OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.

CurrentHumanaPolicy N/A

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

Customize your policy alerts

Sign up for all Humana policy alerts

Know when Humana releases new policies or updates existing guidance.

Monitor payer policy activity

Receive email alerts as soon as relevant payer policies are published or updated.

Lists services and medications requiring prior authorization or notification for Humana Medicare Advantage (MA) and D-SNP plans, and describes provider submission methods and vendor routing; affects providers serving Humana MA and D-SNP members.

Policy Summary

PayerHumana

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

Policy CodePolicy N/A

Change TypeNo material change

Effective DateJuly 1, 2026

Last ReviewJun 1, 2026

Next Review DateN/A

Key ActionSubmit prior authorization requests for Cohere-managed services via the Cohere portal (Next.Coherehealth.com) or call 833-283-0033; include supporting clinical information and use the CP2023011 modifier or medical records when the member is in an active course of treatment during the first 90 days after enrollment.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

Cohere portalprimary submission channel

90 daysactive treatment waiver

7 daysCMS decision timeframe

10 / 6

max codes per request

Prior Authorization & Notification Coverage Criteria

Prior authorization and notification requirements (overview)

Services and medications listed require prior authorization before being provided or administered; specific CPT/HCPCS codes and management instructions are provided per service category. Investigational/experimental items are generally not covered. Urgent/emergent services are exempt.

Services and medications in this list require prior authorization before being provided or administered and must meet Medicare medical necessity guidelines.

Service categories include

Surgical procedures (see listed codes); some surgical services are managed by Evolent (New Century Health) — follow vendor submission instructions.
Cardiac devices and implant procedures (see listed codes); many cardiac device authorizations are managed by Cohere — submit via their portal.
Behavioral health services (e.g., partial hospitalization, TMS) listed require prior authorization as indicated by CPT/CPT-like codes.
Durable medical equipment (DME), diagnostics, advanced imaging, molecular/genetic testing, device implants, and select therapies have code-based prior authorization requirements; reference the code lists in the policy.

Prior authorization coverage criteria (summary)

Service categories and code lists requiring prior authorization/notification (managed via Cohere unless otherwise stated):

Cardiac procedures and devices: listed CPT/HCPCS codes (e.g., catheterization/angioplasty series, implantable device codes) require prior authorization; many are managed via the Cohere portal (Next.Coherehealth.com).

Diagnostic and advanced imaging: CT, MRI/MRA, PET, SPECT and related codes listed require prior authorization/notification; Cohere manages many of these (state exceptions apply).

Durable Medical Equipment (DME): specified DME codes (airway clearance, UV therapy, hospital beds, etc.) require prior authorization as listed in the policy.

Procedural categories: epidural/facet injections, electrophysiology studies, spinal procedures, and other listed procedures have code-specific prior authorization requirements; some are Cohere-managed.

New-member active treatment rule: no prior authorization required for basic Medicare benefits during the first 90 days of a new member's enrollment for active courses of treatment that began prior to enrollment; include CP2023011 modifier or medical records to support active course.

First 90 days active treatment exception

Temporary administrative exception for new members

Humana does not require prior authorization for basic Medicare benefits during the first 90 days of a new member's enrollment for active courses of treatment that started prior to enrollment.

Humana may review services furnished during the active course of treatment against coverage criteria when determining payment; to ensure appropriate claim payment include the modifier per Humana's Medicare Advantage Payment Policy (CP2023011) or attach medical records demonstrating the active course of treatment.

Submission requirements and vendor routing

Vendor-managed authorization routing — submit prior authorization requests through the specified vendor portals or contact channels.

Cohere-managed services: submit prior authorization requests via Next.Coherehealth.com; phone support 833-283-0033; fax 857-557-6787. Expedited/urgent cases can be submitted and monitored on the Cohere portal.

