Humana processes standard prior authorization requests within 14 calendar days. Urgent requests receive decisions within 72 hours per CMS requirements. Medicare Advantage members follow CMS timelines: 7 days standard, 72 hours expedited.
Day 1: Submit via Humana portal or Availity with clinical documentation. Days 2-3: Completeness review. Days 4-14: Clinical determination (commercial). Days 4-7: Clinical determination (Medicare Advantage). If additional info requested: clock pauses until received. Approval: auth number valid 60-90 days. Denial: written notice with appeal rights.
| CARC Code | Reason | Primary Cause | Fix |
|---|---|---|---|
| CO-197 | Precertification absent | No auth on file | Submit PA 10+ days before service |
| CO-11 | Medical necessity denied | Clinical documentation insufficient | Include detailed notes with PA request |
| CO-50 | Not covered per policy | Service excluded | Verify plan coverage before PA |
Appeal PA denials within 180 days. For Medicare Advantage: request a reconsideration within 60 days. Peer-to-peer reviews available within 5 business days of denial. Formal appeals: 30-day response for commercial, 30 days for MA standard, 72 hours for MA expedited.
CMS requires Humana to decide standard Medicare Advantage PA requests within 7 calendar days and expedited requests within 72 hours. If Humana fails to respond in time, the request is deemed approved.
Yes, if the standard timeline could seriously jeopardize the patient's health. Request expedited review at the time of submission. If denied expedited status, the request reverts to standard timeline with written notification.
The review clock pauses. Submit the requested documentation as quickly as possible. If you do not respond within 14 days, Humana may deny the request for insufficient information.
Altair tracks authorization timelines across all Humana plan types and alerts you before deadlines.