Re: Streamlined Referral Process for Humana Gold Plus^®

Dear Physician:

We are pleased to announce that our new Medicare Advantage HMO, Humana Gold Plus, has a referral process designed to minimize physicians’ administrative burden. The enclosed list of commonly used Current Procedural Terminology (CPT) and Healthcare Common Procedure Coding System (HCPCS) codes (including all pertinent evaluation and management codes) includes codes that do not require referrals; however, for laboratory and radiology services, it was more expedient to include the codes that do require a referral. We collaborated with network physicians to develop the enclosed list.

We modified our classic HMO design to simplify the administrative process for both primary care physicians (PCPs) and specialty care physicians (SCPs). Humana Gold Plus members will still need to select a PCP. As part of our process, the PCP will continue to serve in a gatekeeper care-coordination capacity. Members will continue to be advised that their PCPs are responsible for their care and will refer them for specialty care as needed. PCPs will continue to evaluate and treat their Humana-insured patients for all conditions within the scope of their practice, initiate referrals when needed and communicate with the specialist regarding the nature of the consultation.

Going forward, contracted specialists are not required to have a Humana referral authorization to see an eligible Humana Gold Plus HMO-insured patient in their office for any covered service that is billed with one of the codes detailed on the enclosed list. Claims for these services will adjudicate without a referral authorization letter. If the service is on the list, the specialist no longer has to verify with Humana that the referral has been given. Services that are not on the enclosed list, including most nonoffice based services, will still require authorization.

Additionally, once a given specialist has seen a member for a particular condition, this specialist may request authorization for any related service or further refer the patient without going back through the PCP. For example, once a PCP refers a member to a neurosurgeon for back pain, the neurosurgeon may request authorization for a hospital admission, refer a patient to another inpatient neurologist, etc.

These lists are not intended to be static documents; please let us know if you have suggestions regarding additions or deletions to the list. We will review such requests on an ongoing basis. Feel free to contact us at 972-983-0100, extension 1810, or via e-mail at wscott@humana.com or rfreeman@humana.com.

Thank you for your continued care of our members.