Definition: prior authorization vs notification

Defines 'prior authorization' as a process requiring the physician or other healthcare provider to obtain advance approval from the plan as to whether an item or service will be covered. 'Notification' is the process by which the provider notifies Humana of the intent to provide a service; Humana requests notification to help coordinate care but does not issue an approval or denial for notifications.

How to request prior authorization

Prior authorization requests may be initiated online at www.availity.com (registration required) or by calling Humana's IVR at 800-523-0023. For certain PAL services via Availity Essentials, providers may complete a questionnaire that can yield real-time approval or help expedite review if approval is not immediate.

Use delegated/third‑party prior authorization managers

Certain service categories are managed by delegated or third‑party vendors—Evolent (formerly New Century Health) and Cohere Health—and providers must submit authorization requests to the named vendor using their portal, phone, or fax per the instructions in the list.

• Evolent submission methods: Evolent website; phone 844-926-4528 (option 5) ; eFax 213-596-3783 or efax-carepro-oncology@newcenturyhealth.com.
• Cohere submission methods: Cohere portal; phone 833-283-0033; fax 857-557-6787; expedited/urgent cases supported on Cohere portal.

Timeliness: CMS 7‑day decision requirement

Effective Jan. 1, 2026, CMS requires prior authorization decisions within 7 days for certain medical items/services; submit supporting clinical information with the request to facilitate timely adjudication and avoid delayed or adverse decisions.

Urgent services and consequences for missing PA/notification

Urgent and emergent services do not require prior authorization. Failure to obtain required prior authorization or notification may result in financial penalties for the practice, reduced patient benefits, or retrospective medical necessity review.

EPS / 3D mapping — submit to Cohere Health

Electrophysiology Study (EPS) and EPS with 3D mapping are managed by Cohere Health; submit authorization requests via the Cohere portal, phone 833-283-0033 (Mon–Fri 8 a.m.–8 p.m. ET), or fax 857-557-6787. Expedited/urgent cases can be submitted and monitored on the Cohere portal.

• Sample CPT/HCPCS codes listed for EPS/3D mapping are included in the PAL (e.g., 0577T, 93600, 93602, 93603, 93610, 93612).

Diagnostic and cardiac imaging — Cohere Health routing

Many diagnostic and cardiac imaging services (including peripheral angiography, PET, PSMA PET, SPECT and specified echocardiography codes) are managed by Cohere Health; submit authorization requests to Cohere via its portal, phone 833-283-0033, or fax 857-557-6787. Specific CT/MRI cardiac codes require notification as indicated.

• Examples of managed imaging codes: 36245, 78429–78433, 78459, 78491–78492, 78811–78816, 93312–93318, 93355.
• CT/MRI cardiac codes listed in the PAL may be notification‑only per the list.

Laparoscopic hiatal hernia repair — submit to Cohere

Laparoscopic hiatal hernia repair prior authorization requests are managed by Cohere Health; submit requests via Cohere's portal or phone per the instructions in the PAL.

• Codes listed for this group include 43280, 43281, 43282.

Lung biopsy and resection — submit to Evolent

Lung biopsy and resection prior authorization requests are managed by Evolent (formerly New Century Health); submit via Evolent's website, phone 844-926-4528 (option 5), or eFax 213-596-3783 / efax-carepro-oncology@newcenturyhealth.com as provided in the PAL.

• Example procedure codes listed: 32096, 32097, 32505, 32607, 32608, 32666.

Home health / home infusion — managed by One Home Care

Home health and home infusion services are managed by One Home Care; providers must submit prior authorization requests for the listed home health/home infusion codes to One Home Care per the PAL.

• Sample codes managed include 99512, 99600, G0151–G0162, G0299–G0300, G0493–G0496, and multiple T and S codes.

Inpatient admissions require prior authorization

All inpatient admissions (acute hospital, acute rehab, long‑term acute care, mental health and substance use treatment, skilled nursing facilities) require prior authorization; submit requests per the PAL prior to admission.

• The PAL lists 'All' codes for inpatient admissions—authorization is required regardless of specific procedure codes.

EGD — submit authorizations to Cohere Health

Esophagogastroduodenoscopy (EGD) services are managed by Cohere Health; submit authorization requests via the Cohere portal, phone 833-283-0033, or fax as listed. Expedited cases are supported and can be monitored on the Cohere portal.

• EGD procedure codes referenced include 43235, 43237, 43238, 43239, 43242, 43252, 43253, 43259.

