CurrentHumanaPolicy N/A

Prior Authorization and Notification List — Humana Dual Fully Integrated Illinois

Defines prior authorization and notification requirements, submission channels, and code lists for services and medications affecting providers treating Humana Dual Fully Integrated Illinois members.

Policy Summary

PayerHumana

PolicyPrior Authorization and Notification List — Humana Dual Fully Integrated Illinois

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateJul 1, 202618d

Next Review DateN/A

Key ActionObtain prior authorization for listed services and submit requests with member/provider identifiers, procedure/diagnosis codes, dates, location and relevant clinical information via the specified portal/phone/fax or delegated manager.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

2026-07-01listed effective date

June 1, 2026last revision date

Cohere/Evolent/Carelonthird-party managers

CMS 7-daytimely decision rule

~300+codes listed

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Coverage requirements and scope

Prior authorization/notification requirements (partial)

The following services and associated procedure/CPT/HCPCS/Q codes require prior authorization or notification. Many of these services are managed through Cohere Health (Next.CohereHealth.com). Expedited/urgent cases may be submitted and monitored via the Cohere portal. For questions related to Cohere-managed services, call 833-283-0033 (Mon–Fri, 8 a.m.–8 p.m. ET) or fax 857-557-6787.

Please submit prior authorization requests for Cohere-managed services via the Cohere Health portal at Next.CohereHealth.com. If not registered, use https://next.coherehealth.com/organization_onboarding. Additional provider resources are available at www.coherehealth.com/provider/resources.

Expedited/urgent cases for Cohere-managed services can be submitted and monitored on the Cohere portal. Phone support: 833-283-0033 (Mon–Fri, 8 a.m.–8 p.m. ET). Fax: 857-557-6787.

Therapy (physical and occupational) — Prior authorization/notification required for specified CPT codes: 97010, 97012, 97014, 97016, 97018, 97022, 97024, 97026, 97028, 97032, 97033, 97034, 97035, 97036, 97039, 97110, 97112, 97113, 97116, 97124, 97129, 97130, 97139, 97140, 97150, 97164, 97168, 97037, 97530, 97533, 97535, 97537, 97542, 97545, 97546, 97550, 97551, 97552, 97750, 97755, 97760, 97761, 97763, 97799, G0281, G0283.

Transplant evaluation and transplant surgeries — Prior authorization/notification required. Transplant evaluation: code 99199. Transplant surgeries include (not limited to) CPT/HCPCS: 32850, 32851, 32852, 32853, 32854, 33927, 33928, 33929, 33935, 33945, 38205, 38206, 38230, 38232, 38240, 38241, 38243, 44135, 47133, 47135, 48160, 48550, 48554, 48556, 50300, 50320, 50340, 50360, 50365, 50370, 50547, 0584T, 0585T, 0586T, G0341, G0342, G0343, L8698, 02WA3QZ, 02WA4QZ.

Varicose vein surgical treatment and sclerotherapy — Prior authorization/notification required for codes: 36465, 36466, 36468, 36470, 36471, 36473, 36474, 36475, 36476, 36478, 36479, 36482, 36483, 37700, 37718, 37722, 37735, 37760, 37761, 37765, 37766, 37780, 37785, 0524T.

Ventricular assist devices (VADs) — Prior authorization/notification required. Percutaneous VADs and implantation codes include: 33990, 33991, 33995; other VAD procedure codes: 33975, 33976, 33979, 33981, 33982, 33983.

Wearable Cardioverter Defibrillators — Prior authorization/notification required: K0606.

Wheelchairs/scooters — Prior authorization/notification required for listed HCPCS codes (E0986, E1002–E1009, E1010, E1012, E1161, E1220, E1234, E1235, E1239, E2207, E2298, E2310–E2312, E2321, E2322, E2325, E2327–E2331, E2343, E2351, E2358, E2359). Note: prior authorization is not required for member-owned wheelchair repairs.

Spinal cord stimulators — Prior authorization/notification required. Submit via Cohere portal. Affected codes include: 0784T, 0785T, 63650, 63655, 63663, 63664, 63685, 63688, 64999, C1816, C1820, C1822, L8679, L8682.

