CurrentHumanaPolicy N/A

Illinois Humana Gold Plus Integrated Medicare‑Medicaid Plan Prior Authorization and Notification List

Governs prior authorization and notification requirements for medical services and provider‑administered medications for members of the Illinois Humana Gold Plus Integrated Medicare‑Medicaid Plan; applies to participating providers and delegated networks in Illinois.

Policy Summary

PayerHumana

PolicyIllinois Humana Gold Plus Integrated Medicare‑Medicaid Plan Prior Authorization and Notification List

Policy CodePolicy N/A

Change TypeAdministrative update — PAL notice

Effective DateN/A

Next Review DateN/A

Key ActionSubmit prior authorization requests online via Availity, by IVR at 800-523-0023, or follow the specified fax/phone processes for medication authorizations.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

Oct 2025 linkpublished PAL reference

Up to 10procedure codes

Up to 6diagnosis codes

888-447-3430medication PA fax

800-523-0023medical PA phone

Coverage and Authorization Stance

General coverage stance

Covered when ALL of the following are met:

ALL of the following

Pal-listed services or provider-administered medications: Service or provider-administered medication appears on the Prior Authorization and Notification List (PAL) and requires prior authorization prior to being provided or administered.
Medicare coverage guidelines: Services must be provided according to Medicare coverage guidelines established by CMS.
Medical necessity: The item, service, or medication is medically necessary as defined by Medicare policy.

ALL of the following

Policy Summary

PayerHumana

PolicyIllinois Humana Gold Plus Integrated Medicare‑Medicaid Plan Prior Authorization and Notification List

Policy CodePolicy N/A

Change TypeAdministrative update — PAL notice

Effective DateN/A

Next Review DateN/A

Key ActionSubmit prior authorization requests online via Availity, by IVR at 800-523-0023, or follow the specified fax/phone processes for medication authorizations.

SourceLink

On This Page

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Authorization Coding Limits and Rules

Authorization code limitsmixed

max 10	Maximum number of procedure codes per authorization request
max 6	Maximum number of diagnosis codes per authorization request

Procedure code limits

Maximum procedure codes per authorizationUp to 10 procedure codes per authorization request

Context for submissionProcedure codes should be submitted with member identifiers and date of service to expedite review

Examples of procedure code useInclude all applicable procedure codes for the proposed service (e.g., CPT/HCPCS) up to the 10-code limit

Diagnosis code limits

Maximum diagnosis codes per authorizationUp to 6 diagnosis codes (primary and secondary) per authorization request

Context for submissionInclude relevant primary and secondary diagnosis codes with the request to support medical necessity

Expedite reviewSubmitting all relevant clinical information and diagnosis codes at time of request helps expedite determination

What Providers Must Do

Prior Authorization

Definitions: Prior Authorization vs Notification

Prior authorization (also called preauthorization, precertification, or preadmission) is a process through which the physician or other healthcare provider must obtain advance approval from Humana to determine whether an item or service will be covered. Notification is 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 but does not issue an approval or denial for notifications.

Prior authorization = advance approval required from Humana before providing the service or medication.
Notification = telling Humana of intent to provide the service; not an approval or denial.

Prior Authorization

How to Request Prior Authorization

How to request prior authorization from Humana: medical services prior authorizations are available online at Availity (registration required) or by calling Humana's IVR at 800-523-0023. Medications on the prior authorization list should be requested by fax to 888-447-3430 (request forms at Humana.com/MedPA) or by calling 866-461-7273, Monday–Friday, 8 a.m.–11 p.m. ET. For delegated networks or IPAs, providers should follow their IPA/risk network guidance. Urgent/emergent services do not require prior authorization. Not obtaining required prior authorization may result in financial penalties, reduced patient benefits, and retrospective medical necessity review or denial.

Medical services: Online via Availity (www.availity.com) or IVR 800-523-0023
Medications: Fax to 888-447-3430 (forms at Humana.com/MedPA) or call 866-461-7273 (Mon–Fri, 8 a.m.–11 p.m. ET)
Delegated providers: follow IPA or risk network instructions for processing requests
Urgent/emergent services: do not require prior authorization
Failure to obtain required prior authorization: possible financial penalties, reduced benefits, and retrospective review/denials

Note

Real-time Questionnaire Option (Availity Essentials)

Availity Essentials offers an optional questionnaire for certain PAL services. Completing the questionnaire when submitting an online request may yield a real-time approval. If a real-time approval is not returned immediately, the questionnaire responses will be used to expedite Humana's review.

Use Availity Essentials questionnaire for some PAL services — answers may produce real-time approval
If not approved instantly, submitted questionnaire responses help expedite review

Key Term Definitions

Prior authorization

DefinitionPrior authorization is the process requiring the physician or other healthcare provider to obtain advance approval from the plan to determine whether an item or service will be covered

When it appliesApplies to services and provider‑administered medications on the PAL that must be authorized prior to being provided or administered

Coverage standardServices requiring prior authorization must meet Medicare coverage guidelines and be medically necessary

Not applicable to emergent careUrgent/emergent services do not require prior authorization (per provider guidance elsewhere in the document)

Notification

DefinitionNotification is the process by which the physician or other healthcare provider notifies Humana of the intent to provide an item or service; Humana does not issue an approval or denial for notifications

PurposeHumana requests notification to help coordinate care for Humana‑covered patients

Distinction from prior authorizationUnlike prior authorization, notification does not result in an approval or denial decision by Humana