ModifiedHumanaPolicy N/A

Humana Dual Fully Integrated Florida — Prior Authorization and Notification List (PAL)

Governs prior authorization and notification requirements, submission methods, and supporting information for services provided to Humana Dual Fully Integrated Florida members; affects physicians and other healthcare providers delivering services to these members.

Policy Summary

PayerHumana

PolicyPrior Authorization and Notification List — Humana Dual Fully Integrated Florida

Policy CodePolicy N/A

Change TypeMaterial updates — CMS 7‑day decision requirementnew PAL identifiers

Effective DateJan 1, 2026

Next Review DateN/A

Key ActionSubmit complete supporting clinical information with prior authorization requests (include member ID, dates, procedure/diagnosis codes, provider TIN/NPI).

SourceLink

POLICY UPDATE CHANGES

Effective Jan. 1, 2026, CMS requires prior authorization decisions within 7 days for certain medical items/services requests.

New prior authorization requirements and identifiers noted throughout the PAL (marked '*New prior authorization requirement').

7 daysCMS 7-day decision timeframe

90 daysNo prior auth for active treatments (first 90 days)

up to 10Max procedure codes per request

up to 6

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.

Max diagnosis codes per request

Evolent-managedEvolent‑managed surgical preauths

800-523-0023Humana IVR for requests

Prior Authorization and Notification Coverage Criteria

General coverage stance and requirements

Services listed require prior authorization (precertification) or notification as indicated. Prior authorization means advance approval is required from Humana before the item or service is provided. Notification means the provider must inform Humana of the intent to provide the service; Humana does not approve or deny notifications. All services must meet Medicare coverage and medical necessity criteria. This list applies to Humana Dual Fully Integrated Florida members and aligns with Humana MA plan requirements — delegated providers should follow their IPA or risk network guidance.

Prior authorization is required before the service is rendered unless the service is emergent/urgent (see separate urgent/emergent criteria). Failure to obtain required prior authorization or notification may result in claim denial, reduced benefits, or financial penalties per provider contract. Services provided without required prior authorization may be subject to retrospective medical necessity review.

Providers should include the following information when submitting a prior authorization request or notification: Member Humana ID, member name and date of birth; date of actual service or hospital admission; procedure codes (up to 10 per request) and diagnosis codes (up to 6 per request); proposed procedure date (if applicable); service location; referral type and facility/provider TIN and NPI; caller/requestor and attending physician contact information; relevant clinical information and discharge plans.

Humana does not require prior authorization for basic Medicare benefits during the first 90 days of a new member's enrollment for active courses of treatment that started prior to enrollment. To ensure appropriate claim payment for services during an active course of treatment, include the appropriate modifier per Humana's Medicare Advantage Payment Policy or supply medical records demonstrating the active course of treatment.

For services that may be investigational/experimental or have limited coverage, providers may request an Advanced Coverage Determination (ACD). Instructions for ACD and prior authorization submission (fax, mail, telephone, and specialty/vendor routing where applicable) are available through Humana's provider resources and on the prior authorization and notification lists webpage.

Urgent/emergent services and retrospective review

Exceptions for urgent/emergent services and retrospective review guidance.

Urgent/emergent services do not require referrals, prior authorization or notification. Providers should document the emergent nature of the visit and render necessary care.

When prior authorization is not obtained for non-emergent services, Humana may perform retrospective medical necessity review. Providers are encouraged to verify benefit and prior authorization/notification requirements with Humana prior to providing non-urgent services to avoid financial risk to the practice and patient.

Prior authorization/notification code list (segment)

The following categories and CPT/HCPCS/Other codes require prior authorization or notification for Humana Dual Fully Integrated Florida members. This list consolidates procedure categories and associated codes; providers must obtain prior authorization as indicated for each item.