Pain infusion pump — Prior authorization/notification required; submit via Cohere portal. Related codes include 62324, 62325, 62326, 62327, 62350, 62351, 62360, 62361, 62362.

Penile implant — Prior authorization/notification required. Submission options: phone 833-283-0033 or fax 857-557-6787; Cohere portal supports expedited cases. CPT code: 54405.

Percutaneous lumbar intravertebral disc injection — Prior authorization/notification required. Codes: 0627T, 0628T, 0629T, 0630T.

Peripheral revascularization (atherectomy, angioplasty) — Prior authorization/notification required. Codes include: 0234T, 0235T, 0236T, 0237T, 0238T, 37236, 37238, 37254, 37256, 37258, 37260, 37262, 37263, 37265, 37267, 37269, 37271, 37273, 37275, 37277, 37279, 37280, 37282, 37284, 37286, 37288, 37290, 37292, 37294, 37296, 37298, 0505T, C9764.

Orthopedic arthroplasty (hip, knee, shoulder) — Prior authorization/notification required for specified CPT codes: 23472, 23473, 23474, 27125, 27130, 27132, 27134, 27137, 27138, 27437, 27438, 27440, 27441, 27442, 27443, 27446, 27447, 27486, 27487, C8003. Submit Cohere-managed authorizations via Next.CohereHealth.com.

Laparoscopic hiatal hernia repair — Prior authorization/notification required; submit via Cohere portal.

Esophagogastroduodenoscopy (EGD) — Please submit authorizations (follow Cohere submission guidance where indicated).

Codes and billing guidance

No codes listed

Provider responsibilities and submission instructions

Prior Authorization

Obtain prior authorization and include required clinical and identification details

Providers must obtain prior authorization for services and certain medications listed; notifications are required for some services. Prior authorization requests require the member's Humana ID, name, DOB, dates of service, procedure (up to 10) and diagnosis codes (up to 6), service and facility location, provider TIN and NPI, caller/requestor and attending physician contact, and relevant clinical information. Requests may be submitted online via Availity for Humana-managed medical services or via delegated managers (Cohere, Evolent, Carelon) using the manager-specific portals, phone lines or fax numbers listed.

Required data: member Humana ID, name, DOB; procedure codes (≤10); diagnosis codes (≤6); service date/location; provider TIN/NPI; caller and attending physician contact; relevant clinical information.
Submit Humana-managed medical service requests online at www.availity.com or via Humana IVR 800-523-0023.
Submit manager-routed requests via each manager's portal/phone/fax as specified (e.g., Next.Coherehealth.com, my.newcenturyhealth.com, Carelon Behavioral Health portal).
Complete any available questionnaire (e.g., Availity Essentials™) to support real-time or expedited review.

Terms and manager references

Prior authorization — definition

DefinitionPrior authorization is the process through which the physician or other healthcare provider must obtain advance approval from the plan as to whether an item or service will be covered.

PurposeEnsures services and medications on the list meet Medicare coverage guidelines and medical necessity before being provided.

Required informationRequests must include member and provider identifiers, dates of service, procedure and diagnosis codes, place of service and relevant clinical information (see submission instructions).

Notification — definition

DefinitionNotification is the process by which the physician or other healthcare provider notifies Humana of the intent to provide an item or service; Humana does not issue approval or denial for notifications.

Purpose

Policy Summary

PayerHumana

PolicyPrior Authorization and Notification List — Humana Dual Fully Integrated Illinois

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateJul 1, 202618d

Next Review DateN/A

SourceLink

On This Page

Note

No prior authorization or notification for urgent/emergent services

Urgent or emergent services do not require referrals, prior authorization, or notification; however, failing to obtain required authorization for non-urgent services may have consequences.

Prior Authorization

Meet CMS 7-day decision requirement — provide supporting clinical information

For certain items/services CMS requires prior authorization decisions within 7 days effective Jan 1, 2026; submit supporting clinical information with the request to help ensure timely adjudication and avoid delayed or adverse decisions.

Provide all relevant clinical documentation at time of submission; Humana will request additional specific information if needed.

