CurrentHumanaPolicy N/A

Commercial Preauthorization and Notification List

Defines Humana's preauthorization and notification requirements for commercial fully insured plans, what services require prior authorization or notification, and how providers should request them. Applies to providers and facilities delivering care to Humana commercial members.

Policy Summary

PayerHumana

PolicyCommercial Preauthorization and Notification List

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionObtain preauthorization prior to performing services listed on the preauthorization list; notification is requested for some services and does not constitute approval.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

commercial fully insuredPlan applicability

10Procedure code limit

6Diagnosis code limit

888-447-3430Medication fax

866-461-7273Medication phone

Coverage Rules and Scope

inv-01: General coverage rules

Covered with criteria and special situations:

General coverage stance: The preauthorization and notification list applies to Humana commercial fully insured plans (HMO and PPO) and identifies services, items and medications that require preauthorization or notification.

ALL of the following

Preauthorization (also called prior authorization, precertification or preadmission) must be obtained before performing services that are listed as requiring preauthorization on the commercial preauthorization list.
Services or medications provided without preauthorization may be denied payment or subject to reduced member benefits; such services may still be reviewed for medical necessity.

ALL of the following

Policy Summary

PayerHumana

PolicyCommercial Preauthorization and Notification List

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionObtain preauthorization prior to performing services listed on the preauthorization list; notification is requested for some services and does not constitute approval.

SourceLink

On This Page

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Submission and Code Limits

Submission code limitsmixed

procedure codes (up to 10)	Procedure codes to be submitted with preauthorization requests
diagnosis codes (up to 6)	Primary and secondary diagnosis codes to be submitted

Procedure Code Submission Limits

Procedure code limit per requestUp to 10 procedure codes may be submitted with a single preauthorization request

Where statedProcedure codes requirement appears in 'When requesting a preauthorization' guidance

PurposeProcedure codes are used to identify the services for which preauthorization is requested

Diagnosis Code Submission Limits

Diagnosis code limit per requestUp to 6 diagnosis codes (primary and secondary) may be submitted with a single preauthorization request

Where statedDiagnosis code requirement appears in 'When requesting a preauthorization' guidance

PurposeDiagnosis codes provide clinical context for the requested services

Preauthorization, Notification, and Requesting Procedures

Prior Authorization

Preauthorization Required; Emergency Services Exempt

Obtain preauthorization prior to performing services listed on Humana's Commercial Preauthorization and Notification List. Notification (a non-authorization notice) is requested for some services to allow Humana to offer member support programs; notification does not constitute approval or denial. Humana does not require preauthorization or referrals for emergency services. Examples of emergent situations include: the health of the sick or injured person (and/or fetus, if pregnant) would be at serious risk; or services are performed when the health of the person would suffer serious damage to bodily functions, organs or other body parts. It is important that preauthorization is obtained for services on the list. By not obtaining a preauthorization, the healthcare provider could be denied payment or there may be a reduction in benefits for the patient. Services or medications provided without preauthorization may still be reviewed for medical necessity; providers are encouraged to submit a request to verify member benefits.

Emergency services do not require preauthorization.
Failure to obtain required preauthorization may result in denial of payment or reduced member benefits.
Services/medications given without preauthorization may still be reviewed for medical necessity; submit a request to verify benefits.

Documentation Required

Information Required with Preauthorization Requests

When requesting a preauthorization, have the following information available and submit all relevant clinical information at the time of request to expedite review. If additional clinical information is required, Humana will request it. Humana and the member/authorized person will be notified of the determination once the authorization is completed, per state requirements.

Member's ID number, name and date of birth
Date of service or hospital admission
Procedure codes (up to a maximum of 10 per request)
Diagnosis codes (primary and secondary) (up to a maximum of 6 per request)
Service location (inpatient: acute hospital, skilled nursing, hospice; outpatient: telehealth, office, home, off-campus outpatient hospital, on-campus outpatient hospital or ambulatory surgery center)
Referral site (office, off-campus outpatient hospital, on-campus outpatient hospital, ambulatory surgery center, other)
Tax Identification Number (TIN) and National Provider Identifier (NPI) of treatment facility where service is rendered
TIN and NPI of the provider performing the service
Caller/requestor's name and telephone number
Attending physician's telephone number
Relevant clinical information and discharge plans

Note

How to Request Preauthorization

Except where noted via links, preauthorization requests for medical services may be initiated online via Availity (https://www.Availity.com/) — registration required — or by calling Humana's interactive voice response line at 800-523-0023. Online requests are encouraged and may include questionnaires that can produce real-time approvals or expedite review. Preauthorization for medications may be initiated by fax to 888-447-3430 (request forms available at Humana.com/Medpa) or by calling 866-461-7273 (Mon–Fri, 6 a.m.–8 p.m. ET). Notification will be provided if the preauthorization list changes; it may be updated throughout the year for new-to-market medications or services.

Online via https://www.Availity.com/ (registration required)
Humana IVR: 800-523-0023
Medication fax: 888-447-3430 (forms at Humana.com/Medpa)
Medication phone: 866-461-7273 (Mon–Fri, 6 a.m.–8 p.m. ET)

Key Definitions

Preauthorization

DefinitionPreauthorization (also called prior authorization, precertification or preadmission) is the process Humana uses to determine if services are covered by a member's plan and must be followed before services on the preauthorization list are performed.

ScopeApplies to services, items and medications included on the Humana Commercial Preauthorization and Notification List for commercial fully insured plans.

Consequence of omissionIf preauthorization is not obtained for listed services, the provider could be denied payment or there may be a reduction in member benefits; services provided without preauthorization may still be reviewed for medical necessity.

Emergency servicesHumana does not require preauthorization or referrals for emergency services (examples of emergent situations are provided).

Notification

DefinitionNotification is a process Humana requests for some services to allow placement of members in support programs; it is not an approval or denial.

PurposeUsed to best serve members by enabling enrollment in programs that provide support for their condition.

Distinction from preauthorizationNotification does not replace preauthorization and does not grant approval or denial of services.