CurrentHumanaPolicy N/A

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

Defines services that commonly require prior authorization or notification for Humana Healthy Horizons enrollees in Kentucky; applies to providers serving members of this plan and excludes other Humana lines of business.

Policy Summary

PayerHumana

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

Policy CodePolicy N/A

Change TypeNo material change

Effective Dateas written

Next Review DateN/A

Key ActionRequest prior authorization via Availity Essentials, phone 800-444-9137, or fax 833-974-0059 (follow vendor routing for specific services).

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

Kentucky-onlyjurisdiction referenced

multipleservice categories listed

$750MSEA retrospective threshold

2026-03-01effective date noted

Services Requiring Prior Authorization or Notification

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Inpatient admissions: All inpatient admission codes (hospitals, rehabilitation facilities, long-term acute care, inpatient hospice, transplant, and planned inpatient medical and surgical admissions) require prior authorization.

Behavioral health services: Inpatient services and all residential treatment services require prior authorization. Partial hospitalization requires prior authorization (H0035). Intensive outpatient program (IOP) for substance use disorder requires prior authorization (H0015, S9480).

DME/MSEA items: All MSEA items costing more than $750 are subject to retrospective review; a signed clinical record must be submitted with the claim for the retro‑review. Claims submitted without clinical records for these services are denied (denials reconsidered only through the claims appeal process with pertinent clinical records).

Exception: Urgent/emergent services do not require a referral or prior authorization.

Vendor-managed services: Certain services use external vendors (for example: EviCore for advanced imaging and some ancillary services; Progeny Health for NICU/Special Care Nursery notifications; Humana’s National Transplant Network for transplant prior authorization review). Providers must follow vendor-specific submission channels where applicable.

Services on prior authorization/notification list

Services requiring review/authorization

Advanced imaging: Computed tomography (CT), CT angiography (CTA), magnetic resonance angiography (MRA), magnetic resonance imaging (MRI), PET, SPECT and related 3D rendering studies are reviewed by EviCore and are included on the list (examples: 70450, 70551, 75571 and many additional CPT/Codes as listed).

Ancillary therapy services: Physical therapy, occupational therapy and speech therapy codes (examples include 97164, 97165, 97168, 97530, 97533, 97535, 97537, 97597, 97598, 97602, 97750, and G‑series therapy/HCPCS codes) are included; some ancillary services are reviewed by EviCore.

Prior authorization / notification criteria (partial)

Listed services are on the Humana Healthy Horizons Kentucky Prior Authorization and Notification List and generally require prior authorization or notification unless specified otherwise.

Urgent/emergent services do not require a referral or prior authorization.

Specific service groups included on the Kentucky Prior Authorization and Notification List: radiation therapy (including proton beam and stereotactic radiation; e.g., 77520, 77522, 77523, 77525, stereotactic codes), skin and tissue substitutes (Q4101, Q4117, Q4121, Q4158, Q4160, Q4186, Q4187, Q4195, Q4196, Q4197), bariatric surgeries (examples: 43631–43634, 43644, 43770–43775, 43842–43848, 43886–43888), foot surgeries (e.g., 26535, 26536, 28110, 28240, 28285–28299, 28306, 28308, 28310, 28740, 28750), neurostimulator procedures and related codes (e.g., 61850–61888, 63650–63688, 64553–64595, 95970–95972), orthopedic arthroplasty and arthroscopy (examples listed), pain infusion pumps (e.g., 62324–62327, 62350–62362), extensive spinal surgery codes, ventricular assist devices (VADs) and transplant‑related procedures — all as enumerated in the list. These service groups and associated CPT/HCPCS codes require review or prior authorization as specified in the list.

Notification instructions: For infants admitted to a NICU or Special Care Nursery, notify Progeny Health by fax to 866‑610‑2034. For obstetrical admissions, notify when inpatient stay exceeds 48 hours for vaginal delivery or 96 hours for cesarean section to enable concurrent review, care coordination and discharge planning.

Transplant process: Prior authorization requests for transplants are reviewed by Humana's National Transplant Network and can be submitted via Availity.

What Providers Must Do

Note

Prior Authorization vs Notification

Prior authorization (also called precertification/preadmission) requires providers to obtain advance approval from Humana before certain services are provided. Notification is a separate process used to inform Humana of the intent to provide an item or service; Humana does not approve or deny based on a notification.

Prior Authorization

Submission channels and vendor routing

How to request prior authorization for medical and behavioral health services: Except where otherwise noted on the following pages, healthcare providers can request prior authorization online, by phone or fax.

