Illinois Humana Gold Plus Integrated Medicare‑Medicaid Plan Prior Authorization and Notification List
Governs prior authorization and notification requirements for services and provider‑administered medications for Humana Gold Plus Integrated Medicare‑Medicaid Plan members in Illinois; affects participating providers, IPAs, and facilities that deliver covered services.
No material clinical or coverage changes in this revision.
Prior Authorization and Notification Coverage Criteria
Coverage criteria and submission requirements
Covered when ALL of the following are met:
ALL of the following
- Service or provider‑administered medication is listed on the Prior Authorization and Notification List (PAL) and requires prior authorization prior to provision or administration.
- Service is provided in accordance with Medicare coverage guidelines established by CMS and is medically necessary; investigational or experimental procedures are generally not covered.
- For procedures or services that are investigational, experimental, or may have limited benefit coverage, an Advanced Coverage Determination (ACD) may be requested prior to providing the service.
Submission requirements
- Authorization requests or notifications include required information such as member Humana ID, member name and date of birth, date of service or hospital admission, and relevant clinical information.
- Procedure codes: up to 10 procedure codes may be submitted per authorization request.
- Diagnosis codes: up to 6 diagnosis codes (primary and secondary) may be submitted per authorization request.
- Service and location details: service location (inpatient/outpatient), referral source, discharge plans, and proposed procedure date when applicable.
- Provider identifiers and contacts: TIN and NPI of the treatment facility and performing provider, caller/requestor name and telephone number, and attending physician telephone number.
Submission channels
- Medical services prior authorization requests: online via Availity (www.availity.com) or by calling Humana IVR at 800-523-0023.
- Medications on the PAL: submit by fax to 888-447-3430 or by calling 866-461-7273 (Monday–Friday, 8 a.m.–11 p.m. ET).
Authorization Request Coding Limits
| procedure codes (up to 10) | Procedure codes (up to 10 maximum per authorization request) |
| diagnosis codes (up to 6) | Diagnosis codes (primary and secondary), up to 6 maximum per authorization request |
Provider Submission Requirements and Actions
Prior authorization and notification definitions
Prior Authorization Required vs Notification: Prior authorization (also called preauthorization, precertification, preadmission) is advance approval from Humana that a specific item or service will be covered and must be obtained prior to providing or administering services or provider‑administered medications listed on the prior authorization list. Notification is a provider communication to Humana of intent to provide a service; Humana does not approve or deny notifications. Services must meet Medicare/CMS medical necessity and coverage guidelines.
Submission channels and contact
How to request prior authorization: - Medical services managed by Humana: online at www.availity.com (registration required) or via Humana IVR at 800-523-0023. - Medications on the list: fax to 888-447-3430 (request forms at Humana.com/MedPA) or call 866-461-7273, Monday–Friday, 8 a.m.–11 p.m. ET. - Carelon Behavioral Health prior authorizations: online at www.carelonbehavioralhealth.com (registration required); IVR 855-371-9234; direct 855-235-8530 (TTY 855-539-5884); fax 855-371-9232. Online submissions via Availity Essentials may include questionnaires that can produce real‑time approvals or expedite review if not immediately approved.
Urgent services and consequences of no prior auth
Urgent/emergent services do not require prior authorization or referrals. However, failure to obtain required prior authorization for non‑urgent services may lead to financial penalties for the practice, reduced benefits for the patient, and subject services or medications to retrospective medical‑necessity review. Providers are encouraged to verify benefits and prior authorization requirements with Humana prior to providing services. For services that are investigational, experimental, or have limited coverage, providers may request an Advanced Coverage Determination (ACD) to determine payment/coverage before providing the service.
Advanced Coverage Determination (ACD)
Advanced Coverage Determination (ACD): Providers may request an ACD when coverage or payment is uncertain (for investigational/experimental services or to confirm if Humana will pay). ACDs for medical services may be submitted by mail to Humana Correspondence, P.O. Box 14601, Lexington, KY 40512-4601; by fax to 800-266-3022; or by telephone at 800-523-0023. ACDs for medications may be requested by fax to 888-447-3430 or by telephone at 866-461-7273. You may be contacted if additional information is needed.
Key Definitions
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