Definitions — Prior Authorization vs Notification

Prior authorization (also called preauthorization, precertification, or preadmission) is a process by which the healthcare provider must obtain advanced approval from Humana PathWays Dual Care (HMO‑POS D‑SNP) that an item or service will be covered. Notification is the process by which the provider notifies Humana of the intent to provide an item or service; Humana uses notifications to coordinate care but does not issue an approval or denial for notifications.

Decision timeframes and urgent service exception

Urgent/emergent services do not require referrals, prior authorization, or notification. Failure to obtain required prior authorization or notification may result in financial penalties to the provider and reduced patient benefits per contract and the member’s evidence of coverage; services provided without required prior authorization/notification may be subject to retrospective medical necessity review. CMS decision timeframes (effective Jan 1, 2026): standard prior authorization decisions within 7 calendar days and expedited decisions within 72 hours. Indiana Medicaid/PathWays timeframes: standard decisions within 5 business days (or 7 calendar days) and expedited decisions within 48 hours. Provide supporting clinical information at submission to avoid delays; if additional information is needed Humana will contact the requestor.

Submission requirements and required information

Provide the following information when submitting a prior authorization request or notification: PathWays (Medicaid) ID or Member (plan) ID; date of actual service or hospital admission (or proposed procedure date); procedure codes (up to 10 per request) and diagnosis codes (primary and up to 5 secondary, max 6 total); service and specific location (inpatient location, outpatient location); referral source; facility and performing provider TIN and NPI; caller/requestor name and phone; attending provider phone; relevant clinical information and discharge plans. Submitting all relevant clinical information at the time of request supports timely adjudication.

Availity online prior authorization option and questionnaires

How to request prior authorization: For services managed by Humana, online submissions via Availity Essentials are encouraged (registration required). For certain PAL services submitted through Availity Essentials, providers may complete a questionnaire — answers can produce real‑time approvals for supported services; if no immediate approval is returned the questionnaire responses help expedite review. Behavioral health prior authorizations can also be submitted online or by phone (866‑274‑5888, M–F 8 a.m.–8 p.m. ET). Physical health and other medical services have designated phone/fax options as outlined by Humana. Providers should use the Humana‑designated channels for the service type being requested.

Inpatient admissions and observation — authorization and notification

Inpatient admissions require prior authorization for all acute hospital (including inpatient hospice), acute rehab, long‑term acute care, mental health and substance use residential treatment, and skilled nursing facility admissions. Observation status requires notification (Observation notification required; codes = All). For inpatient services, include date of admission and inpatient location when submitting requests or notifications.

Durable medical equipment and home ventilators — DME items requiring prior authorization

Durable medical equipment and home ventilators: many DME items require prior authorization. Examples listed on the PAL include hospital beds and accessories (E0193, E0194, E0265, E0266, E0277, E0296, E0297, E0301, E0302, E0303, etc.), high‑frequency chest compression vests (E0483), neuromuscular stimulators (A4593, A4594, E0764, E0770), and noninvasive home ventilators (E0466, E0468). New prior authorization flags may apply for certain wheelchair/scooter and related DME codes — check the PAL for codes marked as new PA requirements.

Surgical procedures (orthopedic, obesity, oral/TMJ, transplant, etc.) — prior authorization requirements

Surgical procedures requiring prior authorization include (but are not limited to) orthopedic joint arthroplasties (hip, knee, shoulder — e.g., CPT 27125, 27130, 27132, 23472–23474), obesity/bariatric surgeries (codes such as 43631–43634, 43770–43775, 43842–43848, 43886–43888, 43290–43291, 0813T), and oral/orthognathic/TMJ surgeries (examples: 20910, 21010, 21100–21110, 21141–21147, 21206, 29800, etc.). Transplant surgeries and other major procedures listed on the PAL also require authorization; certain breast reconstruction codes (e.g., Q4116, Q4122, Q4128) are exempt from prior authorization after medically necessary mastectomy for breast cancer per the PAL note. Include procedure and diagnosis codes, proposed date, and relevant clinical documentation when requesting authorization for surgical services.