Evolent-managed services (formerly New Century Health): certain surgical, oncology and radiation therapy prior authorizations are managed by Evolent; submit via https://my.newcenturyhealth.com or call 844-926-4528 (options provided), or use eFax where listed.

Home health/home infusion: all states require prior authorization; Tango or Humana Home Solutions manage authorizations for specific states as noted — follow state-specific routing in the policy.

Codes requiring prior authorization

Code-specific prior authorization lists are provided for molecular/genetic testing and many device/DME categories; reference the full lists for applicable codes.

Molecular diagnostic and genetic testing: an extensive list of CPT/HCPCS/proprietary codes (see policy) require prior authorization before testing is performed.

Device and DME items: ventilators, vests, stimulators, skin/tissue substitutes and other HCPCS/CPT/Q-codes listed require prior authorization; consult the specific code lists in the policy for details.

Continuity-of-care rules

Continuity-of-care and claim submission guidance for active treatment during new-member enrollment.

90-day continuity-of-care: Humana does not require prior authorization for basic Medicare benefits during the first 90 days after a member's enrollment for active courses of treatment that began prior to enrollment.

Documentation for claims: include the CP2023011 modifier per Humana's Medicare Advantage Payment Policy or attach medical records showing the member is in an active course of treatment to support appropriate claim payment and avoid disruption of care.

Vendor submission and code-based authorization criteria

Vendor-managed prior authorization requirements and submission instructions — use the vendor-specific portals and contacts for listed service groups.

Submit Cohere-managed service authorizations at Next.Coherehealth.com (organization onboarding link if not registered); phone 833-283-0033; fax 857-557-6787. Expedited/urgent cases can be submitted and monitored on the Cohere portal.

Submit Evolent-managed authorizations (including radiation therapy) via Evolent's portal (https://my.newcenturyhealth.com) or call 844-926-4528 (options provided); eFax options available per policy.

Reference the long code lists in the policy: multiple HCPCS/CPT/Q-code lists identify services requiring vendor-managed authorization; providers must reference the applicable list for their service and jurisdiction.

State-specific note: radiation therapy prior authorization is required in all states and is managed by Evolent; other services may have state exceptions for Cohere management (see state-specific guidance).

90-day active treatment waiver

Prior-authorization waiver for active courses of treatment that began before Humana enrollment.

No prior authorization required for basic Medicare benefits during the first 90 days of a new member's enrollment if the member is in an active course of treatment that started prior to enrollment.

Humana may review services furnished during the active course of treatment against coverage criteria when determining payment; include CP2023011 modifier or medical records documenting active treatment to support claims processing.

Code Lists and Coding Rules

sample codes listed in PALmixedCovered

15830	Abdominoplasty
15847	(listed with abdominoplasty in PAL)
93650	Cardiac ablation (cardiac ablation/electrophysiology codes listed)
90867	Transcranial magnetic stimulation (TMS) code listed
E0747	Bone growth stimulator (example HCPCS)
19120	Breast lumpectomy
33206	Cardiac device implantation (example CPT listed)

Cardiac proceduresCPTCovered

93451-93459	Cardiac catheterization series codes referenced in list
92920	Coronary angioplasty/stent related code (listed with series 92924,92928,92930,92933,92937,92943,92945,92972)
92924	Coronary angioplasty/stent related code
92928	Coronary angioplasty/stent related code
92930	Coronary angioplasty/stent related code
92933	Coronary angioplasty/stent related code
92937	Coronary angioplasty/stent related code
92943	Coronary angioplasty/stent related code
92945	Coronary angioplasty/stent related code
92972	Coronary angioplasty/stent related code