Magnetic resonance imaging (MRI): C8918, C8919, C8920, C8931, C8932, C8933, C8934, C8935, C8936, 70336, 70543, 70554, 70555, 71550, 71551, 71552, 72141, 72142, 72146, 72147, 72148, 72149, 72156, 72157, 72158, 72195, 72196, 72197, 73221, 73222, 73223, 73721, 73722, 73723, 74181, 74182, 74183, 75557, 75559, 75561, 75563, 77046, 77047, 77048, 77049, C8903, C8905, C8906, C8908, C9762, C9763

Myocardial perfusion imaging (MPI - SPECT): 78451, 78452, A9611

Nuclear stress test and related nuclear cardiology: 78453, 78454, 78466, 78468, 78469, 78472, 78473, 78481, 78483, 93350, 93351, C8928, C8930

Peripheral angiography: 36245, 36246, 36247

PET scan / NOPR and related PET imaging: 78429, 78430, 78431, 78432, 78433, 78459, 78491, 78492, 78608, 78811, 78812, 78813

Authorization and notification criteria (partial)

Rules and exceptions related to authorization and notification.

Observation services require notification; inpatient admissions require prior authorization as specified by inpatient type (acute, rehab, LTAC, skilled nursing, mental health/substance use).

Certain surgical categories (for example lung and prostate surgeries) are managed by designated vendors (e.g., Evolent). Providers must submit preauthorization requests following the vendor-specific instructions provided in the list.

For MA PFFS-covered patients, Advanced Coverage Determination requests may be required for some services — contact Humana Clinical Intake at 800-523-0023 to initiate an ACD where indicated.

Prior authorization requirement

The following grouped codes and categories specifically require prior authorization under the Humana Dual Fully Integrated Florida prior authorization list (PAL). Providers must obtain prior authorization per the instructions and vendor routing included in this document.

All inpatient admissions (acute hospital, inpatient hospice, acute rehab, long-term acute care, skilled nursing, and mental health/substance use residential treatment) — Codes: All inpatient admission codes

Observation services — Notification required (Codes: All observation codes)

DME, prosthetics, orthotics, wheelchairs/scooters, and complex home medical equipment — specific HCPCS and K-codes listed throughout the PAL (examples captured in the list above); prior authorization required

Advanced technologies, implants, neurostimulators, spinal procedures, VADs, prosthetics, gene and cell therapies, molecular diagnostics and many surgical interventions listed in this PAL — prior authorization required per listed codes and vendor routing

When a separate manager (vendor) is identified (for example Evolent for lung and prostate surgeries), providers must follow the vendor's submission pathway to obtain authorization.

Codes and Coding Limits

Covered CPT/HCPCS codes - Surgical/Plastic proceduresCPTCovered

15830	Excision, excessive skin and subcutaneous tissue (e.g., abdominoplasty)
15847	Muscle repair during abdominoplasty

Covered CPT/HCPCS codes - Behavioral health servicesCPTCovered

0362T	Applied behavior analysis (ABA) assessment
0373T	ABA adaptive behavior treatment by protocol
97153	Adaptive behavior treatment by protocol, administered by technician
97154	Group adaptive behavior treatment
97155	Adaptive behavior treatment with protocol modification
97156	Family adaptive behavior treatment guidance
97157	Multiple-family group adaptive behavior treatment guidance
97158	Group adaptive behavior treatment with protocol modification
H0015	Clinic or partial hospitalization services (behavioral health)
S9480	Comprehensive community support services

Covered CPT codes - Cardiac devices and interventional cardiologyCPTCovered

33206	Insertion of transvenous pacemaker lead(s) — atrial
33207	Insertion of transvenous pacemaker lead(s) — single or dual
33208	Insertion of transvenous pacemaker lead(s) — replacement
33212	Insertion of loop recorder
33213	Removal of loop recorder
33214	Programming/diagnostic services
33216	Insertion of pacemaker pulse generator
33217	Replacement of pacemaker pulse generator
33221	Insertion of ICD lead
33224	Addition of atrial lead

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Covered CPT/HCPCS codes - Diagnostic and cardiac imaging (CT/MRI/other)CPTCovered

