Definition of prior authorization and encouraged submission methods

Prior authorization is defined as the process requiring advance approval from the plan to determine if an item or service will be covered. Providers should submit prior authorization requests online when possible (e.g., Availity or vendor portals); certain services are routed to third-party vendors (Evolent, Cohere) per the service-specific guidance.

Urgent/emergent services exempt from prior authorization; penalties for noncompliance

Urgent or emergent services do not require referrals, prior authorization, or notification. Failure to obtain required authorizations or notifications for non‑urgent services may result in financial penalties, reduced patient benefits, or retrospective medical necessity review.

CMS 7‑day decision timeframe and required clinical support

Effective Jan 1, 2026, CMS requires prior authorization decisions within 7 days for certain items/services; providers should submit all relevant supporting clinical information at the time of the request to support timely adjudication.

Third‑party vendor management for specified services

Many service categories are managed by third‑party vendors: Evolent (formerly New Century Health) manages specified surgical and oncology/breast/radiation services, and Cohere Health manages numerous device, surgical and procedural authorizations; providers must use the vendor submission routes listed for those services.

Primary submission channels and Cohere contact

For services managed by Cohere Health, submit prior authorization requests via the Cohere portal (Next.Coherehealth.com); Cohere phone: 833‑283‑0033; fax: 857‑557‑6787. Expedited/urgent cases can be submitted and monitored on the Cohere portal.

Service management varies by state (Cohere exceptions)

Some Cohere‑managed services are exceptions by state: Cohere manages many services except for specified states (Florida, Georgia, North Carolina, South Carolina and Virginia), which will be managed by Humana; follow the state‑specific routing in the policy.

New‑member 90‑day active course‑of‑treatment exception and claim requirements

Humana does not require prior authorization for basic Medicare benefits during the first 90 days of a new member's enrollment when an active course of treatment began prior to enrollment; include the Humana MA Payment Policy modifier (CP2023011) or medical records showing the active course of treatment to ensure appropriate claim payment.

Facet injections require prior authorization via Cohere

Facet joint injections require prior authorization and are managed via the Cohere portal (Next.Coherehealth.com); listed CPT/CPT‑like codes include 64490–64495, 64633–64636, 64999, and 0213T–0218T. For questions call Cohere at 833‑283‑0033.

• Codes: 64490, 64491, 64492, 64493, 64494, 64495, 64633, 64634, 64635, 64636, 64999, 0213T, 0214T, 0215T, 0216T, 0217T, 0218T

Home health/home infusion prior authorization required (all states)

Home health and home infusion services require prior authorization in all states; submit requests via the Cohere portal (Next.Coherehealth.com). State routing notes: Tango manages home health for members in AZ, CO and NM (Phone: 888‑705‑5274; Fax: 877‑612‑7066).

• Home health/home infusion codes include: 99512, 99600, G0151–G0153, G0155–G0162, G0299, G0300, G0493–G0496, G2168, G2169
• Tango contact for AZ/CO/NM: Phone 888‑705‑5274; Fax 877‑612‑7066

Noninvasive home ventilators require prior authorization

Noninvasive home ventilators require prior authorization; the policy lists HCPCS codes E0466 and E0468 as requiring authorization.

• Codes: E0466, E0468

Orthopedic arthroplasty prior authorization via Cohere

Hip, knee and shoulder arthroplasty authorizations are managed by Cohere Health; submit prior authorization requests at Next.Coherehealth.com (onboarding link provided) and contact Cohere at 833‑283‑0033 for assistance.

• Example arthroplasty codes listed: 23472, 23473, 23474, 27125, 27130, 27132, 27134, 27137, 27138, 27437, 27438, 27440, 27441, 27442, 27443, 27446, 27447, 27486, 27487, C8003

Lung biopsy/resection prior authorization managed by Evolent

Lung biopsy and resection prior authorization requests are managed by Evolent (formerly New Century Health); submit via Evolent's website (https://my.newcenturyhealth.com) or call 844‑926‑4528, option 5, with eFax option provided.

• Lung biopsy/resection codes include: 32096, 32097, 32505, 32607, 32608, 32666

Molecular diagnostic and genetic testing require prior authorization

Molecular diagnostic and genetic testing require prior authorization; an extensive CPT/HCPCS code list is provided in the policy and must be referenced when submitting requests.