Prior Authorization

Send requests to delegated prior authorization managers using their channels

Certain service categories are managed by delegated prior authorization platforms; submit requests to the named manager using their portal, phone or fax per the service routing.

Carelon Behavioral Health for behavioral health services (registration and portal link provided).
Evolent (formerly New Century Health) for specified surgical and radiation therapy services (my.newcenturyhealth.com; phone/eFax).
Cohere Health for many imaging, device, implantable device, and other procedure categories (Next.Coherehealth.com; phone: 833-283-0033; fax: 857-557-6787).

Denial Risk

Risks of providing services without required authorization/notification

Failure to obtain required prior authorization or to provide required notification may result in financial penalties to the practice, reduced member benefits, and services being subject to retrospective medical necessity review.

Prior Authorization

Submit Cohere-managed prior authorization requests via Next.Coherehealth.com (portal, phone, fax)

Prior authorization requests for many Cohere-managed services must be submitted via the Cohere Health portal (Next.Coherehealth.com); onboarding and provider resources links are available, and Cohere phone support is 833-283-0033 (Mon–Fri 8 a.m.–8 p.m. ET) and fax 857-557-6787. Expedited/urgent cases can be submitted and monitored on the Cohere portal.

Portal: Next.Coherehealth.com (organization onboarding at https://next.coherehealth.com/organization_onboarding).
Phone: 833-283-0033 (Mon–Fri, 8 a.m.–8 p.m. ET).
Fax: 857-557-6787.
Use the Cohere portal to submit and monitor expedited/urgent cases.

Prior Authorization

Submit Evolent-managed prior authorizations via my.newcenturyhealth.com or phone/eFax

Evolent (formerly New Century Health) manages prior authorizations for certain surgical and radiation services; submit requests via https://my.newcenturyhealth.com, call 844-926-4528 (option 5) for surgical services, or use the eFax number 213-596-3783.

Evolent website: https://my.newcenturyhealth.com
Phone: 844-926-4528, option 5 (Mon–Fri, 8 a.m.–8 p.m. ET).
eFax: 213-596-3783.

Documentation Required

Provide observation notifications for inpatient observation and admissions

Observation notifications are required for inpatient observation and inpatient admission categories; the inpatient/observation notification process and applications are described in the inpatient admissions/observation entries.

Follow the inpatient admissions/observation entries for notification procedures and applicable codes.

Prior Authorization

Route pain infusion pump prior authorizations to Cohere (Next.Coherehealth.com)

Pain infusion pump prior authorization requests must be submitted to Cohere via the Cohere portal (Next.Coherehealth.com); onboarding information and provider resources are available on Cohere’s site.

Portal/onboarding: https://next.coherehealth.com/organization_onboarding
Cohere portal login: Next.Coherehealth.com

Prior Authorization

Submit penile implant prior authorizations to Cohere (portal, phone, fax); support expedited cases

Penile implant prior authorization is managed by Cohere; submit requests via the Cohere portal, or contact Cohere by phone (833-283-0033) or fax (857-557-6787). Expedited/urgent cases can be submitted and monitored on the Cohere portal.

Cohere portal: Next.Coherehealth.com (onboarding link provided).
Phone: 833-283-0033 (Mon–Fri, 8 a.m.–8 p.m. ET).
Fax: 857-557-6787.
Expedited/urgent submissions: submit and monitor via Next.Coherehealth.com.

Prior Authorization

Route peripheral revascularization prior authorizations to Cohere (portal, phone, fax)

Peripheral revascularization procedures (e.g., atherectomy, angioplasty) require prior authorization managed by Cohere; submit via Next.Coherehealth.com, phone 833-283-0033 or fax 857-557-6787, and expedited/urgent cases can be submitted and monitored on the Cohere portal.

Common peripheral revascularization CPT/T codes include 0234T, 0235T, 37236, 37238, 37254, and others listed in the policy.
Submission: Next.Coherehealth.com; phone 833-283-0033; fax 857-557-6787.

Prior Authorization

Submit radiation therapy prior authorizations to Evolent (website, phone, eFax)

Radiation therapy prior authorization is managed by Evolent (formerly New Century Health); submit requests via Evolent’s website, phone, or eFax per the instructions in the policy.