70460	CT head/brain without contrast
70461	CT head with contrast
70470	CT orbit/sinus
70471	CT face
70481	CT neck without contrast
70482	CT neck with contrast
70487	CT cervical spine
70488	CT thoracic spine
70491	CT lumbar spine
70492	CT sacrum/coccyx

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Neutral HCPCS/HCPCS-like codes - Durable medical equipment (DME)HCPCS

E0469	Oxygen transfer device for liquid oxygen
E0481	Oxygen conservers
E0482	Oxygen conserving device
E0483	Airway clearance device
E0486	CPAP interface/accessory
E0490	Noninvasive ventilator, pediatric
E0491	Noninvasive ventilator, adult
E0492	Noninvasive ventilator, combined age
E0493	Noninvasive ventilator, other
K1027	Exhaled nitric oxide measurement device

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Neutral/covered molecular diagnostic and genetic testing codesCPT

81105	Cystic fibrosis testing (example code block)
81150	BRCA gene analysis (example)
81200	CFTR gene analysis (example)
81400-81499	Molecular pathology procedures (range)
81503	Oncotype DX or similar molecular test
81518-81525	Specific molecular diagnostic multi-analyte assays
81105-81299	Additional molecular/genetic testing codes (range)
81300-81459	Cytogenetics and molecular pathology codes (range)

Covered CPT codes - Peripheral vascular/interventional proceduresCPTCovered

37236	Transcatheter placement of intravascular stent(s)
37238	Lower extremity peripheral angioplasty, stent
37242	Peripheral vascular intervention, atherectomy
37243	Peripheral angioplasty
37254	Iliac artery stenting
37256	Other peripheral intervention
37258	Peripheral vascular intervention
37260	Peripheral intervention additional
37262	Peripheral intervention additional
37263	Peripheral intervention additional

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Covered CPT/HCPCS codes - Listed procedures and suppliesmixedCovered

36465-36483	Venous procedures range (varicose vein treatments)
37700-37766	Lymphatic/venous procedures range
C9773-C9775	Prostate surgery device codes
55801-55880	Prostatectomy procedure codes range
L-series	Extensive list of prosthetic/orthotic L-codes (selected)
A9282	Prosthetic supplies
G0339	Clinical trivial code (example)
G0340	Clinical trivial code (example)
G0458	Cardiac rehab code
77280-77439	Radiation therapy planning/delivery codes range

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Covered CPT/HCPCS codes requiring authorizationmixedCovered

36245-36247	Peripheral angiography codes (require auth)
36465-36483	Varicose vein treatment codes (authorization may be required)

Covered DME/HCPCS codes requiring authorizationHCPCSCovered

E0986	Power wheelchair, Group 2
E1002	Power wheelchair component
E1003	Power wheelchair component
K0005	Manual wheelchair
K0008	Manual wheelchair
K0009	Manual wheelchair
K0013	Manual wheelchair
K0606	Wearable cardioverter defibrillator

Maximum codes per request — numeric limits

Notification-only example

Submission Processes, Vendor Delegation, and Provider Requirements

Note

Distinction: Prior authorization vs. notification

Prior authorization is advance approval the provider must obtain from the plan before a listed service will be covered. Notification is an informational process by which the provider tells Humana of the intent to provide a service; Humana does not issue an approval or denial for notifications. Services on the list must have prior authorization prior to being provided and must meet Medicare coverage and medical necessity guidelines.

Prior authorization = advance approval required from the plan.
Notification = provider informs Humana; does not result in approval/denial.
Listed services require prior authorization before delivery and must meet Medicare medical necessity.

Prior Authorization

How to submit prior authorization requests

Submit prior authorization requests online at Availity (registration required) or by calling Humana's interactive voice response line at 800-523-0023. Online requests may include questionnaires that can lead to real-time approvals; if not immediate, the questionnaire information supports Humana's review.

Key Definitions and Terms

Prior authorization — definition

DefinitionPrior authorization is a process requiring the physician or other healthcare provider to obtain advance approval from the plan to determine whether an item or service will be covered.

