Humana Healthy Horizons in Louisiana Prior Authorization and Notification List (PAL)
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Lists services, procedures, and medications that commonly require prior authorization or notification for Humana Healthy Horizons members in Louisiana; applies to providers and facilities delivering covered services under this Medicaid product.
No material clinical or coverage changes in this revision.
Prior authorization and notification — coverage overview
PAL coverage categories and operational notes
Selected service categories and example codes included in this PAL (partial list from this document segment):
ALL of the following
ALL of the following
ALL of the following
- Code: E0466
ALL of the following
- Various L- and E-series codes listed in PAL (examples include L0457, L0464, L0482, L0484, L0486, L0639, L0700, L0810, L0999, L1000, L1310, L1499, L1680, L1690, L1700, L1710, L1720, L1730, L1755, L1844, L2005, L2036-L2038, L2128, L2136, L2525, L2627-L2628, L2999, L3740, L3900-L3904, L4000, L4210, L4398)
ALL of the following
ALL of the following
- Codes: 15820-15823, 67900-67917, 67921-67924, 67950
ALL of the following
- Numerous CPT codes listed in PAL (examples include 11922, 11960, 14000-14001, 15769, 15771, 15772, 19301, 19303, 19328, 19330, 53410-53450 series, 54125, 54400-54417 series, 54520, 54660, 54690, 55175-55180, 55899, 56625, 56800-56810 series, 57106-57111, 57291-57296, 57426, 58150, 58180, 58260-58292 series)
ALL of the following
ALL of the following
- Codes: 78608-78609, 78811-78816
ALL of the following
ALL of the following
ALL of the following
- Cardiac implantable devices (example code listed) : 33274
ALL of the following
ALL of the following
- Urgent/emergent services do not require referrals, prior authorization or notification.
- Notification is requested to help coordinate care but does not represent an approval or denial.
PAL criteria excerpt
Services and procedures listed below require prior authorization or notification as indicated in the PAL.
ALL of the following
ALL of the following
- Examples include CPT/HCPCS and procedure codes: 58294, 58541-58554, 58570-58573, 58661, 58720, 58940, 58999, 64856, 64892, 64896, C1789, C1813, C2622, L8600, L8699, S0189, 61885, 64568, 43644-43775 series, 43843-43888 series, 21208-21209, 30400-30468 series, 32850-32854, 33927-33929, 33935, 33945, 38205-38243, 44135, 47133-47135, 48160, 48550, 48554, 48556, 50300-50370 series, 50547, 81370-81383, 0584T-0586T, 0664T-0670T, G0341-G0343, L8698, S2053-S2142 series, 02WA3QZ, 02WA4QZ, 36465-36483 series, 37700, 37765, 33975-33983
ALL of the following
- Humana Healthy Horizons expects notification for obstetrical admissions that exceed 48 hours for vaginal deliveries and 96 hours for cesarean sections to conduct concurrent review for care coordination and discharge planning.
ALL of the following
- For crisis intervention, behavioral health crisis care and mobile crisis, Humana Healthy Horizons expects notification within 48 to 72 hours to conduct concurrent review and care coordination activities.
ALL of the following
- Prior authorization is expected for initiation of ECT when the member is inpatient only.
Example code lists and notification thresholds
How to request prior authorization and required notifications
How to request prior authorization and notifications
How to request prior authorization and notifications: Prior authorization requests for medical services may be initiated by accessing Availity Essentials (registration required), calling Humana Healthy Horizons in Louisiana at 1-800-448-3810 (Monday–Friday, 7 a.m. to 7 p.m.), or faxing the prior authorization form to 1-833-974-0059. Prior authorization requests for behavioral health services may be initiated by calling the Behavioral Health Crisis Line at 1-844-461-2848. Urgent/emergent services do not require referrals, prior authorization, or notification. Not obtaining required prior authorization or notification may result in financial penalties for the practice, reduced member benefits, and retrospective medical necessity review. Providers should verify benefits and prior authorization/notification requirements with Humana prior to providing services. Certain services in the Medicaid PAL may not apply for practitioners in capitated or delegated arrangements; refer to your provider agreement. The PAL applies only to Humana Healthy Horizons and not to Humana commercial, Medicare, or other state Medicaid plans; exclusions may change — refer to Humana.com/PAL for updates.
- Availity Essentials (online, registration required)
- Phone: 1-800-448-3810 (Mon–Fri, 7 a.m.–7 p.m.)
- Fax: 1-833-974-0059
- Behavioral Health Crisis Line: 1-844-461-2848
Electroconvulsive therapy (ECT) prior authorization
Electroconvulsive therapy (ECT) — Prior authorization is expected when initiating ECT while the member is an inpatient.
Obstetrical admission notification
Obstetrical admission notification — Humana expects notification for obstetrical admissions that exceed 48 hours for vaginal deliveries and 96 hours for cesarean sections to enable concurrent review, care coordination, and discharge planning.
Behavioral health crisis notification
Behavioral health crisis notification — For crisis intervention, behavioral health crisis care, and mobile crisis, Humana expects notification within 48 to 72 hours to conduct concurrent review and care coordination activities.
PAL code list (selected examples)
PAL code list (selected examples) — The following is a non‑exhaustive selection of procedure, device, and HCPCS/CPT codes that require prior authorization or notification per the Humana Healthy Horizons in Louisiana PAL. Providers should consult Humana.com/PAL for the full and current list.
- Selected codes (examples): 58294, 58541–58544, 58548, 58550, 58552–58554, 58570–58573, 58661, 58720, 58940, 58999
- Neurostimulators: 61885, 64568
- Obesity surgeries: 43644, 43645, 43770–43775, 43843, 43845–43848, 43886–43888
- Oral/orthognathic/TMJ surgeries: 21208, 21209
- Rhinoplasty: 30400, 30410, 30420, 30430, 30435, 30450, 30460, 30462, 30468
- Transplant-related examples: 32850–32854, 33927–33929, 33935, 33945, 38205, 38206, 38230, 38232, 38240, 38241, 38243, 44135, 47133, 47135, 48160, 48550, 48554, 48556, 50300, 50320, 50340, 50360, 50365, 50370, 50547
- Genetic/test panel codes (examples): 81370–81383, 0584T–0586T, 0664T–0670T, G0341–G0343
- Miscellaneous HCPCS/CPT/HCPCS-like: L8698, L8699, S0189, S2053, S2054, S2060, S2065, S2102, S2142
- Varicose veins (surgical treatment and sclerotherapy): 36465–36466, 36468, 36471, 36473–36475, 36478, 36482–36483, 37700, 37765
- Ventricular assist devices (VADs): 33975, 33976, 33979, 33981–33983
- Device/implant and approach codes (examples): 64856, 64892, 64896, C1789, C1813, C2622, L8600, 02WA3QZ, 02WA4QZ, 0584T–0670T, 81370–81383
Terms used in this PAL
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