CurrentHumanaPolicy N/A

Prior authorization and Notification List — Humana Healthy Horizons (South Carolina)

Governs which services, procedures, durable medical equipment and medications require prior authorization or notification for Humana Healthy Horizons (South Carolina Medicaid) providers; affects providers delivering care to members of this product.

Policy Summary

PayerHumana

PolicyPrior authorization and Notification List — Humana Healthy Horizons (South Carolina)

Policy CodePolicy N/A

Change TypeMinor revision — no material clinical or coverage changes

Effective DateJul 1, 2025

Next Review DateN/A

Key ActionObtain prior authorization for listed services or submit required notifications (use Availity, IVR, or specified fax numbers).

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

≥20Service categories listed

100+ codesExtensive code lists

NICU & OB timingNotification timing

Apr 21, 2026Revision noted

Prior Authorization & Notification Overview

Policy Summary

PayerHumana

PolicyPrior authorization and Notification List — Humana Healthy Horizons (South Carolina)

Policy CodePolicy N/A

Change TypeMinor revision — no material clinical or coverage changes

Effective DateJul 1, 2025

Next Review DateN/A

Key ActionObtain prior authorization for listed services or submit required notifications (use Availity, IVR, or specified fax numbers).

SourceLink

On This Page

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Prior Authorization

Prior authorization and notification overview

Prior authorization is required for the items and services listed in this Prior authorization and Notification List; notification is a separate process and does not constitute plan approval. Urgent/emergent services do not require prior authorization or notification. Providers should verify benefits and PA/notification requirements with Humana prior to providing services.

Prior Authorization

Prior authorization submission channels

Submit prior authorization requests online via Availity.com (registration required), by calling the Humana IVR at 800-523-0023, or by faxing the prior authorization form to 833-441-0950. For behavioral health prior authorization, call the Behavioral Health Crisis Line at 833-364-2274 or use the same Availity/IVR/fax channels. Medication prior authorization requests may be faxed to 888-447-3430 or initiated by calling 866-461-7273 (M–F, 8 a.m.–11 p.m. ET).

Availity.com (registration required)
IVR: 800-523-0023
Fax: 833-441-0950
Behavioral Health Crisis Line: 833-364-2274
Medication fax: 888-447-3430; phone: 866-461-7273 (M–F, 8am–11pm ET)

Which services require prior authorization or notification

General coverage stance — prior authorization and notification overview

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Home health PA requirement

ALL of the following

Home health/home infusion services require prior authorization after five visits.
Codes requiring prior authorization when visits exceed five: 99344, 99501, 99502, 99511, 99512, S5165, S9001, S9128, S9129, S9131, T1021, T1030, T1031.
Providers should submit clinical documentation supporting medical necessity, frequency and duration when requesting authorization.
Requests may be submitted via Availity, Humana IVR (800-523-0023), or fax (833-441-0950).

Authorization and notification requirements (procedures, service categories, and codes)

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Codes and Code Groups Requiring Prior Authorization / Notification

Ablation / Electrophysiology — Covered CPT (prior authorization/notification)CPTCovered

20982	Ablation, secondary procedure (example listed)
20983	Ablation, additional codes
47370	Laparoscopic liver ablation
47371	Laparoscopic liver ablation, additional
47380	Percutaneous liver ablation
47381	Percutaneous liver ablation, additional
47382	Other liver ablation
47383	Other liver ablation, additional
50250	Liver ablation, open
50541	Percutaneous renal tumor ablation

1–10 of 20

1/2

Behavioral Health — Covered HCPCS/CPT/Codes (prior authorization/notification)mixedCovered

H2035	Alcohol/drug day treatment/partial hospitalization
0362T	ABA therapy code
0373T	ABA therapy code
97153	Adaptive behavior treatment by technician
97154	Adaptive behavior treatment with technician (group)
97155	Adaptive behavior treatment with protocol modification
97156	Family adaptive behavior treatment guidance by technician
97157	Multiple-family group adaptive behavior treatment guidance
97158	Group adaptive behavior treatment by technician
H0040	Assertive community treatment (ACT)

1–10 of 28

1/3

Durable Medical Equipment (DME) — Covered HCPCS (prior authorization/notification)HCPCSCovered

E2508	Augmentative/alternative communication device
E2510	AAC device, dedicated speech generating
E2512	AAC component
E2599	Miscellaneous communication device
E0272	Hospital bed accessory
E0277	Hospital bed accessory
E0301	Bed system component
E0302	Bed system component
E0303	Bed system component
E0304	Bed system component

1–10 of 38

1/4

Diagnostic Imaging / Procedures — Covered CPT (prior authorization/notification)CPTCovered

78451	Myocardial perfusion imaging, tomographic (SPECT) with quantitative attenuation correction
78452	Myocardial perfusion imaging, tomographic (SPECT) with attenuation correction, each additional
91110	Capsule endoscopy, small bowel
91111	Capsule endoscopy, colon or combined

Molecular Diagnostic / Genetic Testing — Covered CPT (prior authorization/notification)CPTCovered

81162	EGFR mutation analysis
81163	EGFR mutation analysis, additional
81164	Genetic test
81165	Genetic test
81166	Genetic test
81167	Genetic test
81201	BRCA1 full sequence
81202	BRCA2 full sequence
81203	BRCA rearrangement
81243	Genetic test code listed in policy

1–10 of 45

1/5

Other Services — Covered HCPCS (prior authorization/notification)HCPCSCovered

A2001	Skin substitute product
A2002	Skin substitute product
A2005	Skin substitute product
A2007	Skin substitute product
A2008	Skin substitute product
A2013	Skin substitute product
A2022	Skin substitute product
A2025	Skin substitute product
Q4100	Placental tissue matrix
Q4112	Skin substitute

