Humana Denied Your Specialist Referral?
Humana Inc. denies 14.2% of claims on average. But 56% of appeals succeed when patients fight back. Your specialist referral denial may have grounds for a successful appeal.
Why Humana Denies Specialist Referral
Primary care can manage the condition
Out-of-network specialist not covered
Referral authorization expired or not obtained
Humana's Common Denial Tactics
Incorrect CPT/ICD coding as basis for denial
Claiming services duplicate prior treatments
Denying rehabilitation services as "not improving"
How to Win Your Specialist Referral Appeal
PCP letter explaining why specialist care is needed
Documentation of failed primary care treatment
Evidence no in-network specialist is available for the condition
Laws That Protect You
ACA network adequacy requirements
State any-willing-provider laws
No Surprises Act for emergency specialist care
Tips for Appealing to Humana
Verify CPT and ICD-10 codes match the services rendered
Get your provider to document functional improvement goals
For Medicare Advantage, cite CMS guidelines on coverage determination
Ready to Fight Your Specialist Referral Denial?
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This information is for educational and informational purposes only. It does not constitute legal or medical advice. Statistics cited are from publicly available sources including KFF, HHS OIG, and state insurance department data. Individual results may vary. Consult a qualified professional before taking action on your specific situation.