Humana health insurer rules on preauthorization for genetic testing Humana website
12.18.15
Molecular Diagnostic and
Genetic Testing (MD/GT)
Preauthorization of MD/GT is required for commercial, Medicaid and Medicare Advantage (MA)
health maintenance organization (HMO) and preferred provider organization (PPO) members. In
Puerto Rico, preauthorization is required for all MI Salud (i.e., Medicaid) and commercial products.
Preauthorization is not required for:

MA private fee-for-service (PFFS) plans

Risk groups

CarePlus members

HumanaOne members

MA members in HMO groups in Florida, Illinois, Nevada, Arizona and California
Humana's Genetic Guidance Program
The Genetic Guidance Program is a utilization management initiative designed to share information
with physicians and members about the use and appropriateness of MD/GT. Board-certified genetic
counselors are available to discuss genetic testing services, and preauthorizations. To initiate a
request, you may call 1-800-523-0023. Representatives are available from 8 a.m. to 8 p.m. Eastern
time, Monday through Friday.
Submitting Preauthorization Requests
Physicians and local labs (Puerto Rico only) have several options when submitting their
preauthorization requests:
Submit requests online
Physicians may log into Humana's secure provider portal at Humana.com/providers to initiate a
preauthorization request.
Providers who are registered with Availity, may initiate preauthorization requests through Availity and
the requests will be directed to our genetic counselors.
Submit requests by phone
Physicians may initiate preauthorization request by calling Humana's Interactive Voice Response
system (IVR) at 1-800-523-0023. If needed, representatives are available from 8 a.m. to 8 p.m.
Eastern time, Monday through Friday. A board-certified genetic counselor may ask the physician
questions about the patient's condition and past medical/family history. Genetic counselors can also
answer questions related to the test(s) the physician is ordering and applicable Humana clinical
policies. Requestor will receive notification of the outcome of the request.
Submit requests by fax
Physicians/local labs may also request preauthorization via fax. To do so, download the
preauthorization request form below, fill it out in its entirety and fax it to us at 1-855-227-0677. A
board-certified genetic counselor will review the request and contact the physician/local lab if
additional information is required. Approvals of requests are returned via phone or fax; nonapprovals are sent via mail.
United States Request Form
(265 KB) Download PDFEnglish
Puerto Rico Request Form
(556 KB) Download PDFEnglish
Texas authorization request form
Physicians and other clinicians in Texas may use this form to submit authorization requests for their
Humana-covered patients. Instructions are available here. Once complete, please fax it to Humana
at 1-800-266-3022. Include supporting clinical documentation (e.g., medical records, progress notes,
lab reports, radiology studies, etc.) with your fax form.
Indiana authorization request form
Physicians and other clinicians in Indiana may use this form to submit authorization requests for their
Humana-covered patients. Instructions are included on the form. Once complete, please fax it to
Humana at 1-800-266-3022. Include supporting clinical documentation (e.g., medical records,
progress notes, lab reports, radiology studies, etc.) with your fax form.
Information Needed When Requesting
Preauthorization
The physician should have relevant clinical information available in the patient's chart when
requesting preauthorization, including:

Member name and Humana member ID number

Ordering physician name and provider ID or tax ID number

Telephone and fax numbers of the ordering physician

Name, telephone number and fax number of lab/facility performing the test

Patient diagnosis or clinical indication (ICD code)

Test being ordered (CPT code or test name)

Indication/reason for test

Signs, symptoms and duration

Prior related diagnostic and/or genetic tests and their results

Laboratory studies and results

Family medical/genetic history

Medications and duration (if related)

Prior treatments or other clinical findings (when relevant)

How the test results will be utilized in the member's care

Local laboratory name, provider ID or tax ID (i.e., Puerto Rico lab or facility that will collect the
sample— Puerto Rico only)
Exclusions to Preauthorization
While most genetic tests and molecular diagnostics require prior authorization, the following
categories are excluded:

Routine prenatal screening — Non-invasive prenatal testing does require preauthorization

Routine inpatient newborn screenings

Human leukocyte antigen (HLA) testing for transplant

Chromosomal analysis for leukemia and lymphoma

Infectious disease testing considered to be the standard of care
For all other tests, the health care provider should contact Humana to request preauthorization.
Additional Resources