1–10 of 85

1/9

Pain Management & Spinal Procedures — Covered CPT (prior authorization/notification)CPTCovered

62320	Epidural injection
62321	Epidural injection
62323	Epidural injection
64479	Epidural injection, therapeutic
64480	Epidural injection, therapeutic
64483	Epidural injection, diagnostic
64484	Epidural injection
64490	Facet joint injection
64491	Facet joint injection
64492	Facet joint injection

1–10 of 23

1/3

Radiology: CT, MRI, MRA, Nuclear medicine, PET — Covered CPT (prior authorization/notification)CPTCovered

70450	CT head/brain without contrast
72191	CT cervical spine without contrast
70544	Head MRI with/without contrast
75571	Cardiac MRI
78429	PET whole body

Surgery (selected) — Covered CPT (prior authorization/notification)CPTCovered

15830	Excision, redundant skin (abdominoplasty)
15847	Tissue rearrangement
69930	Cochlear implant procedure
55970	Gender affirmation procedure

Wound Care (NPWT) — Covered CPT/HCPCS (prior authorization/notification)mixedCovered

97605	Negative pressure wound therapy, wound care management
97606	Negative pressure wound therapy, subsequent
A6550	NPWT supply canister
E2402	NPWT disposable canister

Nonemergent Medical Transportation (NEMT) — Covered HCPCSHCPCSCovered

A0090	Nonemergent transportation
A0120	Ambulance mileage
A0430	Ambulance service, basic life support
A0431	Ambulance service, advanced life support
A0435	Ambulance service, specialty care
A0999	Unlisted ambulance service

Home health/home infusion prior authorization thresholdPrior authorization required after five visits for the following home health/home infusion codes: 99344, 99501, 99502, 99511, 99512, S5165, S9001, S9128, S9129, S9131, T1021, T1030, T1031

NICU notification timingNotification within 48 hours of NICU admission

Obstetrical notification timingNotify if admission exceeds 48 hours (vaginal) or 96 hours (cesarean)

What Providers Must Do

Prior Authorization

Prior authorization submission channels (behavioral health specifics)

Availity.com (registration required)
IVR: 800-523-0023
Fax: 833-441-0950
Behavioral Health Crisis Line: 833-364-2274

Prior Authorization

Specialty drugs prior authorization and request process

Prior authorization is required for the specialty drugs listed when administered in the physician's office, clinic, outpatient or home setting; use the fax forms provided to request prior authorization or to provide notification.

PA required for listed specialty drugs in office, clinic, outpatient or home settings
Use fax forms to request PA or provide notification

Documentation Required

Admission notification expectations — NICU and obstetrical

Humana Healthy Horizons expects notification within 48 hours for NICU admissions to conduct concurrent review and care coordination. For obstetrical admissions, notify if the admission exceeds 48 hours (vaginal) or 96 hours (cesarean) to support concurrent review and discharge planning.

NICU: notify within 48 hours
Obstetrical: notify if >48 hours (vaginal) or >96 hours (cesarean)

Key Terms

Prior authorization — definition

DefinitionPrior authorization (also known as precertification or preadmission) is the process through which the provider or other healthcare provider is required to obtain advance approval from the plan as to whether an item or service will be covered.

ScopeApplies to items and services listed in the PAL; urgent/emergent services are excluded.

Provider actionObtain prior authorization from Humana before delivering listed services except in urgent/emergent situations.

Notification — definition and distinction from authorization

DefinitionNotification is the process of the provider or other healthcare provider notifying Humana Healthy Horizons of the intent to provide an item or service; Humana requests notification to help coordinate care for covered patients.

Distinction from authorizationA notification does not constitute plan approval—Humana does not issue an approval or denial related to a notification.

PurposeUsed to coordinate care and facilitate planning (e.g., concurrent review, discharge planning).

NEMT — Nonemergent medical transportation definition

DefinitionNonemergent medical transportation (NEMT) refers to covered transportation services for nonemergency medical needs; example HCPCS codes listed include A0090, A0120, A0430, A0431, A0435, A0999.

Coding examplesCommon NEMT HCPCS codes enumerated in the PAL: A0090, A0120, A0430, A0431, A0435, A0999.

Provider actionFollow PAL requirements for prior authorization/coverage when billing NEMT codes as specified.

CT — Computed tomography (CT) scan definition

DefinitionComputed tomography (CT) scan: radiology subcategory in the PAL enumerating CT procedure codes (examples include 70450, 70460, 70470, 70480, 70481, 70482, 70486, 70487, 70488, 70490, 70491, 70492, 70496, 70498, 71250, 71260, 71270, 71275, 72125, 72126, 72127, 72128, 72129, 72130, 72131, 72132, 72133, 72191, 72192, 72193).

ScopeCT codes listed in the PAL are subject to the plan's prior authorization requirements as indicated elsewhere in the document.

Provider actionVerify PA/notification requirements for CT procedures prior to scheduling per the PAL and member benefits.

MRA / MRI — Magnetic resonance angiogram and imaging definitions

DefinitionMagnetic resonance angiogram (MRA) and magnetic resonance imaging (MRI): radiology subcategories in the PAL with extensive lists of MRA and MRI procedure codes (examples include MRA codes 72194, 73200, 73700, 74150, 75571 and MRI codes 70544, 70546, 70548, 70549, 70551, 70552, 70553, 70554, 70555, 71550, 71551, 71552, 72141, 72142, 72146, 72147, 72148, 72149, 72156, 72157, 72158).

ScopeMRA/MRI procedures listed in the PAL may require prior authorization per the plan's requirements.

Provider actionConfirm PA/notification requirements for MRA/MRI services before providing or scheduling imaging.