1–10 of 17

1/2

Imaging servicesCPT | HCPCSCovered

70460-70492,70496,70498	CT and related head/neck diagnostic imaging codes listed for prior authorization (CT series referenced)
70540-70553	MRI head/neck series listed (MRA/MRI codes listed)
73218-73220	Musculoskeletal MRI codes listed
73718-73720	Lower extremity MRI codes listed
74160-74178	Abdominal/pelvic CT/MRI codes listed
75572-75574	Cardiac CT/MRI codes listed
71260,71270,71275	CT chest series listed
72126,72127,72130,72132,72133,72191,72193,72194	Spine CT/MRI codes listed
70544-70549,71555,72159,72198,73225,73725,74185	MRA/MRI and associated advanced imaging codes listed
C8900-C8936	Proprietary imaging HCPCS codes listed

Durable medical equipment (DME)HCPCSCovered

E0469	Airway clearance device (listed under DME airway clearance)
E0481	Airway clearance device (listed)
E0482	Airway clearance device (listed)
E0691	UV Light Therapy device (E0691-E0694 series listed)
E0692	UV Light Therapy device
E0693	UV Light Therapy device
E0694	UV Light Therapy device
E0193	Hospital bed and accessories (hospital beds and accessories list includes E0193-E0304)
E0194	Hospital bed and accessories
E0265	Hospital bed accessory

1–10 of 18

1/2

Pain management injectionsCPTCovered

62320	Epidural injection (outpatient)
62321	Epidural injection (outpatient)
62322	Epidural injection (outpatient)
62323	Epidural injection (outpatient)
64479	Epidural steroid injection code
64480	Epidural steroid injection code
64483	Epidural steroid injection code
64484	Epidural steroid injection code
64999	Unlisted procedure (epidural-related)
64490	Facet injection code

1–10 of 25

1/3

Sleep studies (facility-based PSG)CPTCovered

95807	Facility-based polysomnography (PSG)
95808	Facility-based sleep study
95810	Polysomnography
95811	Polysomnography

Negative pressure wound therapy (NPWT)mixedCovered

97605	Negative pressure wound therapy, wound(s) ≤50 cm2
97606	Negative pressure wound therapy, wound(s) >50 cm2
A6550	NPWT canister, single use
E2402	NPWT pump/related HCPCS (listed)
K0743	NPWT-related supply code (listed)

Noninvasive home ventilatorsHCPCSCovered

E0466	Noninvasive home ventilator
E0468	Noninvasive home ventilator, with backup rate feature

Cohere-managed device and procedure codes (partial)HCPCS | CPT | mixed

E0782	Pain infusion pump supplies/therapy (listed for Cohere-managed prior authorization)
L2006	Orthotic/prosthetic related HCPCS (example from Cohere list)
L2010	Orthotic/prosthetic HCPCS listed
C1772	Device code listed among Cohere-managed items
C1891	Device code listed among Cohere-managed items
C2626	Device code listed among Cohere-managed items
C9804	Device code listed among Cohere-managed items
C9806	Device code listed among Cohere-managed items

Skin and tissue substitutesHCPCS | Q-code | mixed

A2001	Skin and tissue substitute (listed in skin/tissue substitute list)
Q4101	Skin substitute Q-code (example listed)
Q4151	Q-code listed in additional skin/tissue substitutes list

Additional Q-code listsQ-code | mixed

Q4276	Q-code listed in continuation lists for substitutes and related items
Q4152	Additional Q-code from long list (Q4152)

Spinal cord stimulator codesmixedCovered

0784T	Spinal cord stimulator related T-code listed
0785T	Spinal cord stimulator related T-code listed
63650	Spinal cord stimulator implantation code
63655	Spinal cord stimulator implantation code
63663	Spinal cord stimulator lead insertion code
63664	Spinal cord stimulator lead insertion code
63685	Spinal cord stimulator revision/replacement code
63688	Spinal cord stimulator removal/revision code
64999	Unlisted procedure (used in spinal cord stimulator list)
C1816	Related device HCPCS listed

1–10 of 14

1/2

Transplant and VAD codesmixedCovered

32850	Transplant surgery code listed
32851	Transplant surgery code listed
32852	Transplant surgery code listed
32853	Transplant surgery code listed
32854	Transplant surgery code listed
33927	VAD/heart-related surgery code listed
33928	VAD/heart-related surgery code listed
33929	VAD/heart-related surgery code listed
33935	Cardiac surgery code listed
33945	Cardiac surgery code listed

