CurrentHumanaPolicy N/A

Medicare Advantage and Dual Eligible Special Needs Plans Prior authorization and Notification List

Defines Humana Medicare Advantage (MA) and Dual Eligible Special Needs Plans (D-SNP) prior authorization and notification requirements, who must comply (providers for MA and D-SNP members), and how to request approvals or notifications.

Policy Summary

PayerHumana

PolicyMedicare Advantage and Dual Eligible Special Needs Plans Prior authorization and Notification List

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateJan 1, 2025

Next Review DateN/A

Key ActionObtain prior authorization from Humana before providing services or administering medications listed on the MA and D‑SNP prior authorization list.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

7 daysCMS timeframe (effective Jan 1, 2026)

90 daysNo prior auth for active treatment (first 90 days)

Up to 10Max procedure codes/request

Up to 6Max diagnosis codes/request

Phone, Fax, AvailityAccepted submission channels

Coverage posture and requirements

Coverage posture

Services and medications listed require prior authorization before being provided; investigational or experimental procedures/devices are generally not covered and some services may be excluded depending on the member's plan.

Services and provider‑administered medications on Humana's Prior Authorization and Notification List require prior authorization before being provided or administered.

Services must be provided according to Medicare coverage guidelines and meet medical necessity requirements established by CMS.

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

Certain services may be excluded from coverage depending on the member’s specific plan; providers should verify plan‑specific applicability.

Authorization request coding limits

Policy Summary

PayerHumana

PolicyMedicare Advantage and Dual Eligible Special Needs Plans Prior authorization and Notification List

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateJan 1, 2025

Next Review DateN/A

Key ActionObtain prior authorization from Humana before providing services or administering medications listed on the MA and D‑SNP prior authorization list.

SourceLink

On This Page

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Authorization request coding limitsmixed

procedure codes up to 10	Providers may include up to 10 procedure codes per authorization request
diagnosis codes up to 6	Providers may include up to 6 diagnosis codes per authorization request

inv-03: Procedure code limit

Procedure code limit per authorization requestUp to 10 procedure codes may be included per authorization request

Source guidanceInformation required for a prior authorization request lists procedure codes (up to a maximum of 10 per authorization request).

PurposeEnsures Humana receives complete coding to process authorization determinations efficiently.

inv-04: Diagnosis code limit

Diagnosis code limit per authorization requestUp to 6 diagnosis codes may be included per authorization request

Source guidanceInformation required for a prior authorization request lists diagnosis codes (up to a maximum of 6 per authorization request).

PurposeCaptures primary and relevant secondary diagnoses to support medical necessity review.

What providers must do — authorization, notifications, and timelines

Note

Prior authorization and notification list overview — where to find lists and what they mean

Medicare Advantage and Dual Eligible Special Needs (D‑SNP) plans: The full prior authorization and notification lists apply. Access the MA/D‑SNP prior authorization lists for services and medications via Humana's posted links (see Medicare October 2025 Medical/Behavioral Health PAL and 2025 Provider‑Administered Medication PAL). These lists define which services and physician‑administered medications require prior authorization or notification.

Prior authorization = advance approval required before service/item is provided.
Notification = provider informs Humana of intent to provide; Humana does not issue approval/denial for notifications.

Prior Authorization

Plan‑specific prior authorization applicability

Humana MA HMO and HMO‑POS: the full PAL applies. Florida MA HMO: the full PAL applies; medication requests should be submitted directly to Humana per the MA/D‑SNP Medication PAL. Humana MA PPO: the full PAL applies. Humana MA PFFS: prior authorization is not required (notification is requested); providers may request an Advance Coverage Determination (ACD). Humana Medicare Supplement and Humana commercial plans: this MA/D‑SNP list does not apply (commercial plans follow the Commercial PAL). Providers in delegated IPAs or risk networks remain subject to the PAL and should follow their IPA/risk network guidance.

Delegated providers (IPA/risk networks) should consult their delegation agreements and IPA for submission processes.
ACD submission options (for MA plans): written, fax, or telephone (see contact details).

Documentation Required

Timeliness and documentation requirement

Submit all supporting clinical information at the time of the prior authorization request. CMS requires prior authorization decisions within 7 calendar days for medical items/services effective January 1, 2026; failure to submit required documentation at request time may delay review or lead to adverse decisions. Begin adhering to this requirement immediately.

Provide complete clinical records, progress notes, relevant imaging/labs, and rationale for medical necessity with the initial request.
Incomplete submissions may trigger a retrospective medical necessity review or delayed determination.

Denial Risk

Urgent services and risk of noncompliance

Urgent or emergent services do not require prior authorization or referrals and should not be delayed for authorization. However, failure to obtain required prior authorization for non‑urgent services may result in financial penalties to the practice and reduced patient benefits per the provider contract and member Certificate of Coverage. Services provided without required prior authorization remain subject to retrospective medical necessity review.

If an urgent/emergent service is provided, document the clinical urgency in the medical record.
Verify benefit/authorization requirements for non‑urgent services prior to providing care to avoid potential penalties.

Note

Submission channels — accepted portals, phone, and fax

Primary submission channels: Online via Availity (www.availity.com) — registration required — is encouraged and may offer real‑time approvals for select PAL items via questionnaires; Telephone: Humana IVR at 800‑523‑0023 for medical services; Fax and phone for medications per the PAL: Fax 888‑447‑3430 or call 866‑461‑7273 (Mon–Fri, 8 a.m.–11 p.m. ET). For ACDs and other written requests, mail or fax options are available (see Humana correspondence address and fax numbers). Refer to the PAL pages for service‑specific submission routes and any required forms.

Use Availity for faster processing where available; completing the questionnaire may enable real‑time approval.
Keep a copy of all submissions and supporting clinical documentation; include required modifiers for active course‑of‑treatment claims within the first 90 days of enrollment per Humana Medicare Advantage Payment Policy.

Key definitions

inv-10: Definition — Prior authorization

DefinitionA process through which the physician or other healthcare provider is required to obtain advance approval from the plan as to whether an item or service will be covered.

Alternate termsAlso referred to as preauthorization, precertification, or preadmission in this communication.

ApplicabilityRequired for services and medications listed on Humana's Prior Authorization and Notification List for Medicare Advantage and D-SNP plans.

Relation to coverageServices must meet Medicare coverage and medical necessity standards to be approved.

inv-11: Definition — Notification

DefinitionThe 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; notification is distinct from prior authorization.

ScopeApplies to items and services the provider intends to provide that are designated as notification on Humana's prior authorization and notification list.