CurrentHumanaPolicy CMS-0057-F

Prior authorization timeframe and required documentation (CMS-0057-F)

Governs prior authorization decision timelines and required supporting information for Humana-covered medical items and services in line with CMS final rule, affecting providers submitting authorization requests for Humana members.

Policy Summary

PayerHumana

PolicyPrior authorization timeframe and required documentation (CMS-0057-F)

Policy CodePolicy CMS-0057-F

Change TypeOperational / Added requirement

Effective DateJan 1, 2026

Next Review Date

Key ActionSubmit prior authorization requests with required supporting clinical information at time of request to enable decision within seven calendar days.

SourceLink

POLICY UPDATE CHANGES

CMS requires authorization decisions within seven calendar days for standard (nonurgent) requests effective January 1, 2026.

7 daysdecision timeframe (standard requests)

Jan 1, 2026CMS effective date

up to 6ICD diagnosis codes

up to 10Procedure codes

Submission and Review Criteria

Submission and review criteria

Prior authorization requests must include adequate supporting clinical information at submission to enable timely review (CMS requires decisions for standard requests within seven calendar days effective Jan 1, 2026).

ALL of the following

Submit required supporting clinical information at the time of the prior authorization request to enable decision within seven calendar days for standard (nonurgent) requests.
Required supporting information (include ONE or more of the following as applicable)
- Patient details: full name, date of birth, and Humana policy ID number.
- Referring and servicing provider details: name, National Provider Identifier (NPI), Tax Identification Number (TIN), specialty, and contact information (including fax).

Policy Summary

PayerHumana

PolicyPrior authorization timeframe and required documentation (CMS-0057-F)

Policy CodePolicy CMS-0057-F

Change TypeOperational / Added requirement

Effective DateJan 1, 2026

Next Review Date

Key ActionSubmit prior authorization requests with required supporting clinical information at time of request to enable decision within seven calendar days.

SourceLink

On This Page

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Diagnosis and Procedure Codes Guidance

Diagnosis and procedure codes guidancemixed

Accurate ICD dx codes (up to 6) and procedure codes (up to 10, as applicable) specific to the request

ICD code count

Recommended diagnosis code countAccurate ICD diagnosis codes (up to 6) should be included with requests.

PurposeProvide specific diagnoses relevant to the requested service to support medical necessity.

ApplicabilityInclude up to six ICD codes as applicable per request; list the most relevant primary diagnosis first.

Procedure code count

Recommended procedure code countInclude procedure codes (up to 10) as applicable with the request.

PurposeEnsure requested services are accurately coded to facilitate timely review and authorization.

Details to includeWhen applicable, list all relevant CPT/HCPCS or internal procedure codes associated with the request, up to ten.

Submission Requirements and Provider Responsibilities

Prior Authorization

Prior authorization submission requirements and timeframe

Submit prior authorization requests with all required supporting clinical information at the time of submission to enable Humana to make a decision within seven calendar days for standard (nonurgent) requests, per CMS Interoperability and Prior Authorization Final Rule (CMS-0057-F) effective 2026-01-01.

Decision timeframe: 7 calendar days for standard (nonurgent) requests
Submit complete supporting clinical information at time of request

Denial Risk

Risk of delay or adverse decision

Failure to submit the required clinical information at the time of the prior authorization request may result in a delayed decision or an adverse determination.

Incomplete requests risk delay or denial

Documentation Required

Required documentation for prior authorization

Include the following required documentation with every prior authorization request to avoid delays or adverse decisions: patient identifiers, provider details (including NPI and TIN), diagnosis and procedure codes, treatment specifics, clinical rationale, relevant medical history, and supporting clinical documentation.

Patient details: full name, date of birth, Humana policy ID number
Referring and servicing provider details: name, National Provider Identifier (NPI), Tax Identification Number (TIN), specialty, contact information (including fax)
Diagnosis and procedure codes: accurate ICD-10 codes (up to 6) and procedure codes (up to 10, as applicable) specific to the request
Treatment details: specific service, procedure, item or medication requested, planned date of service, service location (inpatient/outpatient), quantity, medication dosage, frequency, and duration
Clinical rationale: detailed explanation of medical necessity with supporting evidence from medical records; reference Humana coverage policies for clinical guidelines
Relevant medical history: past medical conditions, current medications, allergies, significant laboratory or diagnostic results
Supporting documentation: imaging studies, lab reports, progress notes, documentation of prior treatments/therapies tried and response

Key Terms

standard (nonurgent) request

DefinitionA standard (nonurgent) request is a routine prior authorization request for medical items and services that is not urgent or emergent.

Operational noteCMS requires authorization decisions within seven calendar days for standard (nonurgent) requests effective Jan 1, 2026; submit required supporting clinical information at time of request to enable timely decision.

Consequence of incomplete submissionFailure to submit required clinical information at time of request may result in delayed or adverse decision.

required supporting clinical information

Patient identifiersFull name, date of birth, and Humana policy ID number.

Provider detailsReferring and servicing provider name, National Provider Identifier (NPI), Tax Identification Number (TIN), specialty, and contact information (including fax).

Diagnosis and procedure codesAccurate ICD diagnosis codes (up to 6) and procedure codes (up to 10), as applicable, specific to the request.

Treatment specifics and timingSpecific service, procedure, item or medication requested, planned date of service, service location (inpatient or outpatient), quantity, medication dosage, frequency, and duration.

Clinical rationale and historyDetailed explanation of medical necessity, relevant medical history, current medications, allergies, significant lab results, and supporting clinical notes.

Supporting recordsImaging studies, lab reports, progress notes, treatments/therapies tried, and other relevant clinical documentation that supports the request.