CurrentHumanaPolicy N/A

Illinois Humana Gold Plus Integrated Medicare-Medicaid Plan Preauthorization and Notification List

Governs preauthorization and notification requirements for services and provider-administered medications for members of the Illinois Humana Gold Plus Integrated Medicare-Medicaid Plan; affects participating healthcare providers and facilities serving these members.

Policy Summary

PayerHumana

PolicyIllinois Humana Gold Plus Integrated Medicare-Medicaid Plan Preauthorization and Notification List

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionObtain preauthorization for listed services and medications prior to providing care using Availity, IVR 800-523-0023 for medical services or fax 888-447-3430 / phone 866-461-7273 for medications.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

up to 10procedure codes allowed per authorization request

up to 6diagnosis codes allowed per authorization request

888-447-3430medication preauthorization fax

800-523-0023medical services IVR/phone

Preauthorization Coverage Criteria

Coverage stance and criteria

Services and medications listed require preauthorization and must meet Medicare coverage guidelines and medical necessity; investigational/experimental procedures usually are not covered. Notifications are distinct from preauthorization and do not constitute approval.

Preauthorization is required for listed services and medications delivered in physician office, clinic, outpatient or home settings prior to being provided or administered.

Services must be provided according to Medicare coverage guidelines established by CMS and all care, services, supplies and equipment must be medically necessary.

Investigational and experimental procedures usually are not covered benefits; consult the patient’s Evidence of Coverage or contact Humana for confirmation of coverage.

Notifications: the provider notifies Humana of intent to provide an item or service; Humana requests notification to help coordinate care but does not issue an approval or denial for notifications.

Policy Summary

PayerHumana

PolicyIllinois Humana Gold Plus Integrated Medicare-Medicaid Plan Preauthorization and Notification List

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

SourceLink

On This Page

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Authorization and Coding Limits

Authorization request code limitsmixed

Procedure codes (up to 10) and diagnosis codes (up to 6) required on authorization requests

Procedure code count limit

Maximum procedure codesUp to 10 procedure codes per authorization request

Required procedure code submissionInclude procedure codes for all requested services when submitting authorization

Context for procedure codesProcedure codes are among the required elements (alongside member and service details) to expedite determination

Diagnosis code count limit

Maximum diagnosis codesUp to 6 diagnosis codes per authorization request

Diagnosis code expectationInclude primary and secondary diagnosis codes when applicable

Context for diagnosis codesDiagnosis codes are required elements to help complete the authorization determination

How to Request Authorizations and Provider Responsibilities

Prior Authorization

Preauthorization vs Notification — scope and definitions

Preauthorization is required for the services and provider‑administered medications listed when delivered in the physician's office, clinic, outpatient or home settings. Notification is a separate process in which the provider informs Humana of the intent to provide an item or service; notification does not constitute approval or denial.

Documentation Required

How to submit preauthorization requests

Request preauthorization for medical services online at www.availity.com (registration required) or via Humana's IVR at 800-523-0023. Request preauthorization for medications by fax to 888-447-3430 (forms at Humana.com/medPA) or by phone at 866-461-7273 (Mon–Fri, 8 a.m.–11 p.m. ET).

Denial Risk

Urgent/emergent services and consequences for missing prior auth

Urgent or emergent services do not require referrals or preauthorization and should be provided without delay. Failure to obtain required preauthorization for non‑urgent services may result in financial penalties for the practice, reduced benefits for the patient, and retrospective medical necessity review.

Prior Authorization

Behavioral health preauthorization routing (Carelon)

Some behavioral health preauthorizations are managed by Carelon Behavioral Health and must be submitted through Carelon's channels (online, IVR, direct phone or fax) rather than Humana's Humana/Availity routes.

Online: www.carelonbehavioralhealth.com
IVR: 855-371-9234 (have TIN, member ID and DOB, date of service)
Direct phone: 855-235-8530 (TTY 855-539-5884)
Fax: 855-371-9232

Key Terms

preauthorization / notification

Preauthorization (definition)A process requiring the physician or other healthcare provider to obtain advance approval from the plan as to whether an item or service will be covered

Notification (definition)The process by which the physician or other healthcare provider notifies Humana of the intent to provide an item or service; Humana requests notification to help coordinate care and does not issue an approval or denial for notifications

Scope noteThe list details services and medications delivered in office, clinic, outpatient or home settings that require preauthorization prior to being provided or administered; services must meet Medicare coverage guidelines and medical necessity

Implication for practiceSubmitting required elements (member ID, service date, procedure and diagnosis codes, location, provider TIN/NPI, clinical info) expedites authorization determinations