Evolent manages radiation therapy codes such as 32701, 61796, 61798, 63620, 77280, 77290, 77295, 77301, 77338.
Submission channels: https://my.newcenturyhealth.com; phone and eFax as listed.

Prior Authorization

Submit spinal cord stimulator prior authorizations to Cohere (portal, phone, fax)

Spinal cord stimulator procedures require prior authorization submitted to Cohere; use Next.Coherehealth.com for portal submissions, or contact Cohere by phone (833-283-0033) or fax (857-557-6787). Codes requiring authorization are listed (e.g., 0784T, 0785T, 63650, 63655).

Example codes: 0784T, 0785T, 63650, 63655, 63663, 63664, 63685, 63688, and related device codes listed.
Submission: Next.Coherehealth.com; phone 833-283-0033; fax 857-557-6787; expedited/urgent cases via Cohere portal.

Prior Authorization

Route spinal surgery prior authorizations to Cohere (portal, phone, fax)

Spinal surgeries (fusion, decompression, kyphoplasty, vertebroplasty) require prior authorization managed by Cohere; submit via Next.Coherehealth.com, phone 833-283-0033, or fax 857-557-6787. A detailed CPT code list is provided in the policy.

Example codes: 20999, 22100, 22510, 22600, 22840 and many additional spinal procedure codes listed.
Use Cohere portal for expedited/urgent case submission and monitoring.

Prior Authorization

Submit therapy (physical/occupational) prior authorizations to Cohere

Physical and occupational therapy codes listed in the policy require prior authorization through Cohere; submit requests via Next.Coherehealth.com or contact Cohere by phone (833-283-0033) or fax (857-557-6787).

Therapy codes include examples such as 97010, 97110, 97530, 97750, G0281 and the full list provided in the policy.
Portal: Next.Coherehealth.com; Phone: 833-283-0033; Fax: 857-557-6787.

Prior Authorization

Submit transplants, VADs and varicose vein surgery prior authorizations via Cohere (expedited supported)

Transplant evaluations, transplant surgeries, ventricular assist devices (VADs), and varicose vein surgeries require prior authorization/notification; expedited or urgent cases can be submitted and monitored on the Cohere portal and Cohere can be contacted for questions.

Transplant evaluation example code: 99199; transplant surgery examples: 32850, 33927, 38205, 44135, 50300, and others listed.
VAD examples: 33975, 33976, 33979, 33981, 33982, 33983.
Varicose vein examples: 36465–36483, 37700, 37718, 37722, 0524T.
Submit/monitor expedited cases via Next.Coherehealth.com; phone 833-283-0033.

Prior Authorization

Follow therapy prior authorization/notification submission via Cohere

Therapy codes listed in this section require prior authorization or notification; providers must submit requests via the Cohere portal or contact Cohere using the provided channels.

Therapy prior authorization/notification includes multiple CPT and HCPCS codes; use Next.Coherehealth.com to submit.
Cohere phone: 833-283-0033; fax: 857-557-6787.

Prior Authorization

Submit transplant evaluation and surgery prior authorizations to Cohere (expedited/urgent supported)

Transplant evaluations and transplant surgery codes listed require prior authorization/notification; expedited/urgent submissions can be submitted and monitored via the Cohere portal and Cohere can be contacted for questions.

Refer to the policy's transplant code list (e.g., 32850–32854, 33927–33935, 38205–38243, 44135, 50300, 0584T–0586T, G0341–G0343).
Use Next.Coherehealth.com for expedited/urgent case submission and monitoring.

Prior Authorization

Route varicose vein procedure prior authorizations to Cohere (expedited supported)

Varicose vein surgical treatments and sclerotherapy codes listed require prior authorization/notification; expedited/urgent cases can be submitted and monitored on the Cohere portal and Cohere is available for questions.

Examples: 36465, 36466, 36468, 36470–36479, 36482–36483, 37700, 37718, 37722, 37735, 0524T.
Submit and monitor expedited cases via Next.Coherehealth.com; phone 833-283-0033.

Prior Authorization

Submit VAD prior authorizations to Cohere (expedited/urgent supported)

Ventricular assist devices (VADs) and percutaneous VAD codes require prior authorization/notification; expedited/urgent submissions can be submitted and monitored via the Cohere portal and Cohere can be contacted for assistance.