Orthopedic arthroplasty — submit to Cohere Health

Orthopedic hip, knee and shoulder arthroplasty prior authorization is managed by Cohere Health; submit requests via Cohere's portal, phone 833-283-0033 (Mon–Fri 8 a.m.–8 p.m. ET), or fax 857-557-6787; expedited/urgent cases are supported on the Cohere portal.

• Examples of arthroplasty codes listed: 23472–23474, 27125–27138, 27437–27447, 27486–27487.

Orthopedic arthroscopy — submit to Cohere Health

Orthopedic arthroscopy services are managed by Cohere Health; submit authorization requests via the Cohere portal, phone 833-283-0033 (Mon–Fri 8 a.m.–8 p.m. ET), or fax 857-557-6787. Expedited/urgent cases can be submitted and monitored on the Cohere portal.

• Sample arthroscopy codes include 29805–29827, 29850–29889, 29914–29916, 29999.

Pain pumps and select spine procedures — Cohere Health routing

Pain infusion pumps and select spine procedures (including percutaneous lumbar intravertebral disc injection) are managed by Cohere Health; submit authorization requests using Cohere's portal, phone 833-283-0033, or fax 857-557-6787. Expedited/urgent cases can be handled on the portal.

• Pain pump codes listed: 62324–62327, 62350–62362, 64999, and several C and E device codes.
• Percutaneous lumbar disc injection codes include 0627T–0630T.

Peripheral revascularization and prostate surgeries — vendor routing

Peripheral revascularization procedures are managed by Cohere Health and prostate surgeries (prostatectomy) are managed by Evolent; submit prior authorization requests to the appropriate vendor per the PAL using the vendor's portal, phone or fax.

• Peripheral revascularization example codes: 0234T–0238T, 0505T, 37236–37299 and related C‑codes.
• Prostate surgery example codes: 55801, 55810, 55812, 55815, 55821, 55831, 55840, 55842, 55845, 55866–55880.

Radiation therapy — prior authorization via Evolent

Radiation therapy requires prior authorization in all states; Evolent (formerly New Century Health) manages radiation therapy authorization requests. Submit via Evolent's website, phone 844-926-4528 (option 5), or eFax 213-596-3783 / efax-carepro-oncology@newcenturyhealth.com as listed.

• Radiation therapy CPT/HCPCS codes are enumerated in the PAL (examples include 77280, 77290, 77301, 77338, 77371–77373).

Observation — notification required

Observation status requires notification to Humana rather than prior authorization; providers must submit the notification as indicated in the PAL.

• Observation is listed as 'Notification required' and the PAL indicates 'All' codes for observation notification.

Spinal cord stimulators — submit to Cohere Health

Spinal cord stimulator services are managed by Cohere Health; submit prior authorization requests via Cohere's portal, phone 833-283-0033 (Mon–Fri 8 a.m.–8 p.m. ET), or fax 857-557-6787. Expedited/urgent cases can be submitted and monitored on the Cohere portal.

• Spinal cord stimulator codes listed include 63650, 63655, 63663, 63664, 63685, 63688, 64999, 0784T, 0785T, and device codes C1816/C1820/C1822.

Spine surgery — submit to Cohere Health

Spine surgery services (spinal fusion, decompression, kyphoplasty, vertebroplasty) are managed by Cohere Health; submit authorization requests via Cohere's portal, phone 833-283-0033, or fax 857-557-6787. Expedited/urgent cases can be handled on the Cohere portal.

• Examples of listed spine procedure codes include 20999, 22510, 22800–22812, 22830, 27278, 62330, and many others enumerated in the PAL.

Therapy (physical & occupational) — submit to Cohere Health

Physical and occupational therapy services are managed by Cohere Health; submit prior authorization requests via Cohere's portal, phone 833-283-0033, or fax 857-557-6787. Expedited/urgent cases can be submitted and monitored on the Cohere portal.

• Therapy service codes listed include 97010, 97112, 97530 and G0281 among others.

Transplant evaluation — notification required

Transplant evaluation requires notification, not prior authorization; submit the required notification for transplant evaluation per the PAL (notification code 99199).

Ventricular assist devices — prior authorization required

Ventricular assist devices (VADs) require prior authorization; select percutaneous VAD services are managed by Cohere Health—submit requests via Cohere's portal, phone 833-283-0033, or fax 857-557-6787 as indicated.

• VAD example codes include 33990, 33991, 33995, and additional implant codes listed in the PAL.