• Sample codes include: 81105, 81112, 81120, 81121, 81161–81168, 81175–81195, and numerous 812xx–813xx series codes (see policy list)

Pain infusion pumps require prior authorization via Cohere

Pain infusion pumps and related supplies require prior authorization via the Cohere portal (Next.Coherehealth.com); submit requests online or via Cohere phone/fax and include necessary documentation.

• Pain infusion pump codes include: 62324–62327, 62350, 62351, 62360–62362, 64999, C1772, C1891, C2626, C9804, C9806, E0782, E0783, E0785

Examples of Cohere‑managed services and submission requirement

Many device and procedure codes (examples listed: L2006, L2010, E0782, C1772, etc.) are managed by Cohere Health; prior authorization requests for these services must be submitted through the Cohere portal, phone or fax and expedited cases can be monitored on the portal.

• Example Cohere‑managed HCPCS/CPT codes: L2006, L2010, L2020, L2030, L2106, E0782, C1772

Peripheral revascularization and prostate surgery prior authorization routing

Peripheral revascularization procedures (atherectomy, angioplasty) require prior authorization via the Cohere portal (Next.Coherehealth.com); prostate surgeries (prostatectomy) prior authorizations are managed by Evolent and should be submitted via their website or phone.

• Peripheral revascularization example codes: 0234T–0238T, 37236–37298 series, 0505T, C9764–C9775
• Prostate surgery codes: 55801, 55810, 55812, 55815, 55821, 55831, 55840, 55842, 55845, 55866–55869, 55880

Radiation therapy requires prior authorization (Evolent managed)

All states require prior authorization for radiation therapy; Evolent (formerly New Century Health) manages radiation therapy prior authorizations—submit via Evolent's website or call 844‑926‑4528 (option 4); eFax option also provided.

• Radiation therapy sample codes: 32701, 61796, 63620, 77280, 77290, 77301, 77338, 77371–77373, 77402, 77407, 77412, 77423–77425, 77436–77438, G0339, G0340, L8499, L8720, L8721

Prosthetics codes listed; follow provider contact instructions for authorization

A large list of prosthetics codes in the policy indicates prior authorization requirements or inclusion; providers should follow the surgical services contact instructions (call Evolent Surgical Services or eFax) for submission and inquiries.

• Sample prosthetics codes include: 21081, 21082, 21084, A9282, L5000–L5681 (extensive list in policy)

90‑day active treatment prior‑authorization waiver and required supporting indicator

During the first 90 days after a member's Humana enrollment, prior authorization is waived for basic Medicare benefits for active courses of treatment that began prior to enrollment; Humana may review services against coverage criteria when determining payment—include CP2023011 modifier or medical records showing active course of treatment.

Cohere Health submission required for specified spinal and device services

Certain services listed (spinal cord stimulators; spinal fusion/decompression/kyphoplasty/vertebroplasty; select device and surgical codes) must be submitted to Cohere Health via Next.Coherehealth.com; onboarding information, phone (833‑283‑0033) and fax (857‑557‑6787) are provided and expedited/urgent cases can be submitted and monitored on the portal.

• Examples: spinal cord stimulator codes 0784T, 0785T, 63650, 63655, 63663, 63664, 63685, 63688, 64999, C1816, C1820, C1822, L8679, L8682

Notification/authorization required for transplants, VADs, and varicose vein procedures

Transplant evaluations require notification via the Cohere portal (Next.Coherehealth.com); transplant surgeries, ventricular assist devices (VADs) and varicose vein surgical treatments require prior authorization or notification via the Cohere portal with phone (833‑283‑0033) and fax (857‑557‑6787) support; expedited/urgent cases can be submitted and monitored on the portal.

• Transplant surgery example codes: 32850–32854, 33927–33929, 33935, 33945, 38205–38206, 38230–38243, 44135, 47133, 47135, 48160, 48550–48556, 50300–50370, 50547, 0584T–0586T, G0341–G0343, L8698
• VAD codes: 33990–33995
• Transplant evaluation notification code: 99199*