Online via Availity Essentials (registration required).
Phone via Humana's interactive voice response line: 800-444-9137.
Fax: Submit the prior authorization form to 833-974-0059.
Advanced imaging and certain vendor-managed services may require submission via vendor portals (see Advanced imaging — EviCore and other vendor instructions).
Tivity (Whole Health Living) managed services: Online: http://www.wholehealthpro.com/; Phone: 866-430-8647; Fax: 888-492-1025.
New Century Health for chemotherapy/supportive drug prior authorization: Online via New Century Health portal or call 855-427-1372 for access; phone intake available per New Century Health instructions.

Prior Authorization

Inpatient admission prior authorization requirement

All inpatient admission codes (hospitals, rehabilitation facilities, long‑term acute care, inpatient hospice, transplant, and planned inpatient medical/surgical admissions) require prior authorization. Transplant prior authorization requests are reviewed by Humana's National Transplant Network and can be submitted via Availity. Obstetrical admissions: Humana requests notification for admissions that exceed 48 hours for vaginal deliveries and 96 hours for cesarean sections to conduct concurrent review for care coordination and discharge planning. For infants admitted to a NICU or Special Care Nursery notify Progeny Health via fax 866-610-2034.

Documentation Required

Retro-review and documentation requirement for MSEA (> $750)

Durable medical equipment (MSEA/DME) items costing more than $750 are subject to retrospective review. Humana requires a signed clinical record submitted with the claim to perform the retro‑review. Claims submitted without clinical records for these services are denied. Denials are only reconsidered through the claim appeal process with pertinent clinical records.

This retro‑review requirement applies in addition to any specific prior authorization requirements for listed DME items.
Example listed DME codes subject to review include: E0294, E0295, E0296, E0297, E0300, E0301, E0302, E0303, E0304, E0316, E0328, E0329, E0371, E0372, E0373, E0462, E0912, E0747, E0748, E0760, 69930, L8614, L8619, L8627, L8628, L7499, L8044, L8499.
Unlisted supply/equipment codes (A9900, A9999, E1399) and high‑cost items (wheelchairs, power chairs, ventilators, VADs, cochlear implants, CGMs, etc.) may trigger the >$750 review.

Prior Authorization

Ancillary services — prior auth/notification

Ancillary services such as nonemergent medical transportation (NEMT), EEG, diagnostic endoscopy for certain ages, physical/occupational/speech therapy, respiratory therapy, home health and home infusion, and molecular/genetic testing may require prior authorization or notification as indicated below. Some therapy services are managed by EviCore (see Advanced imaging/EviCore block).

Nonemergent medical transportation (NEMT) codes: A0428, A0430, A0431.
EEG codes: 95812, 95813, 95822.
Diagnostic esophagogastroduodenoscopy/esophagoscopy (for patients younger than 59): 43191, 43193, 43197, 43198, 43202, 43239.
Physical/occupational/speech therapy and related codes: 92507, 92508, 92511, 92523, 92526, 92626, 92627, 95992, 97012, 97014, 97032, 97035, 97110, 97112, 97113, 97116, 97124, 97140, 97150, 97161–97168, 97530, 97533, 97535, 97537, 97597, 97598, 97602, 97750, G0151–G0153, G0157–G0161, G0281–G0283.
Respiratory therapy: G0239.
Home health and home infusion examples: 99344, B9002, B9004, B9006, B9998, B9999, G0155, G0299, G0300, G0494, G0495, S‑series home health codes, T1004, T1019–T1031, T1502–T1503.
Molecular/genetic testing — many CPT codes listed require prior authorization: 81162–81168, 81170–81176, 81177–81194, 81200–81222, 81212, 81215–81220, 81222, etc.

Prior Authorization

Advanced imaging — EviCore review

Advanced imaging services are reviewed by EviCore. Prior authorization requests for CT, CTA, MRA, MRI, PET, SPECT and related services must be submitted according to the EviCore process. Providers should use the EviCore portal for submission when indicated.

CT codes include (examples): 0633T–0638T, 0710T–0713T, 70450, 70460, 70470, 71250–71275, 72125–72133, 73200–73206, 73700–73706, 74150–74178, 75571, 75574, 75635, 76380, 76497, 77078, S8092.
CTA codes: 75572, 75573.
MRA codes include: 70544–70549, 71555, 72159, 72198, 73225, 74185, and various C‑codes (C8900–C8936 series).
MRI codes include: 0697T–0698T, 70336, 70540–70555, 71550–71552, 72141–72158, 72195–72197, 73218–73223, 73718–73723, 74181–74183, and related C/CPT codes.
PET/SPECT/3D rendering codes include: 78429–78433, 78459, 78491–78492, 78608, 78811–78816, G0235, 78451–78452, 78469, 76376–76377.

