Humana Provider Guide
Complete credentialing, billing, and authorization guide for Humana Medicare Advantage and commercial plans
Avg. Credentialing
90-120 Days
Timely Filing
365 Days
Appeal Window
365 Days
Portal
Availity
Humana Overview
Humana is one of the largest Medicare Advantage insurers in the United States. While they also offer commercial insurance, the majority of Humana members are Medicare beneficiaries. Understanding Humana's Medicare Advantage policies is critical for most providers.
Medicare Advantage
Primary product line
Commercial Plans
Group and individual coverage
Medicaid
Select state markets
Credentialing & Enrollment
Humana Credentialing Process
Application Steps
- Complete and maintain current CAQH profile
- Submit credentialing application via Humana provider portal
- Provide required documentation (licenses, insurance, certifications)
- Complete Medicare enrollment (CMS-855) if billing Medicare Advantage
- Await credentialing committee approval (90-120 days)
Important Notes
- • Medicare Advantage providers must be enrolled in Medicare
- • CAQH must be updated within 120 days
- • Malpractice requirements: $1M/$3M minimum
- • Some specialties may require board certification
Prior Authorization
Services Requiring Prior Auth
- • Inpatient admissions
- • Advanced imaging (MRI, CT, PET)
- • Outpatient surgery
- • DME and prosthetics
- • Home health services
- • Skilled nursing facility
- • Specialty medications (Part B drugs)
How to Submit
Online Portal
Availity or Humana portal
Phone
1-800-555-6669
Fax
1-800-522-8879
Turnaround Time
Standard: 3-5 business days
Medicare Advantage Specifics
Key Differences from Traditional Medicare
Authorization Requirements
Unlike traditional Medicare, Humana MA plans require prior authorization for many services that Original Medicare doesn't.
Network Restrictions
Most Humana MA plans are HMO or PPO with network restrictions. Out-of-network services may not be covered.
Star Ratings
Humana focuses heavily on CMS Star Ratings. Quality metrics and patient satisfaction impact plan performance.
Value-Based Care
Many Humana contracts include value-based payment models and quality incentives.
Common Humana Denials
CO-197: Prior authorization requiredVery Common
Why This Happens
Humana MA plans have extensive prior auth requirements
Resolution
Submit retroactive authorization with medical records. Success rates vary by service type.
CO-109: Not covered for this patient
Why This Happens
Service may be covered by Medicare but not included in the patient's specific MA plan benefits
What to Do
Verify patient's specific plan benefits. Appeal if service should be covered. May be patient responsibility.
Important Contacts
Provider Services
General Provider Line
1-800-555-6669
Prior Authorization
1-800-555-6669
Claims Support
1-800-486-2620
Credentialing
1-877-877-4862
Online Resources
Provider Portal
Availity or Humana PortalCoverage Policies
Medical Policies