How to request prior authorization and notification

How to request prior authorization and notification: Prior authorization requests should be submitted online at Availity (www.availity.com; registration required) or by calling Humana's interactive voice response line at 800-523-0023. Online submissions are encouraged; for certain services on the PAL, Availity Essentials™ may present a questionnaire which can support real-time approval or speed review. Provide all relevant clinical information with the initial submission to support timely adjudication. For vendor-managed categories (see vendor-specific callouts below), follow the vendor submission channels listed for Cohere, Evolent, and One Home Care.

• Online: www.availity.com (registration required)
• Phone: Humana IVR 800-523-0023
• Availity Essentials™ questionnaires may enable real‑time approvals
• Submit complete clinical documentation with the initial request

Timeliness requirement (CMS)

Timeliness requirement (CMS): Effective January 1, 2026, CMS requires that prior authorization decisions for certain medical items and services be made within 7 calendar days. Submit all supporting clinical information with the initial request to help ensure timely adjudication. If Humana requires additional information, a representative will contact the requester; failure to provide necessary information may delay or adversely affect the decision. Adherence to this process should begin immediately.

• CMS rule effective 2026-01-01: decision within 7 days for certain items/services
• Provide supporting clinical information at submission to avoid delays

Urgent/emergent services and risk of noncompliance

Urgent/emergent services: Urgent and emergent services do not require prior authorization or referrals. However, failure to obtain required prior authorization or provide required notification for non-urgent services may result in retrospective medical necessity review and potential financial penalties for the provider or reduced benefits for the member. Providers are advised to verify benefits and authorization/notification requirements with Humana before providing non-urgent services.

• Urgent/emergent services do not require prior authorization
• Services without required prior authorization/notification may be subject to retrospective review and financial penalties

Information required for a prior authorization request or notification

Required information for requests: Include member identifiers and visit details and attach relevant clinical documentation when submitting a prior authorization request or notification. Typical required items include the member's Humana ID, name, DOB, date(s) of service or admission, procedure codes (up to 10 per request), diagnosis codes (up to 6 per request), service location, provider TIN and NPI, caller contact, attending physician contact, relevant clinical information, and discharge plans when applicable.

• Member Humana ID, name, date of birth
• Date of actual service or hospital admission (or proposed procedure date)
• Procedure codes (up to 10) and diagnosis codes (up to 6)
• Service location and referral type
• TIN and NPI of facility and performing provider
• Caller/requestor name and telephone number; attending physician contact
• Relevant clinical documentation and discharge plans

Cohere Health-managed diagnostic/cardiac imaging prior authorization

Cohere Health-managed diagnostic and cardiac imaging: Many diagnostic and cardiac imaging services (including specified CT and MRI codes, myocardial perfusion studies, nuclear imaging, PET, SPECT, TEE, coronary and peripheral angiography, and cardiac device procedures) are managed by Cohere Health. Submit authorization requests through the Cohere Health portal, by phone at 833-283-0033 (Mon–Fri, 8 a.m.–8 p.m. ET), or by fax to 857-557-6787. Expedited/urgent cases can be submitted and monitored via the Cohere portal. If you have questions, call Cohere Health at 833-283-0033.

• Cohere portal for prior authorization requests
• Phone: 833-283-0033, Monday–Friday, 8 a.m.–8 p.m. ET
• Fax: 857-557-6787
• Expedited/urgent cases may be submitted and monitored on the Cohere portal
• Notification is required for CT/MRI codes listed (e.g., 70460–70498, 70540–70553, 73218–73220, 73718–73720)

Evolent-managed lung biopsy and resection prior authorization

Evolent-managed lung biopsy and resection: Lung biopsy and resection procedures are managed by Evolent (formerly New Century Health). Submit prior authorization requests via Evolent's website. Additional submission channels include calling Evolent at 844-926-4528 (option 5 for surgical services), Monday–Friday, 8 a.m.–8 p.m. ET, or eFax to 213-596-3783 (or eFax via email to efax-carepro-oncology@newcenturyhealth.com) when applicable.

• Evolent website submission
• Phone: 844-926-4528, option 5 (Mon–Fri, 8 a.m.–8 p.m. ET)
• eFax: 213-596-3783 or efax-carepro-oncology@newcenturyhealth.com

One Home Care-managed home health/home infusion

One Home Care-managed home health and home infusion: Home health and home infusion services require prior authorization and are managed by One Home Care. Submit authorization requests through the channels directed by One Home Care and include the applicable HCPCS/T codes listed on the PAL when requesting authorization.

• Managed by One Home Care
• Applicable codes include 99512, 99600, G0151–G0162, G0299–G0300, G0493–G0496, G0513, G2168–G2169, S9122, T1000–T1031, T1502–T1503
• Follow One Home Care submission instructions for authorization

Observation notification

Observation notification: Notification to Humana is required for all Observation services. Notification (not prior authorization) must be submitted for any observation encounter so Humana can coordinate care; Humana does not issue an approval or denial for notifications.

• Notification required for all Observation services (codes: All)
• Observation is a notification-only requirement (not a prior authorization)