Prior authorization vs Notification

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

How to submit prior authorization and delegated partners

Providers may request prior authorization online via Availity Essentials (registration required), by phone using Humana's IVR at 800-444-9137, or by fax using the prior authorization form to 833-974-0059. Humana uses specialty managed authorization partners (for example, eviCore, Tivity, New Century Health) that have separate submission portals, phone numbers and fax lines as noted in the document.

• Availity Essentials (online; registration required)
• Phone: Humana IVR 800-444-9137
• Fax: Submit prior authorization form to 833-974-0059
• Delegated partners: eviCore (phone 866-672-8115; fax 800-540-2406 / 855-774-1319), Tivity (portal/phone/fax details), New Century Health (portal/phone)

Exceptions and provider-specific rules

Urgent or emergent services do not require prior authorization. Providers participating under nonparticipating, capitated, or delegated arrangements should follow their provider agreement, as some services may not be subject to the listed prior authorization requirements.

• Urgent/emergent services: no prior authorization required
• Nonparticipating providers and providers in capitated/delegated arrangements: refer to provider agreement for applicable requirements

Retro-review and documentation requirement for MSEA/DME

All MSEA/DME items costing more than $750 are subject to retrospective review; Humana requires a signed clinical record submitted with the claim for retro-review. Claims submitted without clinical records for these services are denied and will only be reconsidered through the claim appeal process with pertinent clinical records.

• Retro-review threshold: items > $750
• Signed clinical record required with claim for retro-review
• Claims without records are denied and reconsidered only via claim appeal with clinical records

Advanced imaging — eviCore managed review

Advanced imaging services (CT, CTA, MRA and related codes) are reviewed by eviCore; these services are listed with specific CPT/Codes that require prior authorization or review through eviCore.

• eviCore phone: 866-672-8115 (Mon–Fri 7 a.m.–7 p.m. ET); fax: 800-540-2406 / 855-774-1319
• Examples of codes reviewed: 70450, 70460, 70470, 71250, 71260, 71270, 70544, 70545, 70546, 75571, 75574

Home health and home infusion — authorization applies

All home health and home infusion services are included on the prior authorization/notification list and are associated with specific CPT/HCPCS codes.

• Example codes: 99344, B9002, B9004, B9006, B9998, B9999, G0155
• Includes a broad list of home health and infusion service codes (T‑codes and S‑codes listed)

Authorization required for major orthopedic (arthroplasty) procedures

Orthopedic arthroplasty and related major orthopedic surgery codes (hip, knee, shoulder) are listed and require prior authorization or notification as specified on the list.

• Example arthroplasty codes: 27125, 27130, 27437, 27438, 27440, 27441
• All listed inpatient admission codes require prior authorization

Foot surgeries (bunionectomy, hammertoe) require prior authorization/notification

Prior authorization or notification is required for foot surgeries listed on the document, including bunionectomy and hammertoe procedures.

• Example foot surgery codes: 26535, 26536, 28110, 28240, 28285, 28289, L8641

Laparoscopic hiatal hernia repair requires authorization/notification

Laparoscopic hiatal hernia repair procedures are included on the list and require prior authorization or notification.

• Example codes: 43280, 43281, 43282

Neurostimulator and pain infusion pump — prior authorization required

Implantable neurostimulator procedures and pain infusion pump procedures (and related neurosurgical/implantable device codes) are listed and require prior authorization or notification.

• Neurostimulator example codes: 61850, 61860, 63650, 63655, 64553, 64555, 95970
• Pain infusion pump example codes: 62324, 62325, 62326, 62327, 62350, C1772, E0782, E0783

Orthopedic arthroplasty (hip, knee, shoulder) on authorization/notification list

Hip, knee and shoulder arthroplasty procedures are explicitly included on the prior authorization/notification list and require authorization or notification as indicated.

• Included example codes: 23472, 27125, 27130, 27437, 27438, 27440, 27441, 27486

Orthopedic arthroscopy — notification required

Orthopedic arthroscopy procedures are included on the notification list and require notification as listed in the policy.

• Example arthroscopy codes: 29805, 29806, 29807, 29819, 29820, 29914–29916

Transplants — submit via Availity to Humana's National Transplant Network

Transplant prior authorization requests are reviewed by Humana's National Transplant Network and can be submitted via Availity.

• Submit transplant prior authorization requests through Availity for review by Humana's National Transplant Network

NICU / Special Care Nursery notification to Progeny Health

For infants admitted to a NICU or Special Care Nursery, providers must notify Progeny Health by fax; notifications can be submitted to 866-610-2034.

• NICU/Special Care Nursery notifications: fax to 866-610-2034

Obstetrical admission notification thresholds (48/96 hours)

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

• Notify when admission > 48 hours (vaginal) or > 96 hours (cesarean)