Humana Healthy Horizons SC Prior Authorization and Notification List (PAL)
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Defines services, procedures, devices and medications that require prior authorization or provider notification for Humana Healthy Horizons members in South Carolina; applies to providers serving South Carolina Medicaid recipients under this product.
No material clinical or coverage changes in this revision.
Services Requiring Prior Authorization or Notification
Services Requiring Prior Authorization or Notification
Prior authorization or notification is required for the following service subcategories and codes. When a subcategory lists "All" admissions or procedures, prior authorization/notification is required for all applicable services within that subcategory. For obstetrical admissions: notification is required when stays exceed 48 hours for vaginal deliveries and 96 hours for cesarean sections for concurrent review, care coordination and discharge planning. Specialty drugs administered in physician office, clinic, outpatient or home settings require prior authorization (see pharmacy/specialty drug process).
ALL of the following
- Ablation (cardiac electrophysiology and ablation for bone, liver, kidney, prostate cancers)
Codes require prior authorization
ALL of the following
- Behavioral health: Alcohol and/or drug treatment - day treatment/partial hospitalization
H2035
- Behavioral health: All residential admissions
All residential admissions require authorization/notification
- Behavioral health: Applied behavioral analysis (ABA) therapy
Codes: 0362T, 0373T, 97153, 97154, 97155, 97157, 97158, 97156
- Behavioral health: Assertive community treatment (ACT)
H0040
- Behavioral health: Community support services
H2017
- Behavioral health: Inpatient admissions
All inpatient admissions require authorization/notification
ALL of the following
- Cellular (including CAR T), genetic, tissue and transplant therapies
Codes include 38999, 60699, C9399, J3392-J3394, J3490, J3590, Q2041-Q2056, many XW/ XW0.. and XW1.. device/procedure modifiers — prior authorization required
ALL of the following
- Diagnostic/cardiac imaging: Myocardial perfusion imaging (MPI SPECT)
Codes: 78451, 78452
- Diagnostic procedures: Capsule endoscopy
Codes: 91110, 91111
- Diagnostic procedures: Diagnostic EGD or esophagoscopy for patients 59 and younger (site-of-service evaluation)
Codes: 43191, 43193, 43197, 43198, 43200, 43202, 43235, 43237, 43238, 43239, 43242, 43252, 43253, 43259
- Diagnostic procedures: Facility-based sleep studies (polysomnography, PSG)
Codes: 95807, 95808, 95810, 95811
ALL of the following
- Durable medical equipment (DME): Augmentative and alternative communication systems
Codes: E2508, E2510, E2512, E2599
- DME: Beds and accessories
Codes: E0194, E0272, E0277, E0301, E0302, E0303, E0304, E0372, E0912
- DME: Continuous glucose monitoring devices and supplies
Codes: A9277, A9278
- DME: CPAP/BiPAP devices
Codes: E0470, E0471, E0472, E0601
ALL of the following
- Infertility testing and treatment
Codes: 89268, 89272, 89280, 89281, 89344, 89346, 89352, 89353, 89354, 89398
ALL of the following
- Inpatient admissions: Acute hospital (includes inpatient hospice)
Prior authorization/notification required; see NICU/obstetrical note
- Inpatient admissions: Acute rehabilitation facilities
Prior authorization/notification required; see NICU/obstetrical note
- Inpatient admissions: Long-term acute care
Prior authorization/notification required; see NICU/obstetrical note
- Inpatient admissions: Skilled nursing facilities
Prior authorization/notification required; see NICU/obstetrical note
ALL of the following