TimingMust be obtained prior to providing services listed on the Humana Dual Fully Integrated Florida PAL unless an exception applies (e.g., urgent/emergent services).

PurposeEnsures services meet Medicare coverage guidelines and medical necessity before provision.

Notification — definition and distinction

DefinitionNotification is the process by which the provider notifies Humana of the intent to provide an item or service; Humana requests notification to help coordinate care but does not issue an approval or denial for notifications.

Distinction from authorization

Policy Summary

PayerHumana

PolicyPrior Authorization and Notification List — Humana Dual Fully Integrated Florida

Policy CodePolicy N/A

Change TypeMaterial updates — CMS 7‑day decision requirementnew PAL identifiers

Effective DateJan 1, 2026

Next Review DateN/A

Key ActionSubmit complete supporting clinical information with prior authorization requests (include member ID, dates, procedure/diagnosis codes, provider TIN/NPI).

SourceLink

On This Page

PSMA / PET CT (prostate): A9587, A9593, A9594, A9595, A9596, A9597, A9608, A9616, A9800

Transesophageal echocardiogram (TEE): 93312, 93313, 93314, 93315, 93316, 93317, 93318, 93355, C8925, C8926, C8927

Durable Medical Equipment (DME) - Airway Clearance Devices: E0469, E0481, E0482

DME - Diabetic Treatment and Supplies: A4238, A4239, A9274, E0784, E2102, E2103

Obstructive Sleep Apnea Non-Surgical Treatments (DME): E0486, E0490, E0491, E0492, E0493, K1027

Electrical Stimulators (DME): E0762, E0766

Pneumatic Compression (DME): E0650, E0651, E0652, E0658, E0659, E0660, E0665, E0666, E0667, E0668, E0669, E0670, E0671, E0672, E0673, E0675, E0676, E0677, E0678, E0679, E0680, E0681, E0682, E0683

UV Light Therapy (DME/therapy codes): E0691, E0692, E0693, E0694

Emerging technology / new indications for existing technology: 0446T, 0447T, 0448T, 0716T, 0745T, 0746T, 0747T, 0935T, 0947T, 31647, 31648, 31649, 31651, 43284, 53865, 53866, C1735, C1736, E0738, E0739

Epidural injections (outpatient only): 62320, 62321, 62322, 62323, 64479, 64480, 64483, 64484, 64999

Esophagogastroduodenoscopy (EGD): 43235, 43237, 43238, 43239, 43242, 43252, 43253, 43259

Facet injections: 0213T, 0214T, 0215T, 0216T, 0217T, 0218T, 64490, 64491, 64492, 64493, 64494, 64495, 64633, 64634, 64635, 64636, 64999

Facility-based sleep studies: 95807, 95808, 95810, 95811

Foot surgeries (bunionectomy, hammertoe) and related codes: 26535, 26536, 28110, 28240, 28285, 28289, 28291, 28292, 28295, 28296, 28297, 28298, 28299, 28306, 28308, 28310, 28740, 28750, L8641

Gastric pacing: 43647, 43648, 43881, 43882

Gene and cell therapy: J3391, Q2058

Genicular nerve ablation and blocks: 64454, 64624

High-frequency chest compression vests: E0483

Home health / home infusion services and codes: 99512, 99600, G0151, G0152, G0153, G0155, G0156, G0157, G0158, G0159, G0160, G0161, G0162, G0299, G0300, G0493, G0494, G0495, G0496, G0513, G2168, G2169, S9122, S9123, S9124, S9211, S9213, S9214, T1000, T1002, T1004, T1005, T1021, T1022, T1028, T1030

Hospital beds and accessories (DME): E0193, E0194, E0265, E0266, E0277, E0296, E0297, E0301, E0302, E0303, E0304

Hyperbaric therapy: 99183, G0277

Inpatient admissions (acute hospital, inpatient hospice, acute rehab, LTAC, skilled nursing, mental health/substance use including residential): All inpatient admission services require prior authorization or notification as specified

