Virginia Prior Authorization and Notification List
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This document lists services, procedures, and supplies that require prior authorization or notification for Humana Dual Fully Integrated Medicare Advantage plans in Virginia, and explains how providers should request authorizations/notifications and submit supporting information.
No material clinical or coverage changes in this revision.
Prior Authorization and Notification Requirements
Prior authorization and notification requirements (by service category)
The document lists numerous categories of services and associated codes that require prior authorization or notification; some service categories are now managed via Cohere Health and require submission through that portal.
Examples of categories requiring prior authorization
- Advanced imaging and other imaging-related services (see Cohere-managed list) — Codes listed in imaging groups (see Cohere Health-managed services).
- Epidural and facet injections — Epidural outpatient codes 62320–62323, 64479–64484, 64999; facet/injection codes listed elsewhere in the document.
- Hospice services — Notification required; codes: All (see hospice entry).
- Inpatient admissions (acute hospital, acute rehab, long-term acute care, mental health/substance use, skilled nursing) — Require prior authorization/notification (codes listed as 'All').
- Observation services — Notification required (observation codes listed).
- Orthopedic surgeries — Hip, knee, shoulder arthroplasty and related procedures; numerous CPT ranges listed (examples include 27437–27447, 27486–27487, etc.).
- Orthopedic arthroscopy — Codes include arthroscopy ranges and specified CPTs (e.g., 29805–29999 series and related codes).
- Pain infusion pumps and related implant/procedural codes — Codes include 62324–62362, 64999 and multiple C-/E- supply codes (managed via Cohere Health for prior authorization submission).
- Spinal procedures and devices — Spinal cord stimulators and spinal fusion/decompression/kyphoplasty/vertebroplasty (see dedicated Cohere-managed entries).
- Therapy services (physical and occupational) — CPT and G-codes listed; these services will now be managed via Cohere Health.
- Transplant evaluation — Notification required; code: 99199.
Cohere Health-managed services
Services managed via Cohere Health require submission of prior authorization requests to the Cohere Health portal; registration instructions and contact details are provided. Expedited/urgent cases can be submitted and monitored on the Cohere portal.
Service groups managed via Cohere Health (examples)
- Spinal cord stimulators and spine surgeries — See dedicated Cohere-managed spine and neuromodulation entries (codes listed in chunks 60, 62).
- Therapy (physical and occupational) — Codes listed in therapy group (chunk 65); these services are managed via Cohere Health and require submission through the Cohere portal.
One Home Care-managed services
Home health and home infusion services are managed by One Home Care and listed codes require authorization/notification via that manager.
Refer to One Home Care for submission instructions and authorization requirements; the document identifies these services as managed by One Home Care.
Notification-required services
Certain services require notification rather than prior authorization; providers must notify Humana (or the designated manager) as specified.
Services requiring notification (examples)
- Hospice services — Notification required; codes: All.
- Observation services — Observation notification required; observation-related procedure codes listed in the observation entries.
- Transplant evaluation — Notification required; code: 99199.
Prior authorization and submission requirements for listed services
Submission expectations and management notes for prior authorization requests covering many listed services.
When services are managed by Cohere Health, follow Cohere-specific submission forms and any real-time questionnaire workflows; some questionnaires may yield real-time approval as noted in the broader submission guidance.
Partial coverage/authorization nodes
Service categories and associated codes with administrative notes (examples of partial coverage/authorization rules and service-specific management).
Code Lists and Limits
| A4238 | Insulin pump, supplies |
| A4239 | Insulin pump, alternate |
| A9274 | CPAP supplies |
| E0277 | Commode chair, motorized |
| E0301 | Hospital bed, semi-electric |
| E0302 | Hospital bed, full electric |
| E0303 | Hospital bed, other |
| E0304 | Hospital bed accessory |
| E0469 | Powered pressure reducing mattress |
| E0481 | Sleep apnea device, oral (Mandibular advancement) |
| 62324-62362 | Intrathecal pump/procedure codes range |
| 64999 | Unlisted procedure, nervous system |
| C1772 | Biologic/prosthetic, specific |
| C1891 | Implantable device |
| C2626 | Product code |
| C9804 | CAR T-cell product |
| C9806 | Cellular therapy product |
| E0782 | Support device |
| E0783 | Support device |
| E0785 | Support device |
| 0234T-0238T | Atherectomy/peripheral revascularization (Category III) |
| 37224-37298 | Endovascular procedures for arterial occlusion/stenosis |
| 0505T | Peripheral device procedure (Category III) |
| C9764-C9775 | Peripheral revascularization HCPCS temporary codes |
| 21150-21240 series | Maxillofacial/mandibular prosthetic and reconstruction codes (selected series) |
| A9282 | Supply/implant orthotic/prosthetic |
| L5000-L6999 | Selected L-codes for prosthetics/orthotics (listed separately) |
| 32701 | Thoracic surgery related |
| 61796 | Stereotactic radiosurgery related |
| 61798 | SRS cranial code |
| 63620 | Spinal implantation and therapeutic |
| 77280-77778 | Radiation treatment planning and delivery (simulation through complex therapy) |
| G0339 | Prostate HDR brachytherapy global |
| G0340 | Prostate HDR brachytherapy add-on |
| G0458 | Radiation therapy prior authorization/plan |
| 27096 | Injection procedure for SI joint |
| A2001-A2039 | Skin and tissue substitute product HCPCS range (selected A-codes) |
| A4100 | Dermal substitute |
| C1832 | Allograft tissue product |
| C8002 | Skin substitute |
| C9354-C9364 | Allograft/skin substitute C-codes range |
| Q4101-Q4184 | Manufacturer-specific Q-codes for skin/tissue substitutes |
How to Request Authorizations, Notifications, and Contact Information
Definitions — Prior Authorization and Notification
Prior authorization: A process by which the physician or other healthcare provider must obtain advance approval from Humana that an item or service will be covered prior to providing the service. Notification: 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 help coordinate care; notification does not result in an approval or denial.
