Humana Prior Authorization Process
Overview
Humana is a national health insurer offering commercial, Medicare Advantage, and Medicaid plans. Claim filing deadline is 90 days from date of service. Appeal timelines differ by plan: commercial plans allow 180 days, Medicare Advantage allows 65 days. Most non-emergency services require prior authorization through the provider portal at provider.humana.com. Common denial codes include CO-50 (payment denied at discretion), CO-16 (late filing), CO-197 (missing authorization), and PR-1 (patient responsibility). Emergency services bypass prior authorization requirements.
Key Requirements
- 90-Day Claim Filing Deadline: File all claims within 90 days from the date of service. Claims submitted after 90 days are automatically denied.
- Most Non-Emergency Services Require Prior Auth: Specialist referrals, imaging (MRI, CT, PET), surgery, behavioral health, and durable medical equipment require pre-approval.
- Emergency Services Do Not Require Prior Auth: ER visits, urgent stabilization, and emergency transport are covered without pre-approval. Submit authorization requests within 24–48 hours of emergency treatment.
- Use the Provider Portal: Submit prior authorization requests through provider.humana.com. Contact Humana's provider line for portal access or technical support.
Timeline & Process
Verify Humana coverage and plan type before service delivery. Submit prior authorization requests 5–10 business days before the scheduled non-emergency service. Routine authorization requests are processed within 3–5 business days. Emergency authorizations are issued within 24–48 hours. File claims within 90 days of service. For denied claims, identify the reason (CO-50, CO-16, CO-197, PR-1) and file appeals within the plan-specific deadline: 180 days for commercial, 65 days for Medicare Advantage.
Common Denials
| Code | Reason |
|---|---|
| CO-16 | Claim submitted after 90-day filing deadline. |
| CO-50 | Payment denied at Humana's discretion (usually medical necessity). |
| CO-197 | Prior authorization not obtained before service delivery. |
| PR-1 | Patient responsibility (patient owes coinsurance or deductible). |
Appeal Process
File written appeals within the plan-specific deadline: 180 days for commercial plans, 65 days for Medicare Advantage. Include the original denial letter, claim number, and supporting clinical documentation. For medical necessity denials (CO-50), include physician statements explaining why the service was medically required. Submit appeals through the provider portal or by mail to the address on the denial notice. Humana must respond within 30 days. If you disagree with Humana's appeal decision, further escalation options may be available depending on the plan type.
Common Questions
What services require Humana prior authorization?
Most non-emergency services require prior authorization: specialist referrals, imaging (MRI, CT), surgery, behavioral health, and durable medical equipment. Emergency services do not require pre-approval.
What's the filing deadline for Humana claims?
Humana allows 90 days from the date of service to file claims. Late submissions are typically denied. File early to avoid claim loss.
How long do I have to appeal a Humana denial?
Commercial plans: 180 days. Medicare Advantage: 65 days. File appeals within the applicable deadline to preserve rights.
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This reference is for informational purposes. Payer policies change frequently. Always verify against Humana's current provider documentation. Last updated: 2026-03-16.