Laparoscopic hiatal hernia repair: 43280, 43281, 43282

Lung biopsy and resection (managed by Evolent for preauthorization): 32096, 32097, 32505, 32607, 32608, 32666 (submit per Evolent instructions)

Micro-invasive glaucoma surgery (MIGS): 0253T, 0449T, 0450T, 0474T, 0660T, 0661T, 0671T, 66989, 66991

Molecular diagnostic and genetic testing (extensive list of CPT/HCPCS and gene panel codes including many 0xxxU, 8xxxU, and 8xx/81xxx series codes) — examples: 0020M, 0005U, 0009U, 0018U, 0026U, 0029U, 0037U, 0045U, 0087U, 0088U, 0089U, 0090U, 0118U, 0172U, 0211U, 0212U, 0213U, 0214U, 0216U, 0217U, 0239U, 0242U, 0245U, 0250U, 0288U, 0299U, 0313U, 0315U, 0326U, 0329U, 0333U, 0334U, 0340U, 0345U, 0347U, 0349U, 0355U, 0356U, 0358U, 0359U, 0378U, 0379U, 0388U, 0411U, 0419U, 0422U, 0433U, 0434U, 0437U, 0449U, 0473U, 0475U, 0485U, 0486U, 0487U, 0489U, 0493U, 0510U, 0532U, 0533U, 0534U, 0537U, 0538U, 0539U, 0540U, 0543U, 0549U, 0552U, 0553U, 0554U, 0555U, 0560U, 0561U, 0562U, 0565U, 0566U, 0567U, 0569U, 0571U, 0572U, 0575U, 0576U, 0578U, 0585U, 0602U, 0605U, 0611U, 0612U, 0613U, 0620U, 0630U, 81105, 81112, 81120, 81121, 81161–81168, 81175–81195, 81200–81205, 81212, 81216, 81218, 81219, and numerous additional molecular/genetic codes

Negative pressure wound therapy (NPWT): 97605, 97606, A6550, E2402, K0743

Neuromuscular stimulators: A4593, A4594, E0764, E0770

Neurostimulators (including many implantable neuromodulation device codes and HCPCS): 0587T, 0588T, 0783T, 0786T, 0787T, 0816T, 0817T, 0818T, 0819T, 0908T, 0909T, 0910T, 0911T, 0912T, 0956T–0960T, 0968T–0969T, 0988T–0989T, 1013T–1015T, 61860, 61863, 61867, 61885–61892, 64553, 64555, 64561, 64566–64568, 64575, 64581, 64590, 64596–64598, C1607, C1767, C1787, C1826, C1827, C9807, E0721, E0734–E0737, E0743, L8683

Noninvasive home ventilators: E0466, E0468

Obesity surgeries (bariatric procedures): 0813T, 43290, 43291, 43631–43634, 43644–43645, 43770–43775, 43842–43848, 43886–43889, C9785

Observation services: All observation codes require notification

Oral/orthognathic/TMJ surgeries: 20910, 21010, 21050, 21070, 21085, 21100, 21110, 21125, 21127, 21141–21147, 21150–21155, 21159–21160, 21188, 21193–21196, 21198–21199, 21206, 21208, 21210, 21215, 21240, 21242–21244, 21247, 29800, 29804

Orthopedic arthroplasty (hip, knee, shoulder): 23472–23474, 27125, 27130, 27132–27138, 27437–27447, 27486–27487, C8003

Orthopedic arthroscopy (hip, knee, shoulder) and related codes: 23929, 27299, 27412, 27599, 29805–29807, 29819–29827, 29828, 29850–29851, 29860–29877, 29879–29889, 29914–29916, 29999, C9781, J7330

Orthotics — extensive HCPCS L-codes and K-codes list (examples): K1007, L0452, L0456–L0464, L0480–L0488, L0624, L0629, L0631–L0640, L0700, L0710, L0720, L0999, L1000, L1200, L1300, L1499, L1680–L1700, L1730, L1834, L1840, L1843–L1846, L1848, L1851–L1860, L1907, L1932–L1952, L1960, L1970, L2000–L2038, L2106, L2108, L2128, L2136, L2350, L2525–L2526, L2627, L2999, L3671, L3674, L3720–L3766, L3900–L3905, L3961, L3971–L3977