- Miscellaneous laboratory and molecular pathology codes
Examples: 81376, 81418, 81448, 81451, 81456, 81479, 81500, 81503, 81509-81512, 81525, 81535-81540, 81546, 81560, 81595, 81599, 86305, 88120-88121, 88377, 0018M, 0087U, 0088U, 0118U, 0319U
ALL of the following
- Nonemergent medical transportation (NEMT)
Codes: A0090, A0120, A0430, A0431, A0435, A0999
ALL of the following
- Other services: Skin and tissue substitutes
Extensive list of A/Q codes (A2001-A2014, A2022, A2025, Q4100-Q4310 etc.) — prior authorization required
- Other services: Varicose veins – surgical treatment and sclerotherapy
Codes: 36465, 36466, 36470, 36471, 36473, 36474, 36482, 36483, 37700, 37718, 37722, 37735, 37760-37766, 37780, 37785
ALL of the following
- Pain management: Epidural injections (outpatient only)
Codes: 62320, 62321, 62323, 64479, 64480, 64483, 64484, 64999
- Pain management: Facet injections
Codes: 64490-64495, 64633-64636, 64999
- Pain management: Pain infusion pump
Codes: 62324-62327, 62350-62362, 64999
- Pain management: Sacroiliac (SI) joint injections
Code: 27096
- Pain management: Spinal cord stimulators
Codes: 63650, 63655, 63663, 63664, 63685, 63688, 64999
- Pain management: Spinal fusion, decompression, kyphoplasty and vertebroplasty
Extensive list including 20999, 22206-22214, 22222, 22510-22515, 22526, 22532-22534, 22548, 22551-22558, 22585-22595, 22600-22614, 22630-22634, 22800-22899, 27278-27280, 62287, 62380, 63001-63102, 63170-63290, 63300-63307
- Pain management: Trigger point injections
Codes: 20552, 20553
ALL of the following
- Physical, occupational and speech therapy
Codes include 92507, 92508, 92520, 92526, 92606, 92609-92611, 95851, 97012, 97016, 97018, 97022, 97024, 97026, 97028, 97032-97036, 97110, 97112, 97113, 97116, 97124, 97139, 97140, 97150, 97164, 97168, 97530, 97533, 97535, 97537, 97750, 97755, 97760, 97761, 97763, 97799, G0237, S9152
ALL of the following
- Radiology: CT scans
Codes include 70450-70498, 71250-71275, 72125-72133, 72191-72194, 73200-73206, 73700-73706, 74150-74178, 74261-74263, 75571-75574, 75635, 76125, 76380, 77078
- Radiology: MRA
Codes: 70544, 70546, 70548, 70549, 73725
- Radiology: MRI
Codes include 70336, 70540-70555, 71550-71552, 72141-72149, 72156-72158, 72195-72197, 73218-73223, 73718-73723, 74181-74183, 74712-74713, 75557, 75559, 75561, 75563, 75565, 76390-76391, 77022, 77046-77049, 77084
- Radiology: Nuclear medicine
Codes include 78012-78020, 78070-78075, 78102-78104, 78185, 78201-78232, 78258, 78261-78266, 78278, 78290-78291, 78300, 78305
- Radiology: Nuclear stress test
Codes: 78453, 78454, 78466, 78468, 78469, 78472, 78473, 78481, 78483, 93350, 93351
- Radiology: PET scan
Codes: 78429, 78430, 78459, 78491, 78492, 78608, 78609, 78811-78816, A9552
ALL of the following
- Routine maternity care
All; notification is requested
ALL of the following
- Surgery: Abdominoplasty
Codes: 15830, 15847
- Surgery: Cochlear and auditory brainstem implants
Codes: 69930, L8614-L8625
- Surgery: Gender affirmation
Codes: 55970, 55980
- Surgery: Neurostimulators
Codes: 61863, 61867, 61885, 61886, 61888, 64561, 64566, 64568-64570, 64581, 64590
- Surgery: Obesity surgeries
Codes: 43631-43634, 43644-43645, 43770-43775, 43842-43848, 43886-43888
- Surgery: Other implantable or semi-implantable hearing aids and devices
Codes: 69710, 69711, L8691
- Surgery: Otoplasty
Codes: 69300, 69320
- Surgery: Rhinoplasty
Codes: 30400, 30410, 30420, 30430, 30435, 30450, 30460, 30462, 30468
ALL of the following
- Transplant surgeries (includes genetic testing)
Codes include 32850-32854, 33927-33935, 33945, 38205-38206, 38230, 38232, 38240-38243, 44135, 47133, 47135, 48160, 48550, 48554, 48556, 50300, 50320, 50340, 50360-50370, 50547, 81370-81373, 81375-81383, 0584T-0586T, 0664T-0670T, G0341-G0343, L8698, S2053-S2065, S2102, S2142, S9975, selected ICD-10-PCS 02WA3QZ, 02WA4QZ