1–10 of 39

1/4

inv-24: maximum procedure codes per request

Maximum procedure codes per authorization request10 procedure codes per authorization request (include up to 10 CPT/HCPCS procedure codes)

Required patient identifiersMember Humana ID, name and date of birth (include date of service or admission)

Provider identifiersTIN and NPI of performing provider and TIN/NPI of facility where service is rendered

Service location and datesSpecify service location (inpatient/outpatient/ASC/home) and date of proposed procedure or admission

Provider Submission Steps, Contacts, and Operational Guidance

Prior Authorization

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.

Denial Risk

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.

Key Definitions

inv-49: prior authorization

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

PurposeDetermines coverage and ensures services meet Medicare medical necessity guidelines

Relation to notificationsDistinct from notification; notification informs Humana of intent to provide a service but does not constitute approval or denial

inv-50: notification

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

PurposeHelps Humana coordinate care for covered patients

Policy Summary

PayerHumana

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

Policy CodePolicy N/A

Change TypeNo material change

Effective DateJuly 1, 2026

Last ReviewJun 1, 2026

Next Review DateN/A

SourceLink

On This Page

Clinical/supporting informationPrimary and secondary diagnosis codes (up to 6), relevant clinical information, attending physician contact, and discharge plans

inv-25: maximum diagnosis codes per request

Maximum diagnosis codes per authorization request6 diagnosis codes per authorization request (include primary and secondary diagnoses)

Required clinical detailsRelevant clinical information and attending physician telephone number to support diagnoses

Claim support recommendationInclude medical records when relevant to substantiate diagnosis and medical necessity

Link to active treatment guidanceWhen applicable include modifier CP2023011 or medical records to document active course of treatment for new members

inv-26: Drug list updates

Chemotherapy/supportive drug code listThe chemotherapy, supportive agents and symptom management drug code list is subject to change; follow the linked/current codes list as indicated in the policy

Active-treatment continuity noteTo prevent disruption of care during transitions, include CP2023011 modifier or medical records when chemotherapy/supportive drugs are part of an active course of treatment

Onboarding and vendor managementSome drug-related authorizations or associated services may be managed via vendor portals (see Cohere onboarding instructions) — verify current routing before submission

inv-27: Home health prior auth - state routing

Home health prior authorization requirementAll states require prior authorization for home health services; prior authorization must be obtained before services are provided

State routing — TangoTango manages home health prior authorization requests for Humana MA members in Arizona, Colorado and New Mexico (Phone: 888-705-5274; Fax: 877-612-7066)

Vendor portal and Cohere contactHome health requests are monitored on the Cohere portal (Next.Coherehealth.com) and questions can be directed to Cohere at 833-283-0033

Code examples for home health/home infusionCommon home health/home infusion codes include 99512, 99600, G0151–G0162, G0299–G0300, G0493–G0496, G2168–G2169

Prior Authorization

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.

Prior Authorization

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.

Prior Authorization

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.

Prior Authorization

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.

Documentation Required

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.

Prior Authorization

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

Prior Authorization

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

Prior Authorization

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

Prior Authorization

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

Prior Authorization

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

Prior Authorization

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)

Prior Authorization

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

Prior Authorization

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

Prior Authorization

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

Prior Authorization

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

Documentation Required

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)

Prior Authorization

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.