Pain infusion pump and related implantable/infusion device codes: 62324–62327, 62350–62362, 64999, C1772, C1891, C2626, C9804, C9806, E0782, E0783, E0785, E0786

Penile implant: 54405

Percutaneous lumbar intravertebral disc injection: 0627T, 0628T, 0629T, 0630T

Peripheral revascularization (atherectomy, angioplasty) and endovascular procedures: 0234T–0238T, 37236, 37238, 37242, 37243, 37254, 37256, 37258, 37260, 37262–37263, 37265, 37267, 37269, 37271, 37273, 37275, 37277, 37279–37280, 37282, 37284, 37286, 37288, 37290, 37292, 37294, 37296, 37298

Prostate surgeries (prostatectomy) — managed by Evolent for preauthorization (submit per Evolent instructions): C9773, C9774, C9775, 55801, 55810, 55812, 55815, 55821, 55831, 55840, 55842, 55845, 55866–55869, 55880

Prosthetics (extensive L-/A-/Q-code list): 21081, 21082, 21084, A9282, L5000–L5399 series examples, and many additional prosthetic codes (providers should verify specific prosthetic codes prior to ordering)

Radiofrequency ablation for the SI joint: 64625

Rhinoplasty and nasal procedures: 30400, 30410, 30420, 30430, 30435, 30450, 30460, 30462, 30468, 30469

Sacroiliac (SI) joint injections: 27096

Skin and tissue substitutes (biologic grafts and related A-codes): A2001–A2030 (examples) and related skin substitute codes

Breast reconstruction related codes and specific Q-codes (Q4436–Q4440) require prior authorization unless for breast reconstruction following medically necessary mastectomy where certain codes (Q4116, Q4122, Q4128) are exempt from preauthorization for reconstruction after cancer-related mastectomy

Spinal cord stimulators: 0784T, 0785T, 63650, 63655, 63663, 63664, 63685, 63688, 64999

Spinal fusion, decompression, kyphoplasty and vertebroplasty (extensive list of CPT/HCPCS and category codes): 0095T, 0098T, 0164T, 0165T, 0202T, 0219T, 0220T, 0221T, 0222T, 0274T, 0656T, 0657T, 0719T, 0790T, 20999, 22100–22103, 22510–22515, 22526–22534, 22548, 22551–22558, 22585–22590, 22595, 22600, 22610, 22612, 22614, 22630, 22632–22634, 22800, 22802, 22804, 22808, 22810, 22812, 22818, 22819, 22830, 22836–22846 and many related spinal procedure codes

Varicose vein surgical treatment and sclerotherapy: 36465, 36466, 36468, 36470, 36471, 36473–36476, 36478, 36479, 36482, 36483, 37700, 37718, 37722, 37735, 37760, 37761, 37765, 37766

Ventricular assist devices (VADs) including percutaneous VADs and implantable VADs: 33990, 33991, 33995, 33975, 33976, 33979, 33981, 33982, 33983

Wheelchairs / scooters and extensive equipment HCPCS/K-codes: E0986, E1002–E1012, E1161 and a broad set of subsequent HCPCS codes (see full DME list)

Wearable cardioverter defibrillator: K0606

Online: www.availity.com (registration required).
Phone: Humana IVR 800-523-0023.
Use online questionnaires when available to potentially obtain real-time approval.

Prior Authorization

Advanced Coverage Determination (ACD) for investigational/experimental services

For investigational or experimental services (or to confirm whether Humana will pay), request an Advanced Coverage Determination (ACD) prior to providing the service; ACDs may be submitted by written mail, fax, or telephone as specified.

Mail ACD requests to: Humana Correspondence P.O. Box 14601 Lexington, KY 40512-4601.
Fax ACD requests to: 800-266-3022.
Phone ACD requests: 800-523-0023.
Medication ACD fax: 888-447-3430; phone: 866-461-7273.

