two business days before the posted window closes
Respond to pend requests the same day with exactly what’s asked—no extra noise
For urgent scenarios, follow Humana’s instructions for expedited review when a delay risks health or function. Document the concrete medical reason for urgency (e.g., rapidly progressive neurologic deficit, risk of hospitalization, time-sensitive oncology staging).
The “No-Pend” Checklist Before You Click Submit
Codes and Units: Correct CPT/HCPCS and units; laterality specified
Place of Service: Matches the planned facility; facility NPI included
Names Match: Requesting vs. rendering provider names/NPI/TIN are correct
Dates Align: DOS on request meshes with scheduling window
Imaging/Labs Attached: Actual reports included, not just orders
Conservative Care: Named, dated, and outcomes documented
Rationale: One-page, bullet-friendly summary with policy tie-backs
Contact Info: Direct line for the clinical contact who can answer reviewer questions
How to Handle Pended and Denied Requests
If pended:
Read the pend reason word-for-word in the portal/letter.
Upload the specific missing item(s) (e.g., MRI report dated xx/xx/2025; PT log), and include a two-line note that names the items.
Keep your case number and time-stamp the upload.
If denied:
Identify whether the issue is policy criteria (e.g., conservative care not met) or documentation (missing/contradictory).
For clinical nuance, request a peer-to-peer so the physician reviewer hears the context that isn’t obvious from checkboxes (safety risks, atypical presentation).
For policy disputes, submit an internal appeal with a tight cover letter that quotes the cited criteria and answers them point-by-point, attaching the missing evidence.
Step-By-Step: Submitting a Humana Medical PA in the Portal
Eligibility and Benefits: Confirm active coverage and product type; note any site-of-care or program rules.
Search Requirement: Enter the CPT/HCPCS to confirm whether a PA is needed for this plan.
Enter Request: Member demographics auto-populate; complete provider fields, POS, codes/units, and DOS.
Upload Attachments: One-page summary + labeled reports (imaging, labs, consults, therapy notes).
Submit and Capture ID: Save the confirmation number and posted turnaround time.
Track and Follow Up: Set calendar nudges; respond to pends the same day.
Escalate When Needed: Peer-to-peer or internal appeal if denied.
Template: One-Page Medical Necessity Summary
Patient / Plan: [Name, DOB, Humana ID, product type]
Service: [CPT/HCPCS, units, POS/facility NPI, planned DOS]
Diagnosis & Severity: [ICD-10 codes] – Brief function-forward snapshot (ADL limits, pain scores, risk)
Conservative Treatment: [Named interventions with dates/durations and outcomes; adverse events/contraindications]
Imaging/Labs/Consults: [Report names and dates with key findings]
Medical Necessity Rationale: [Tie to policy: e.g., failure of conservative therapy, imaging-confirmed pathology, risk mitigation]
Risk & Monitoring: [Peri-procedural plan, anesthesia considerations, discharge safety, objective follow-up measures]
Avoid These Common Pitfalls
Dose or Code Mismatch: For procedures with drug components (e.g., infused agents), make sure CPT/HCPCS, units, and the narrative align across request, orders, and attachments.
Missing Reports: Submitting imaging orders instead of reports is a fast path to a pend.
Vague Conservative Care: “Failed PT” isn’t enough—list dates, sessions, and outcomes.
Wrong Channel: Some services are reviewed outside the core portal flow; follow the plan’s specified channel for that category.
Site-of-Care Blind Spots: If the request depends on an outpatient hospital vs. ASC, document why the selected site is clinically appropriate (airway risk, comorbidities, equipment).
Unreachable Contacts: Provide a direct clinical callback; missed reviewer calls can add days.
Build a Small “PA Pod” To Scale Approvals
You don’t need a big team; you need clear ownership and checklists.
Intake & Routing Lead: Confirms benefit, product, and whether PA is required; selects the correct channel and verifies POS and facility details.
Clinical Packager: Writes the one-page summary, assembles imaging/labs/therapy notes, and checks for contradictions.
Tracker & Escalations: Logs confirmation IDs, monitors deadlines, triggers follow-ups, and schedules peer-to-peers or appeals.
Hold a 15-minute weekly huddle to review “Pending > 3 Business Days,” then fix the top three causes together.
Frequently Asked Questions
Do all Humana plans use the same PA rules?
No. Requirements vary by product (Medicare Advantage, Medicaid, commercial) and by state. Always verify for the specific plan and specific code before scheduling.
Do approvals expire?
Yes. Most approvals cover a defined window or number of units. If you reschedule past that window or need more units, submit a revision or extension per Humana’s instructions.
What if I have to change the site of care?
You may need to update the authorization with the new facility’s details and NPI—do not assume it transfers automatically.
When should I request expedited review?
When delay risks serious harm or loss of function. State the concrete clinical reason and reference supporting notes or data.
Is a peer-to-peer always available?
Often, yes—especially for medical necessity disputes. Use it when clinical nuance (safety, atypical presentation, prior adverse events) matters more than checkboxes.
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