CurrentHumanaPolicy N/A

Humana Healthy Horizons in Louisiana Prior Authorization and Notification List (PAL)

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.

Policy Summary

PayerHumana

PolicyHumana Healthy Horizons in Louisiana Prior Authorization and Notification List (PAL)

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateJul. 1, 2026

Next Review DateN/A

Key ActionSubmit prior authorization requests via Availity Essentials online, by phone at 1-800-448-3810, or by fax to 1-833-974-0059; behavioral health requests via 1-844-461-2848.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

Jul. 1, 2026Policy effective date

Jun. 1, 2026Most recent revision

multipleService categories listed

48/96hObstetrical notification threshold

48-72hBehavioral health crisis notification

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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

ANY of the following
- Codes: 97151, 97152, 97153, 97154, 97155, 97156, 97157, 97158, 0362T, 0373T
ALL of the following
- Code: H0039
ALL of the following
- Code: H0036
ALL of the following
- Codes: H2011, H0045, S9484, S9485 (see comments: CBCS prior authorization required for services beyond 16 units; no prior authorization required for initial visit, only concurrent)
ALL of the following
- Code: H0015
ALL of the following
- Code: H2033
ALL of the following
- Code: H0038 (service eligibility for members 21 years and over)
ALL of the following
- Code: H2013
ALL of the following
- Codes: 96116, 96121, 96130-96133, 96136-96139, 96146
ALL of the following
- Codes: 0858T, 64999, 90867-90869

ALL of the following

ANY of the following
- Codes: E0747, E0748, E0760
ALL of the following
- Code: E0466
ALL of the following
- Codes: E1902, L8690, L8691
ALL of the following
- Codes: V5120, V5150, V5211-V5215, V5221, V5269, V5272
ALL of the following

ALL of the following

ALL of the following
- Codes: 15830, 15847
ALL of the following
- Codes: 15820-15823, 67900-67917, 67921-67924, 67950
ALL of the following
- Codes: 11920, 11921, 11970, 19030, 19361, 19364, 19367-19371, 19380 (includes separate listing of breast procedure codes and exclusions for reconstruction following medically necessary mastectomy)
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
- Codes: 81162-81460 series and others listed in PAL (examples: 81162-81167, 81170, 81192-81194, 81201-81223, 81235, 81292-81383, 81419, 81425-81427, 81460, 81519, 81560, 81595)

ALL of the following

ALL of the following
- Codes: 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
ALL of the following
- Codes: 38999, 60699, C9399, J3392-J3394, J3490, J3590, Q2041-Q2056, XW033* series

ALL of the following

ALL of the following
- Codes: A0430, A0431, A0435, A0436
ALL of the following
- Codes: T1019, T1025, T1026, T2002
ALL of the following
- Codes: 92507, 92508, 97110, 97530
ALL of the following
- Codes: Q4101, Q4121, Q4160, Q4186, Q4195, Q4196

ALL of the following

Cardiac implantable devices (example code listed) : 33274
ALL of the following
- Codes: 33975, 33976, 33979, 33981-33983

ALL of the following

Codes: 61885, 64568

ALL of the following

Codes: 36465, 36466, 36468, 36471, 36473-36475, 36478, 36482-36483, 37700, 37765

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

Example code lists and notification thresholds

Behavioral health service codes (examples)CPTCovered

97151-97158, 0362T, 0373T	Applied behavioral analysis (ABA) codes
H0039	Assertive community treatment (ACT)/FACT
H0036	Community psychiatric supportive treatment (CPST)

Durable medical equipment and device codes (examples)HCPCSCovered

E0747, E0748, E0760	Bone growth stimulators
E0466	Noninvasive home ventilators
L8690, L8691	Auditory osseointegrated device / AAC

Radiology and surgical procedure codes (examples)CPTCovered

78608-78609, 78811-78816	PET scan related codes
15830, 15847	Abdominoplasty codes
11920, 11921, 19361, 19364	Breast procedure codes

Examples from PAL code listmixed

58294
58541

inv-07: Obstetrical admission notification thresholds — 48 hours (vaginal), 96 hours (cesarean)

Vaginal delivery thresholdNotification expected when obstetrical admission exceeds 48 hours for vaginal deliveries.

Cesarean delivery thresholdNotification expected when obstetrical admission exceeds 96 hours for cesarean sections.

Purpose of notificationHumana Healthy Horizons requests notification to conduct concurrent review for care coordination and discharge planning.

inv-08: Behavioral health crisis notification window — 48-72 hours

Notification windowNotification expected within 48 to 72 hours for crisis intervention, behavioral health crisis care, and mobile crisis.

How to request prior authorization and required notifications

Prior Authorization

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

Terms used in this PAL

inv-14: Notification — definition clarifying notification is informational and not an approval/denial

DefinitionNotification is the process of a healthcare provider notifying Humana Healthy Horizons in Louisiana of the intent to provide an item or service.

Not a coverage decisionHumana Healthy Horizons does not issue an approval or denial related to a notification.

PurposeNotifications are requested to help coordinate care for covered patients and are distinct from prior authorization.

inv-15: Prior authorization — definition that prior authorization/precertification/preadmission requires advance approval from the plan

DefinitionPrior authorization (also precertification/preadmission) requires a healthcare provider to obtain advance approval from the plan as to whether an item or service will be covered.

Policy Summary

PayerHumana

PolicyHumana Healthy Horizons in Louisiana Prior Authorization and Notification List (PAL)

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateJul. 1, 2026

Next Review DateN/A

Key ActionSubmit prior authorization requests via Availity Essentials online, by phone at 1-800-448-3810, or by fax to 1-833-974-0059; behavioral health requests via 1-844-461-2848.

SourceLink

On This Page

Codes: E0260, E0261, E0265, E0266, E0294-E0297, E0301-E0304

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

Codes: 30400, 30410, 30420, 30430, 30435, 30450, 30460, 30462, 30468

ALL of the following

Codes: 21208, 21209

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.

Purpose of notificationUsed to conduct concurrent review and care coordination activities following crisis care.

ScopeApplies to behavioral health crisis intervention and mobile crisis services per PAL guidance.

Prior Authorization

Electroconvulsive therapy (ECT) prior authorization

Electroconvulsive therapy (ECT) — Prior authorization is expected when initiating ECT while the member is an inpatient.

Prior Authorization

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.

Prior Authorization

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.

Prior Authorization

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

Prior authorization requests may be initiated via Availity Essentials online, phone (1-800-448-3810), or fax (1-833-974-0059); behavioral health via Behavioral Health Crisis Line (1-844-461-2848).

ConsequencesServices provided without required prior authorization may be subject to retrospective medical necessity review and potential financial penalties per provider contract.

inv-16: Humana Healthy Horizons in Louisiana — definition of the plan name and organizational identity

Plan nameHumana Healthy Horizons in Louisiana.

Organizational identityA Medicaid product of Humana Health Benefit Plan of Louisiana, Inc.

ApplicabilityPAL and related prior authorization/notification requirements apply specifically to Humana Healthy Horizons in Louisiana and not to Humana commercial, Medicare, or other state Medicaid plans.