Prior Authorization

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

Prior Authorization

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*

DistinctionNotification is distinct from prior authorization and does not replace authorization when required

inv-51: Cohere-managed services (scope)

ScopeServices handled by Cohere include numerous surgical, device and procedure categories (e.g., MRI/CT imaging, spinal procedures, pain pumps, orthopedic arthroplasty, transplant notification/ surgeries, varicose vein treatments)

Submission methodsSubmit prior authorization requests via Cohere portal (Next.Coherehealth.com), phone 833-283-0033, or fax 857-557-6787; expedited/urgent cases can be submitted and monitored on the portal

OnboardingIf not registered, use Cohere organization onboarding link: https://next.coherehealth.com/organization_onboarding

inv-52: Active course of treatment exemption (short)

Exception summaryHumana does not require prior authorization for basic Medicare benefits during the first 90 days of a new member's enrollment for active courses of treatment that started prior to enrollment

Payment reviewHumana may review services furnished during the active course of treatment against coverage criteria when determining payment

Documentation for claimsInclude the modifier per Humana Medicare Advantage Payment Policy (CP2023011) or medical records showing the member is in an active course of treatment

inv-53: Active course of treatment (definition)

DefinitionActive course of treatment: ongoing clinically necessary care that started prior to a member's Humana enrollment

90-day ruleDuring the first 90 days post-enrollment Humana does not require prior authorization for basic Medicare benefits for these ongoing treatments

Claim supportTo ensure appropriate payment include CP2023011 modifier or provide medical records evidencing active treatment

inv-54: Cohere portal (portal/contact)

Portal URLNext.Coherehealth.com (Cohere Health portal) is the primary online submission channel for Cohere-managed prior authorizations

Phone supportCohere provider phone: 833-283-0033, Monday–Friday, 8 a.m.–8 p.m. Eastern

Fax numberCohere fax: 857-557-6787; expedited/urgent cases can be sent and monitored via the portal

inv-55: Active course of treatment (alternate chunk)

Alternate wording of active treatment ruleTo prevent disruption of care, Humana does not require prior authorization for basic Medicare benefits during the first 90 days of a new member's enrollment for active courses of treatment that started prior to enrollment

Evidence requirementHumana may review services against coverage criteria; include CP2023011 modifier or medical records to document active course of treatment

ApplicabilityApplies to basic Medicare benefits for Humana MA and D‑SNP members

inv-56: Cohere-managed services (submission channels)

Submission channelsCohere portal (Next.Coherehealth.com), phone 833-283-0033, and fax 857-557-6787 are supported submission channels for Cohere-managed services

Expedited/urgent handlingExpedited/urgent cases can be submitted and monitored on the Cohere portal

Onboarding linkProviders not registered should use https://next.coherehealth.com/organization_onboarding to request a Cohere account

inv-57: Evolent-managed services

ScopeEvolent (formerly New Century Health) manages prior authorizations for radiation therapy and certain surgeries (e.g., lung biopsy/resection)

Submission optionsSubmit via Evolent website (https://my.newcenturyhealth.com) or call 844-926-4528 (optioned lines); eFax 213-596-3783 or efax-carepro-oncology@newcenturyhealth.com

All-states requirement for RTAll states require prior authorization for radiation therapy, and Evolent will manage these requests

inv-58: Active course of treatment (detailed)

Detailed definitionActive course of treatment: an ongoing treatment that started prior to the member's Humana enrollment; prior authorization is not required for basic Medicare benefits during the first 90 days of new enrollment

Humana reviewHumana may review services furnished during the active course against coverage criteria when determining payment

Claim documentationInclude CP2023011 modifier or medical records evidence to support active course of treatment for claim payment

inv-59: Cohere-managed services (detailed scope)

Cohere-managed scope (detailed)Cohere manages prior authorizations for multiple service categories including imaging (CT/MRI), spinal procedures (fusion, decompression, kyphoplasty/vertebroplasty), orthopedic arthroplasty, pain infusion pumps, transplant notification/surgery, varicose vein procedures and many device-related items

Contact and monitoringUse Next.Coherehealth.com portal; phone 833-283-0033; fax 857-557-6787; expedited/urgent cases can be submitted and monitored on the portal

Registration/onboardingProviders should use the Cohere organization onboarding link if not registered: https://next.coherehealth.com/organization_onboarding