Denial Risk

Urgent/emergent exceptions and potential consequences

Urgent or emergent services do not require referrals, prior authorization, or notification. However, failing to obtain required prior authorization for non-urgent services may lead to financial penalties, reduced patient benefits, and retrospective medical necessity review.

No prior authorization or notification required for urgent/emergent services.
Services provided without required prior authorization may be subject to retrospective review and financial/consequential penalties.

Prior Authorization

Delegated/vendor-managed authorizations (Evolent/New Century Health)

Certain specialty and surgical services are delegated to third‑party vendors (Evolent/New Century Health) for preauthorization; when a service is vendor‑managed, providers must submit requests to the vendor using the specified vendor channels rather than Humana.

Evolent (formerly New Century Health) manages preauthorizations for multiple specialty services (e.g., ablation, breast procedures, cellular therapies).
Follow the vendor submission methods and contact the vendor for decisions on delegated services.

Prior Authorization

Evolent-managed preauthorization for lung biopsy/resection

Evolent manages all preauthorization requests for lung biopsy and resection. Submit requests via Evolent's website, call 844-926-4528 (option 5 for surgical services) Monday–Friday 8 a.m.–8 p.m. ET, or eFax 213-596-3783 or email carepro-oncology@newcenturyhealth.com.

Phone: 844-926-4528, option 5 for surgical services (Mon–Fri 8 a.m.–8 p.m. ET).
eFax: 213-596-3783.
Email: carepro-oncology@newcenturyhealth.com.
Submit via Evolent's website when available.

Prior Authorization

Evolent-managed preauthorization for prostate surgeries

Evolent manages all preauthorization requests for prostate surgeries (prostatectomy). Providers must submit requests via Evolent's website, call 844-926-4528 (option 5 for surgical services) Monday–Friday 8 a.m.–8 p.m. ET, or eFax 213-596-3783.

Phone: 844-926-4528, option 5 for surgical services (Mon–Fri 8 a.m.–8 p.m. ET).
eFax: 213-596-3783.
Submit via Evolent's website to reach a live representative.

Prior Authorization

Vendor-managed preauthorization for prostate surgeries and radiation therapy

For prostate surgeries and radiation therapy, preauthorization requests are managed by Evolent/New Century Health. Submit via the vendor website, call 844-926-4528 (option 5 for surgical services; option 4 for radiation therapy) Monday–Friday 8 a.m.–8 p.m. ET, or eFax 213-596-3783.

Phone: 844-926-4528 — option 5 for surgical services, option 4 for radiation therapy (Mon–Fri 8 a.m.–8 p.m. ET).
eFax: 213-596-3783.
Submit via the vendor website as an alternative to phone/fax.

Prior Authorization

Humana Clinical Intake contact for ACD (MA PFFS)

For MA PFFS‑covered patients requesting an Advanced Coverage Determination (ACD) for a listed service, contact Humana's Clinical Intake team at 800-523-0023.

Humana Clinical Intake phone for MA PFFS ACD requests: 800-523-0023.

Prior Authorization

Transplant authorization and notification process

Transplant prior authorization requests will be reviewed by the Humana National Transplant Network and should be submitted via Availity. Transplant evaluation (code 99199) requires notification only.

Submit transplant surgery prior authorization via Availity for National Transplant Network review.
Transplant evaluation (99199) = notification required only.

Prior Authorization

Prior authorization required — varicose vein procedures

Prior authorization is required for varicose vein surgical treatment and sclerotherapy; providers must submit prior authorization before performing these procedures.

Codes requiring prior authorization include CPTs in the ranges: 36465–36483 and procedure codes 37700, 37718, 37722, 37735, 37760, 37761, 37765, 37766.

Prior Authorization

Prior authorization required — ventricular assist devices (VADs)

Ventricular assist devices (VADs), including percutaneous VADs, require prior authorization and providers must submit for authorization before the service.