ALL of the following
- Ventricular assist devices (VADs)
Codes: 33975, 33976, 33979, 33981-33983
ALL of the following
- Wound care: Negative pressure wound therapy (NPWT)
Codes: 97605, 97606, A6550, E2402
ALL of the following
- Specialty drugs delivered in physician office, clinic, outpatient or home settings
Prior authorization required; request via fax forms per Humana process
Code Lists and Coding Rules
| 81162 | CPT molecular pathology, target region sequencing, 1-6 exons/regions |
| 81163 | CPT molecular pathology, target region sequencing, 7-12 exons/regions |
| 81164 | CPT molecular pathology, target region sequencing, 13-18 exons/regions |
| 81165 | CPT molecular pathology, target region sequencing, 19-24 exons/regions |
| 81166 | CPT molecular pathology, target region sequencing, 25-29 exons/regions |
| 81167 | CPT molecular pathology, target region sequencing, 30-34 exons/regions |
| 81201 | BRCA1 (breast cancer 1) full gene sequence |
| 81202 | BRCA2 (breast cancer 2) full gene sequence |
| 81203 | BRCA1 and BRCA2 full gene sequence |
| 81212 | EGFR (epidermal growth factor receptor) gene analysis |
How Providers Request Authorization and Notifications
Definitions: prior authorization vs. notification
Prior authorization is a process requiring the provider to obtain advance approval from the plan to determine whether an item or service will be covered. Notification is the process of informing Humana Healthy Horizons of the intent to provide an item or service; Humana does not issue an approval or denial for notifications.
How to request prior authorization
Prior authorization requests may be initiated online via Availity (registration required), by calling the Humana Healthy Horizons IVR at 800-523-0023, or by faxing the prior authorization form to 833-441-0950. Behavioral health prior authorization may be initiated via the Behavioral Health Crisis Line at 833-364-2274 using the same online/IVR/fax methods. Medication prior authorization requests may be faxed to 888-447-3430 or initiated by phone at 866-461-7273.
- Online: Availity.com (registration required)
- Phone (IVR): 800-523-0023
- Fax (medical services): 833-441-0950
- Behavioral health phone: 833-364-2274
- Medication fax: 888-447-3430; medication phone: 866-461-7273 (Mon–Fri 8 a.m.–11 p.m. ET)
Urgent/emergent services — no prior auth required
Urgent or emergent services do not require referrals, prior authorization, or notification.
Consequences of not obtaining prior authorization/notification
Failure to obtain required prior authorization or notification may result in financial penalties for the practice and reduced patient benefits; services provided without prior authorization or notification may be subject to retrospective medical necessity review.
How to request prior authorization/notification (fax forms)
To request prior authorization or to provide required notification via fax, use the Humana Healthy Horizons prior authorization/notification fax forms as directed in the PAL.
- Access fax forms referenced in the PAL for submission instructions.
Obstetrical admission notification thresholds
Humana Healthy Horizons expects notification for obstetrical admissions that exceed 48 hours for vaginal deliveries and 96 hours for cesarean sections to allow concurrent review for care coordination and discharge planning.
- Notify Humana when vaginal delivery admission > 48 hours.
- Notify Humana when cesarean delivery admission > 96 hours.
Key Terms and Abbreviations
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