Prior authorization (PA) is the process through which the PCP or other healthcare provider obtains approval from the plan as to whether an item, drug or service is covered, and is an important component to managed care.
Requests for PA should be made as soon as possible but at least 14 days in advance of the service date. If PA is required and not obtained, it may result in a reduction or denial of payment. Services provided without PA also may be subject to retrospective review. When retrospective reviews are performed, clinical information should be included to perform a medical necessity review. A summary of why PA was not obtained should also be included in the review.
Our PA list can be found at
Humana Healthy Horizons does not require referrals from primary care physicians (PCPs) to see participating specialists; however, prior authorization must be obtained to see nonparticipating providers. Members may self-refer to any participating provider.
If a member requires medically necessary services from a nonparticipating provider, the provider may call the Provider Services Contact Center to obtain prior authorization at 855-223-9868 (TTY: 711), Monday through Friday, 8 a.m. to 5 p.m. Central time to obtain prior authorization.
The utilization management (UM) department performs all UM activities including prior authorization, concurrent review, discharge planning and other related UM activities for medical and behavioral health.