VAD procedure codes listed include 33990, 33991, 33995 and ranges 33975–33983.

Prior Authorization

Prior authorization required — wheelchairs/scooters and other DME

Wheelchairs, scooters and many other DME/HCPCS items require prior authorization per the Humana list; providers must submit authorization requests for these HCPCS K- and E‑series codes before providing equipment.

Examples of HCPCS requiring authorization: E0986, E1002–E1012, E1161, E1220, and numerous K‑series codes (K0005, K0008–K0899).
Wearable cardioverter defibrillator (K0606) is included in the DME authorization list.

Prior Authorization

Prior authorization required — wearable cardioverter defibrillator (K0606)

The wearable cardioverter defibrillator (HCPCS K0606) is listed and requires prior authorization; submit an authorization request before supplying the device.

Code: K0606 — wearable cardioverter defibrillator requires prior authorization.

Notification does not replace prior authorization and does not constitute approval; services requiring prior authorization must still obtain authorization unless specifically noted as notification-only.

Use caseUsed for services like transplant evaluation (99199) where only notification is required per the PAL.

CMS 7-day requirement

CMS 7-day decision requirementEffective Jan. 1, 2026, CMS requires certain prior authorization decisions be completed within 7 days when applicable.

Provider actionSubmit all relevant supporting clinical information at time of request to support timely adjudication; failure may delay or adversely affect the decision.

Humana follow-upIf additional information is needed, a Humana representative will contact the individual who submitted the request to request specific information to complete the authorization process.

Inpatient admissions — definition and included facility types

DefinitionInpatient admissions include acute hospital (including inpatient hospice), acute rehabilitation facilities, long-term acute care, mental health and substance use treatment (including residential), and skilled nursing facilities.

Authorization scopeAll inpatient admissions are listed as requiring authorization/notification (codes = All) per the PAL.

Service locations includedAcute hospital, inpatient hospice, acute rehab, long-term acute care, mental health/substance use residential, skilled nursing facilities.

Evolent-managed preauthorizations — definition and delegation

DefinitionEvolent is the delegated manager for preauthorization requests for specified surgical services (e.g., lung biopsy/resection, prostate surgeries, radiation therapy) and manages requests on behalf of Humana.

Delegation scopeDelegation means Evolent handles intake and adjudication according to its processes; providers must submit requests to the vendor rather than directly to Humana for delegated services.

Submission methodsWeb portal, phone (844-926-4528, options vary by service), eFax (213-596-3783), or email (carepro-oncology@newcenturyhealth.com) depending on service and vendor instructions.

External vendor managing preauthorization requests — Evolent/New Century Health contact overview

Vendor names and phoneEvolent / New Century Health — phone: 844-926-4528 (option 5 for surgical services; option 4 for radiation therapy)

Hours of operationMonday–Friday, 8 a.m.–8 p.m. Eastern time for live representative assistance.

Alternate submission methodsProviders may also submit via Evolent's website, eFax 213-596-3783, or email (carepro-oncology@newcenturyhealth.com) as applicable.

Administrative/coverage determination contact process for MA PFFS patients

Contact for ACD (MA PFFS)For MA PFFS-covered patients requesting an Advanced Coverage Determination (ACD), contact Humana's Clinical Intake team at 800-523-0023.

Use caseACD requests are applicable when providers seek determinations for coverage of specific services for MA PFFS members.

Submission guidanceFollow Humana instructions for ACD submission; contact the Clinical Intake team directly for MA PFFS cases.

Prior authorization list entries — explanation

DefinitionEntries enumerated in this document are items and procedures on the Humana Dual Fully Integrated Florida Prior Authorization and Notification List and thus require prior authorization or notification as specified.

ImplicationProviders must obtain the required prior authorization or submit the required notification before providing listed services to Humana Dual Fully Integrated Florida members.

ScopeList includes procedure CPT/HCPCS codes, DME codes, device codes and broad categories (e.g., VADs, wheelchairs/scooters, varicose vein procedures, transplant surgeries).