VAD codes include examples such as 33990, 33991, 33995 and 33975–33983.
Submit via Next.Coherehealth.com; phone 833-283-0033 for questions.

Prior Authorization

Prior authorize Wearable Cardioverter Defibrillator (K0606) via Cohere

Wearable Cardioverter Defibrillator (K0606) requires prior authorization/notification; expedited/urgent cases may be submitted and monitored via the Cohere portal.

Code: K0606.
Use Next.Coherehealth.com for submission and expedited/urgent case monitoring; phone 833-283-0033 for assistance.

Prior Authorization

Prior authorization required for wheelchairs/scooters (member-owned repairs exempt)

Wheelchairs, scooters and associated DME HCPCS codes listed require prior authorization/notification and can be submitted via the Cohere portal; note that prior authorization is not required for member-owned wheelchair repairs.

Submission: Next.Coherehealth.com; phone 833-283-0033; fax 857-557-6787.
Member-owned wheelchair repairs are exempt from prior authorization.

Helps coordinate care for Humana-covered patients and distinguishes notification from prior authorization.

When usedApplied to services where Humana requests awareness but not an approval determination prior to service delivery.

Micro-Invasive Glaucoma Surgery (MIGs)

Procedures listedMicro‑Invasive Glaucoma Surgery (MIGS) codes included: 66989, 66991, 0253T, 0449T, 0450T, 0660T.

Submission channelPrior authorization requests for MIGS must be submitted via Cohere Health portal: Next.Coherehealth.com.

Cohere contactFor questions or urgent handling call Cohere at 833-283-0033 (Mon–Fri, 8 a.m.–8 p.m. ET) and fax 857-557-6787 where applicable.

Myocardial perfusion imaging (MPI SPECT)

TermMyocardial perfusion imaging single photon emission computed tomography (MPI SPECT).

Example codes78451, 78452, A9611 listed for MPI SPECT in the imaging/nuclear section.

ContextMPI SPECT is included among imaging services that require prior authorization per the PAL's imaging and nuclear medicine entries.

Cohere — third-party manager

OrganizationCohere Health (portal: Next.Coherehealth.com) — delegated prior authorization manager for many procedural and device categories (e.g., pain infusion pumps, penile implants, peripheral revascularization, MIGS).

PortalPortal login for prior authorization requests: Next.Coherehealth.com; account onboarding: https://next.coherehealth.com/organization_onboarding.

Contact detailsPhone: 833-283-0033 (Mon–Fri 8 a.m.–8 p.m. ET); Fax: 857-557-6787. Expedited/urgent cases can be submitted and monitored via the Cohere portal.

Evolent — third‑party prior authorization manager

OrganizationEvolent (formerly New Century Health) — third‑party prior authorization manager for radiation therapy and selected surgical services.

Submission optionsRequests can be submitted via Evolent's website: https://my.newcenturyhealth.com, by phone at 844-926-4528 (option 5) for surgical services, or by eFax (213-596-3783).

ScopeEvolent will manage prior authorizations for radiation therapy codes and other surgical categories as specified in the PAL.

Expedited / urgent submissions (Cohere portal)

Expedited/urgent submissionsExpedited/urgent cases for Cohere‑managed services can be submitted and monitored on the Cohere portal at Next.Coherehealth.com.

Portal monitoringUse Cohere portal to track expedited/urgent requests for categories such as penile implants, peripheral revascularization, transplants, VADs and other Cohere-managed services.

Cohere contact for urgent casesCall Cohere at 833-283-0033 for questions and support during business hours; portal supports expedited workflows.

Member‑owned wheelchair repairs — prior authorization

Policy notePrior authorization is not required for member‑owned wheelchair repairs.

Related DME codesWheelchairs/scooters and associated HCPCS codes (e.g., K0005, E0986, E1002, etc.) otherwise require prior authorization/notification per the PAL.

Submission for other wheelchair servicesExpedited/urgent prior authorization submissions for wheelchair/scooter services can be submitted and monitored via the Cohere portal (Next.Coherehealth.com).