- Do not proceed assuming coverage without prior authorization when a service is listed as prior authorization required.
- Notifications do not substitute for prior authorization — they are for coordination only.
Submission channels and hours
Submit prior authorization requests for Humana‑managed medical services via Availity (registration required) or Humana IVR at 800-523-0023 (available 24/7). Online requests are encouraged; Availity Essentials questionnaire responses may yield real‑time approvals for certain services. For services managed by Cohere Health, register and submit requests at the Cohere Health portal (https://www.next.coherehealth.com).
- Humana IVR: 800-523-0023 (24/7)
- Availity: www.availity.com (registration required)
- Cohere Health portal: www.next.coherehealth.com (phone 833-283-0033, Mon–Fri 8 a.m.–8 p.m. ET)
Urgent/Emergent Services
Urgent or emergent services do not require referrals, prior authorization, or notification. When care is urgent/emergent, provide necessary treatment; retrospective review may still occur to confirm medical necessity.
- If a service was rendered as urgent/emergent, document the clinical circumstances in the medical record for any subsequent review.
Documentation expectations and timeliness
Providers must submit all relevant clinical information at the time of the prior authorization request to support timely adjudication. CMS requires certain prior authorization decisions within 7 calendar days for requests effective Jan. 1, 2026. Failure to submit necessary information may delay or adversely affect the decision. If additional information is needed, Humana will contact the requestor.
- Include member Humana ID, name, DOB, dates of service or admission, procedure and diagnosis codes (procedure ≤10, diagnosis ≤6), service location, treating facility TIN/NPI, provider TIN/NPI, caller name/phone, attending physician phone, relevant clinical information, and discharge plans.
Advanced Imaging
Advanced imaging services listed on the prior authorization list (including CT, CTA, MRI, MRA, nuclear medicine) are managed by Cohere Health. Submit prior authorization requests and supporting clinical information via the Cohere Health portal. Expedited/urgent cases can be submitted and monitored on the Cohere Health portal.
Esophagogastroduodenoscopy (EGD)
Esophagogastroduodenoscopy (EGD) services are managed by Cohere Health. Submit prior authorization requests and clinical documentation via the Cohere Health portal. If not registered, visit Cohere Health: Registration for providers to create an account. Expedited/urgent cases can be submitted and monitored on the Cohere Health portal.
Home health / Home infusion (managed by One Home Care)
Home health and home infusion services on the prior authorization list are managed by One Home Care. Prior authorization or notification is required per the service listing; submit requests according to One Home Care procedures.
Spine Surgeries and Spinal Cord Stimulators (managed by Cohere Health)
Spine surgeries (including spinal fusion, decompression, kyphoplasty, vertebroplasty) and spinal cord stimulator services are managed by Cohere Health. Submit prior authorization requests and supporting clinical documentation via the Cohere Health portal. If not registered, visit Cohere Health: Registration for providers. Expedited/urgent cases can be submitted and monitored on the Cohere Health portal.
- Cohere Health phone: 833-283-0033 (Mon–Fri, 8 a.m.–8 p.m. ET); fax: 857-557-6787
- Spinal cord stimulator example codes: 0784T–0785T, 63650, 63655, 63663–63664, 63685, 63688, 64999, C1816, C1820, C1822, L8679, L8682
- Spine surgery example codes: 20999, 22100–22103, 22510–22515, 22526–22533, 22552–22595, 22600–22634, 22800–22899, 27278–27280, 62287, 62330–62331, 62380, 63001–63191 (see full code list)
Key Terms and Portal References
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