Prior Authorization

Prior authorization / notification entries (expanded)

The policy includes extensive prior authorization and notification entries across multiple service categories. Providers must obtain prior authorization where indicated for the listed procedures, surgeries, devices and supplies. Examples of categories and representative codes subject to prior authorization/notification are provided below — this is not an exhaustive code list; refer to the full list for complete codes.

Surgeries and procedures (examples): Bariatric surgery codes 43631–43634, 43644, 43770–43775, 43842–43888; Foot surgeries (bunionectomy/hammertoe) 26535, 26536, 28110, 28240, 28285, 28289–28310, 28740, 28750, L8641; Laparoscopic hiatal hernia repair 43280–43282.
Neurostimulator and pain procedures: 61850, 61860, 61880, 61885–61888, 63650, 63655, 63661–63664, 63685, 63688, 64553–64595, 95970–95972, C1823.
Orthopedic surgeries: Hip/knee/shoulder arthroplasty codes 23472–23474, 27125, 27130, 27132–27138, 27437–27447, 27486–27487; Arthroscopy and related codes include 23929, 27299, 27412, 29805–29999 series.
Spinal surgeries and implants: Extensive spine codes (e.g., 20999, 22100–22226, 22510–22633, 22800–22869, 22899, 27279–27280, 62287, 62380, 63001–63090, 63101–63197, 63200–63308, 0274T, C1821, C2614, C9757).
Ventricular assist devices (VADs): 33975, 33976, 33979, 33981–33983.
Radiation and proton therapies: 77520, 77522, 77523, 77525, stereotactic radiation and related codes 32701, 61796–61799, 63620, 77371–77373.
Skin and tissue substitutes: Q4101, Q4117, Q4121, Q4158, Q4160, Q4186–Q4197.
Devices and implants (examples): Spinal cord stimulators and related device codes 63685, 63688, C1816, C1820, C1822, L8679–L8688; Cochlear/auditory implants 69930, L8614, L8619, L8627–L8628.

Key Terms

Prior authorization

DefinitionPrior authorization (also known as precertification or preadmission) is a process that requires providers to obtain advance approval from the plan as to whether an item or service may be covered.

PurposeUsed to determine whether a proposed item or service meets plan coverage criteria before it is provided.

Distinction from notificationPrior authorization results in an approval/denial decision, unlike notification which only informs Humana of intent to provide a service.

Notification

DefinitionNotification is the process by which a healthcare provider notifies Humana of the intent to provide an item or service; Humana requests notification to help coordinate care for Humana-covered patients.

No approval/denialNotification differs from prior authorization: Humana does not issue an approval or denial related to a notification.

PurposeUsed to coordinate care rather than to determine coverage eligibility in advance.

EviCore review

Vendor-managed reviewAdvanced imaging services are reviewed by EviCore (includes CT, CTA, MRA, MRI, PET, SPECT, 3D rendering and specified CPT/HCPCS codes).

Example service typesIncludes computerized tomography (CT) and magnetic resonance imaging (MRI) codes listed in the Advanced imaging section.

Code listingsSpecific CPT/HCPCS codes for CT, CTA, MRA, MRI and related services are enumerated in the document and routed to EviCore.

Urgent/emergent services

DefinitionServices provided for urgent/emergent conditions that do not require a referral or prior authorization.

ScopeApplies to urgent/emergent services across the listed service categories (statement repeated throughout the document).

Operational impactProviders may proceed with urgent/emergent care without obtaining prior authorization or a referral.

Urgent/emergent services (clarification)

Operational ruleUrgent/emergent services do not require a referral or prior authorization (statement reiterated in multiple sections).

Exception handlingEven when services are listed on the Prior Authorization and Notification List, urgent/emergent instances remain exempt from prior authorization requirements.

Provider actionProviders should document the urgent/emergent nature of the service as appropriate when submitting claims or notifications.

Transplant prior authorization

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

Submission channelSubmit transplant prior authorization requests through Availity for routing to the National Transplant Network.

Related notificationsTransplant requests are handled separately from routine prior authorization items and follow the National Transplant Network review process.

Policy Summary

PayerHumana

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

Policy CodePolicy N/A

Change TypeNo material change

Effective Dateas written

Next Review DateN/A

Key ActionRequest prior authorization via Availity Essentials, phone 800-444-9137, or fax 833-974-0059 (follow vendor routing for specific services).

SourceLink

On This Page

OpenPayer

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

Services Requiring Prior Authorization or Notification

Relevant CPT / HCPCS / Other Codes

What Providers Must Do

Key Terms