Prior authorization vs Notification — key definitions

Prior authorization (also called precertification or preadmission) requires providers to obtain advance approval from the plan before an item or service may be covered. Notification is a separate process in which the provider notifies Humana of the intent to provide a service; Humana does not issue an approval or denial for a notification.

Submission channels and vendor routing

Submit prior authorization requests online via Availity Essentials (registration required), by phone at 800-444-9137, or by fax using the prior authorization form to 833-974-0059. Certain services are managed by vendor partners (examples: New Century Health, eviCore, Tivity, Progeny) and must be submitted using the partner-specific portals, phone numbers, or fax numbers listed by service.

• New Century Health (chemotherapy agents/supportive drugs): phone 855-427-1372 or New Century Health website
• eviCore (advanced imaging, certain therapy reviews): phone 866-672-8115; fax 800-540-2406 or 855-774-1319; eviCore online portal
• Tivity (Whole Health Living): online portal http://www.wholehealthpro.com/; phone 866-430-8647; fax 888-492-1025
• Progeny Health (NICU/Special Care Nursery notifications): fax 866-610-2034

Urgent/emergent services and consequences of noncompliance

Urgent or emergent services do not require referral or prior authorization. However, failure to obtain required prior authorization or to provide required notifications before the date of service may result in financial penalties to the practice, reduced member benefits, and services may be subject to retrospective medical necessity review.

Inpatient admissions require prior authorization

All inpatient admission codes — including hospital, rehabilitation, long‑term acute care, inpatient hospice, transplant, and planned inpatient medical and surgical admissions — require prior authorization. Transplant prior authorization requests are reviewed by Humana's National Transplant Network and can be submitted via Availity.

Advanced imaging — prior authorization and eviCore review

Advanced imaging services (CT, CTA, MRA, MRI, PET, SPECT, 3D rendering and related CPT/HCPCS codes) are included on the prior authorization/notification list and certain advanced imaging services are reviewed by eviCore.

• Examples of included codes: 70450, 70460, 70470, 71250, 72125, 73700, 74150 and many additional CT/MR/CTA/MRA codes listed in the PAL

Therapy services flagged for eviCore review

Certain therapy services and codes are routed to eviCore for clinical review prior to authorization; these services are noted in the list as 'Reviewed by EviCore.'

• Examples of therapy codes noted as Reviewed by EviCore: 97533, 97535, 97537, 97597, 97598, 97602, 97750 (plus additional G‑codes and home health/home infusion codes listed)

DME / Assistive device authorization/notification

Durable medical equipment and assistive device codes (MSEA/DME), including pneumatic compression (E0651, E0652) and speech devices (E2510), are included on the authorization/notification list.

• Pneumatic compression example codes: E0651, E0652
• Speech device example code: E2510
• All MSEA items costing more than $750 are subject to retro‑review and require a signed clinical record submitted with the claim (see MSEA retro‑review threshold).

Bariatric surgery requires prior authorization

Bariatric surgery CPT codes are included on the prior authorization/notification list and require authorization per the PAL.

• Example bariatric procedure codes listed: 43631, 43632, 43633, 43634, 43644, 43770–43775, 43842–43848, 43886–43888

Transplant prior authorization routed to National Transplant Network

Prior authorization requests for transplants are reviewed by Humana's National Transplant Network and should be submitted via Availity for review by the network.

• Submit transplant prior authorization requests through Availity as indicated in the PAL routing guidance.

NICU / Special Care Nursery — notification to Progeny Health

Notify Progeny Health when an infant is admitted to a NICU or Special Care Nursery; notifications may be submitted by fax to 866-610-2034 to support care coordination.

• Fax notifications to Progeny Health: 866-610-2034

Obstetrical admissions — notification for extended stays

Humana requests notification for obstetrical admissions that exceed 48 hours for vaginal deliveries or 96 hours for cesarean sections to allow concurrent review for care coordination and discharge planning.