Humana Authorization/Referral Request Form (Fax)

Humana's standard fax form lets a provider's office request a prior authorization or referral, now chiefly for Medicare Advantage members since Humana left commercial medical insurance in 2025. It covers inpatient admissions and outpatient services from surgery and diagnostic testing to home health and DME. Humana records its decision in a stamp box reserved for its use, and the approval applies only to the services listed on the request.

Who completes it

The requesting provider's office completes every field, including the treating physician and facility details, the service request and the diagnosis and procedure codes, then signs and dates it. The patient has no section, and the stamp box at the bottom is for Humana's use only.

How to fill it in

Fax and phone routing (top of form)

Before filling in the form, pick the route. Services scheduled in advance go to the general fax line, and behavioral health services go to a separate fax line. Same-day appointments and urgent requests are phoned in, not faxed. Availity accepts new referrals and authorizations online 24/7. The header also gives a Medicare benefit verification line and asks for an area code with every phone and fax number.

Contact person, Requesting provider, Phone number, Fax number, NPI or Tax ID

In the box at the top right, enter the contact person, the requesting provider, a phone number and fax number with area codes, and the requesting provider's NPI or Tax ID. This block identifies who is asking for the service and where questions should go, so name a contact who can answer clinical questions or send more records.

Patient Details

Enter the Humana ID number, the patient's first and last name, date of birth and ZIP code. The block asks for no street address or phone, so the Humana ID and date of birth identify the member. Verify benefits first; the form notes that payment responsibility depends on membership eligibility and benefit limitations.

Provider Details

Two columns cover the treating physician and the facility. For each, give the name, NPI or Tax ID, phone number and fax number. The treating physician is the clinician who will provide the service and may differ from the requesting provider at the top of the form. Complete the facility column for admissions, observation, surgery and other facility-based services.

Service Request: Update or New Request, and Inpatient

Mark New Request or Update, and give the case number if one exists. For an inpatient stay, enter the admission date and the admission type (ER, Non-ER, SNF, Rehab, LTAC or Other) and the bed type. Add the discharge date and where the patient was discharged to once known; an Update with the case number carries that information to the existing request.

Service Request: Outpatient

Choose the outpatient service type: evaluate and treat, observation, home health or hospice, DME rental, DME purchase, diagnostic testing, surgery or other. Enter the first and last service dates and the period the authorization should be valid for, either 30, 60 or 90 days or 1 year. The approval covers only the services listed; the form says anything else needs an additional authorization.

ICD-10 Code, Diagnosis Description, CPT/HCPC Codes, Number of Visits/Units, Description of Codes

Enter the ICD-10 code and the diagnosis description, then the CPT or HCPCS codes, the number of visits or units, and a plain-language description of the codes. Check the codes against Humana's prior authorization search tool, which shows requirements by state and plan, and keep them consistent with what will be billed, since services outside the request need a separate authorization.

Supporting documentation, Signature and Stamp

Attach supporting documentation if needed, such as medical records, progress notes, lab reports and radiology studies; the form points to CMS.gov guidance and Humana's Prior Authorization List for further information. Sign and date the form. Leave the stamp box at the bottom empty, since it is marked for Humana use only.

Common mistakes

Leaving fields blank, when the form asks offices to complete all fields.
Writing phone or fax numbers without an area code, which the form specifically asks every requester to include.
Faxing a same-day or urgent request, when the form says to call those in to Humana instead.
Sending a behavioral health request to the general fax line instead of the separate behavioral health fax printed on the form.
Assuming an approval covers services added later, when the form says any other services require an additional authorization.
Omitting supporting records such as progress notes, lab reports or radiology studies when the service's criteria call for them.

Submitting and payment

How to submit it: Fax services scheduled in advance to the general line on the form and behavioral health services to the separate behavioral health fax; call the number on the form for same-day appointments or urgent requests. Humana also takes new referrals and authorizations online through Availity, available 24/7.
Who pays: The form states it does not guarantee payment by Humana; payment depends on membership eligibility, benefit limitations, and subrogation and coordination-of-benefits rules.

Good to know

Humana's prior authorization search tool, which filters by state and plan, and its lists for Medicare, Medicaid and provider-administered drugs show whether a service needs authorization before you fax.
The form asks offices to complete all fields and to include an area code with every telephone and fax number, including those for the requesting provider, physician and facility.
Outpatient requests state a first and last service date and the validity period wanted: 30, 60 or 90 days, or 1 year.
Drug prior authorizations use a separate, state-specific Humana Clinical Pharmacy Review Prior Authorization Request Form rather than this authorization and referral form.

Get the official form

Download the current version from the source each time; forms change without notice.

Authorization/Referral Request Form

Official page PDF

How this list is checked

A form is listed only after its name and number were confirmed on the issuing agency’s or insurer’s own website, or in the form itself. Each entry links to that source. The list was last checked in October 2026. Forms and their requirements change without notice, so check the official page for the current version before you complete one.

Sources for this guide

Vero is not affiliated with, or endorsed by, the agencies and insurers listed here. Read our editorial policy.

Frequently asked questions

Where do I fax a Humana prior authorization request?

The form lists one fax line for services scheduled in advance and a separate line for behavioral health services, and tells offices to call rather than fax for same-day appointments or urgent requests. Availity is the preferred alternative, where new referrals and authorizations can be created online at any hour.

Does the Humana authorization form apply to commercial plans?

Humana exited commercial medical insurance in 2025, so the form is now used mainly for Medicare Advantage members. Its benefit verification line is for Medicare, and its footer points providers to CMS.gov guidance and Humana's Prior Authorization List. Humana also publishes separate prior authorization lists for its Medicaid plans.

How do I update an existing Humana authorization?

Mark Update instead of New Request at the top of the Service Request block and enter the case number, if you have one. Add the changed details, such as a discharge date and discharge destination for an inpatient stay, or revised codes and units. The form says any other services require an additional authorization.

What documentation should I attach to the Humana fax form?

The form asks for supporting documentation if needed, naming medical records, progress notes, lab reports and radiology studies, and points to CMS.gov guidance and Humana's Prior Authorization List. Humana's prior authorization categories include advanced imaging, cardiac interventions, molecular and genetic testing, orthopedic surgery and pain management, and transplant services.