Definitions: prior authorization vs. notification

Prior authorization is 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 before it is provided. 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 coordinate care but does not issue an approval or denial for notifications.

Which products this list applies to

The full prior authorization list applies to Humana MA HMO, HMO POS and MA PPO members; MA PFFS plans do not require prior authorization but do request notification and allow advance coverage determinations (ACDs); Humana Medicare Supplement plans are excluded from this list.

How to submit requests and ACDs

Submit prior authorization requests online via Availity Essentials (registration required) or by calling Humana's interactive voice response line at 800-523-0023; advance coverage determinations (ACDs) may be submitted by mail, fax or phone as listed for medical services and medications.

• ACD (medical services) mail: Humana Correspondence P.O. Box 14601 Lexington, KY 40512-4601
• ACD (medical services) fax: 800-266-3022; phone: 800-523-0023
• ACD (medications) fax: 888-447-3430; phone: 866-461-7273

Timeliness: CMS 7‑day decision requirement

Per CMS effective Jan. 1, 2026, certain prior authorization decisions must be made within 7 days; providing supporting clinical information at the time of the initial submission helps ensure timely adjudication and reduces the risk of delay or adverse decisions.

Required information to include with requests

Include the member ID, name and DOB; date of actual service or admission and proposed procedure date; procedure (up to 10) and diagnosis codes (up to 6); service location; TIN and NPI for facility and performing provider; caller/requester and attending physician contact; relevant clinical information and discharge plans.

• Procedure codes: maximum 10 per authorization request
• Diagnosis codes: maximum 6 per authorization request
• Service location options include inpatient, outpatient, telehealth, office, home, ASC

Route requests to delegated managers when indicated

When services are delegated, submit prior authorization requests to the named vendor (for example, Evolent/New Century Health or Cohere Health) per the routing instructions in the list—Evolent manages certain oncology/surgical lines and specific procedures; Cohere Health manages many cardiac devices, imaging and orthopedic lines.

• Evolent (formerly New Century Health) manages certain ablation and oncology surgical requests (see Evolent contact in list).
• Cohere Health manages many cardiac devices and related procedures; use Cohere portal/phone/fax per vendor instructions.

Exceptions: urgent care and active treatment protection

Urgent or emergent services do not require prior authorization or notification. New members in an active course of treatment have a 90‑day protection during which Humana does not require prior authorization for basic Medicare benefits started before enrollment.

• Urgent/emergent services: no referrals, prior authorization or notification required
• Active course of treatment protection: first 90 days of new member enrollment

Consequences of not obtaining required authorization/notification

Failure to obtain required prior authorization or notification may result in financial penalties to the practice, reduced patient benefits per contract/Evidence of Coverage, and retrospective medical necessity review of services provided without authorization.

Diagnostic & cardiac imaging: submit to Cohere Health

Prior authorization requests for diagnostic and cardiac imaging codes listed in the policy (CT/MRI and related codes) must be submitted to Cohere Health via their portal, by phone at 833-283-0033, or by fax at 857-557-6787; expedited/urgent cases can be submitted and monitored on the Cohere portal.

• Sample imaging codes include: 70460, 70470, 70540, 73718, 74170 (see list for full codes)
• Cohere portal is the preferred online submission method

Lung biopsy/resection: managed by Evolent

Lung biopsy and resection preauthorization requests are managed by Evolent (formerly New Century Health); submit requests on Evolent's website or call Evolent at 844-926-4528, option 5 for Surgical Services to speak to a live representative.

• Sample procedure codes: 32096, 32097, 32505, 32607, 32608, 32666

Home health: submit authorizations to One Home Care

Home health services and the listed home health CPT/G‑codes require authorization through One Home Care; submit authorizations to that vendor per the routing in the list.

• Sample home health codes: 99512, 99600, G0151–G0157 (see list for full set)

Inpatient admissions require prior authorization

All inpatient admissions—including acute hospital, acute rehabilitation, long‑term acute care and mental health/substance use treatment (including residential)—require prior authorization.

• Codes/comments: ALL (authorization required for all inpatient admissions)

Orthopedic arthroplasty: managed by Cohere Health

Hip, knee and shoulder arthroplasty prior authorization requests are now managed by Cohere Health; submit via the Cohere portal, by phone at 833-283-0033, or by fax at 857-557-6787; expedited cases can be submitted and monitored on the Cohere portal.

Orthopedic arthroscopy: managed by Cohere Health

Hip, knee and shoulder arthroscopy prior authorization requests are managed by Cohere Health; submit via the Cohere portal, phone 833-283-0033, or fax 857-557-6787; expedited cases can be submitted and monitored on the Cohere portal.

Peripheral revascularization: submit to Cohere Health

Peripheral revascularization procedures (atherectomy, angioplasty and listed T/CPT codes) are managed by Cohere Health; submit prior authorization on the Cohere portal or via phone/fax, and use the portal for expedited/urgent case submission and monitoring.

• Sample codes include: 0627T–0630T, 0234T–0238T, 37236, 37238, 37254–37271 (see list for full codes)

Prostate surgery & radiation therapy: managed by Evolent

Prostate surgeries (prostatectomy) and radiation therapy preauthorization requests are managed by Evolent (formerly New Century Health); submit via Evolent's website or call 844-926-4528, option 5 for Surgical Services; eFax and email contact details for oncology/radiation submissions are provided.

• Evolent live reps available Monday–Friday, 8 a.m.–8 p.m. ET
• Evolent eFax number: 213-596-3783; eFax email for oncology: efax-carepro-oncology@newcenturyhealth.com

Wound therapy and pain pumps require authorization

Negative pressure wound therapy (NPWT) and pain infusion pump codes listed in the policy require prior authorization/notification per the list.

• Sample NPWT and related codes: 97605, 97606, A6550, E2402, K0743
• Pain infusion pump and related injection codes listed (see policy for full code set)

Radiation therapy prior auth routing: Evolent

Radiation therapy preauthorizations are managed by Evolent (formerly New Century Health); requests may be submitted via Evolent's website or by calling 844-926-4528, option 5 for Surgical Services, with live representatives available M–F 8 a.m.–8 p.m. ET and eFax/email options provided.

• Radiation therapy sample codes: 77280–77778, 77387, G0339, G0340, G0458 (see list for full codes)

Cohere Health prior authorization routing and contacts

Cohere Health now manages prior authorizations for multiple service lines including spinal cord stimulators, spine surgeries (fusion, decompression, kyphoplasty/vertebroplasty) and other listed services; submit on Cohere Health's portal, or call 833-283-0033 M–F 8 a.m.–8 p.m. ET or fax 857-557-6787. Expedited/urgent cases can be submitted and monitored via the Cohere portal.

• Spinal cord stimulator sample codes: 0784T–0785T, 63650–63688, C1816, L8679 (see list for full codes)
• Spine surgery sample codes include 20999, 22100–22634, 22800–22899, 27278–27280 (see list)

Use vendor portals for expedited/urgent submissions

Select service lines (for example transplant evaluation/surgeries, varicose vein procedures, VADs and other specified services) allow expedited/urgent submission and monitoring through the vendor portal (Cohere Health) for faster handling of urgent cases.

• Use Cohere portal to submit and monitor expedited/urgent cases
• Examples calling out expedited routing include transplant evaluation/ surgeries and varicose vein procedures