Definitions and general authorization guidance

The policy defines “prior authorization” as the process requiring the physician or other healthcare provider to obtain advance approval from the plan before an item or service will be covered. “Notification” is defined as the process by which the provider notifies Humana of the intent to provide an item or service; Humana does not issue approval or denial for notifications. The PAL lists services and medications that require prior authorization before being provided or administered and notes that services must meet Medicare/CMS medical necessity guidelines.

How to request prior authorization

Submit prior authorization requests to the manager indicated for the service: Humana-managed medical requests online via Availity (www.availity.com) or by Humana IVR at 800-523-0023; Carelon Behavioral Health requests via their portal, phone (IVR 855-371-9234 or direct 855-235-8530) or fax 855-371-9232.

Vendor-managed authorization routing

Certain service categories are managed by external vendors and must be submitted through those vendors' channels (for example, many cardiac devices/procedures, transcatheter valves, cellular/CAR-T and other specialized therapies). Providers must route requests to the vendor managing that service as listed in the PAL.

Urgent services and CMS timeline

Urgent or emergent services do not require referrals, prior authorization or notification. For certain prior authorization requests CMS requires decisions within 7 days effective Jan 1, 2026; include supporting clinical information at submission to support timely adjudication.

Required information for authorization requests

Authorization or notification requests should include patient identifiers, service dates, coding and provider details: at minimum member Humana ID, name and DOB; actual or proposed service date; up to 10 procedure codes and up to 6 diagnosis codes per request; service and inpatient/outpatient location; TIN and NPI of facility and performing provider; caller name/phone; attending physician phone; relevant clinical information; and discharge plans as applicable.

• Procedure codes: up to 10 maximum per authorization request
• Diagnosis codes: up to 6 maximum per authorization request

Cohere submission instructions

For services managed by Cohere Health, submit prior authorization requests via the Cohere portal at Next.Coherehealth.com; onboarding information is at https://next.coherehealth.com/organization_onboarding. Cohere provider resources are at www.coherehealth.com/provider/resources and Cohere phone is 833-283-0033 (Mon–Fri 8 a.m.–8 p.m. ET); fax 857-557-6787. Expedited/urgent cases can be submitted and monitored on the Cohere portal.

• Onboarding link: https://next.coherehealth.com/organization_onboarding
• Portal login: Next.Coherehealth.com
• Phone: 833-283-0033; Fax: 857-557-6787

Evolent submission instructions

Evolent (formerly New Century Health) manages certain surgical and radiation therapy prior authorizations; submit requests via Evolent's website (https://my.newcenturyhealth.com) or call 844-926-4528 (option 5 for Surgical Services) Mon–Fri 8 a.m.–8 p.m. ET; eFax 213-596-3783 is available.

• Evolent portal: https://my.newcenturyhealth.com
• Phone: 844-926-4528 (options vary by service)
• eFax: 213-596-3783

Inpatient and observation

Inpatient admissions and observation notifications are required as listed for settings including acute hospital (including inpatient hospice), acute rehabilitation, long‑term acute care (LTAC), mental health/substance use/residential treatment and skilled nursing; observation requires notification for all observation services.

• Inpatient locations: acute hospital, acute rehab, LTAC, mental health/substance use/residential treatment, skilled nursing
• Observation: observation notification required (All)

Cohere-managed authorizations (examples)

Examples of services managed by Cohere include pain infusion pumps, spinal procedures (e.g., spinal cord stimulators), imaging/MRA, peripheral vascular procedures and many orthopedic surgeries — submit via Next.Coherehealth.com, phone 833-283-0033 or fax 857-557-6787; expedited/urgent cases can be submitted and monitored on the portal.

Evolent-managed authorizations (examples)

Evolent manages examples such as prostate surgeries and radiation therapy; providers must submit those prior authorization requests via my.newcenturyhealth.com or by calling Evolent (phone 844-926-4528) per the PAL instructions.

• Examples: prostate surgeries, radiation therapy

Submission requirement (Cohere)

For Cohere‑managed clinical areas (for example spinal procedures, therapy, peripheral vascular and many orthopedic procedures), providers are required to use the Cohere portal/onboarding link when submitting prior authorization requests.

• Portal onboarding required when submitting for Cohere-managed clinical areas

Expedited/Urgent Submission

Expedited or urgent cases for Cohere‑managed services can be submitted and monitored through the Cohere portal (Next.Coherehealth.com). For questions about expedited submissions contact Cohere at 833-283-0033.

Code-based Prior Authorization/Notification

Many services and supplies listed in the PAL require prior authorization or notification based on code lists — examples include transplant surgeries, varicose vein procedures, ventricular assist devices (VADs), wearable cardioverter defibrillators and wheelchair/scooter DME codes; follow the PAL code lists for specific authorization/notification requirements.

• Transplant surgery codes (e.g., 32850–32854, 33927, 38205, G0341–G0343)
• Varicose vein procedure codes (e.g., 36465–36476, 37700, 0524T)
• VAD procedure codes (e.g., 33975–33983, 33990–33995)
• Wearable Cardioverter Defibrillator: K0606
• Wheelchair/scooter HCPCS lists

Wheelchair Repair Exception

Prior authorization is not required for member‑owned wheelchair repairs; providers do not need to obtain prior authorization for those repairs.