Humana Denied Your Specialist Referral?
Published data shows denial and appeal outcomes vary by plan, product year, denial reason, and documentation. Use this page to spot the issues to request and the evidence to gather before you decide what to submit.Sources include KFF ACA Marketplace Transparency Data, HHS OIG reports, and state insurance department filings. Aggregate rates are context, not predictions for an individual case.
Based on published government and industry research. Individual results vary based on denial type, insurer, and documentation.
Why they said no
Why Humana Denies Specialist Referral
Primary care can manage the condition
Out-of-network specialist not covered
Referral authorization expired or not obtained
Humana patterns
Humana's Common Denial Patterns
Incorrect CPT/ICD coding as basis for denial
Claiming services duplicate prior treatments
Denying rehabilitation services as "not improving"
What works
How to Strengthen 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
Your rights
Laws That Protect You
ACA network adequacy requirements
State any-willing-provider laws
No Surprises Act for emergency specialist care
Playbook
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
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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.