Humana Medicare prior authorization in 2026

Humana keeps one prior authorization list for its Medicare Advantage and D-SNP plans and a separate list for drugs. The current Humana Medicare prior authorization list took effect July 1, 2026 and was revised October 1, 2026, according to Humana. It applies in full to Humana Medicare Advantage HMO, HMO point-of-service and PPO plans, while private fee-for-service plans ask only for notification and Medicare Supplement plans are outside it.

Requests go through Availity or Humana’s phone line, and Humana sends some services to outside reviewers, mainly Cohere and Evolent. Which reviewer takes a request depends on the service and, for some imaging, on the state.

At a glance

• Cohere reviews outpatient physical and occupational therapy on Humana Medicare Advantage plans.
• Bilevel positive airway pressure devices join Humana’s Medicare Advantage list on January 1, 2027.
• Drugs given in the office go to Humana through CoverMyMeds or by fax to 888-447-3430.
• Humana reported a median decision time of 0 days in 31 of 32 contracts for 2025.
• For 90 days, a new member’s active treatment under basic benefits needs no Humana prior authorization.

Services on Humana’s 2026 Medicare Advantage list

The list covers inpatient stays (acute, rehabilitation, long-term acute care, behavioral health and skilled nursing), home health in every state, outpatient physical and occupational therapy, imaging, cardiac procedures, durable medical equipment, molecular testing, radiation therapy, and spine and pain procedures. Some CT and MRI codes need only a notification. Outpatient speech therapy codes and ABA codes are not on the list.

Humana adds services to the list from time to time. From January 1, 2027, for example, bilevel positive airway pressure devices (E0470 and E0471) need prior authorization for Medicare Advantage and D-SNP members, according to a Humana notice. For Humana’s commercial plans and its Part D process, see the Humana prior authorization guide.

Who reviews each Humana Medicare request

The table below shows the reviewer for each service on Humana’s list:

Cohere’s own Humana page (July 2026) adds that, for musculoskeletal services, it isn’t used for members with Medicare HMO plans in Florida, California and Hawaii, who get authorizations through their primary care provider.

Learn where Silna would route each Humana Medicare request

How to send a Humana Medicare request and which form to use

Humana encourages online requests through Availity, and some answers to its questionnaires there can bring an approval in real time. Requests can also go through Humana’s phone line at 800-523-0023. A request carries up to 10 procedure codes and up to 6 diagnosis codes. Services that Cohere or Evolent review go through those companies’ own portals.

Humana Medicare prior authorization form

The Humana Medicare prior authorization form for services Humana reviews is its one-page Authorization/Referral Request Form, faxed to 800-266-3022 for services scheduled in advance or to 469-913-6941 for behavioral health. Same-day and urgent requests go by phone to 800-523-0023, according to the form itself. Drugs are on Humana’s separate medication list (revised October 2026). Humana prefers requests for those drugs through CoverMyMeds and also takes them by fax at 888-447-3430. The medication prior authorization guide covers how drug requests differ from service requests.

Humana’s provider flyer on the 2026 rules (December 2025) warns that leaving out clinical information when you submit “may result in a delayed and/or adverse decision.”

How fast Humana decided in 2025, and the 2026 limit

From January 1, 2026, a Medicare Advantage plan must decide a standard request for an item or service within 7 calendar days and an expedited one within 72 hours, under 42 CFR part 422. Either deadline can be extended by up to 14 days. The limit for a standard request had been 14 days, and the Medicare prior authorization guide covers how these rules apply across plans.

Humana’s 2025 results, measured under the earlier limit, are posted for each of its 32 Medicare Advantage contracts, as insurer-reported figures for items and services:

In KFF’s enrollment-weighted analysis of insurers’ posted figures (August 2026), Humana denied 7% of standard requests and 10% of expedited ones. Of the standard denials that were appealed, 64% were overturned.

Humana’s prior authorization cuts and its gold card plan

Humana says it removed prior authorization for more than 340 codes across 2024 and 2025, about a third of its 2025 outpatient diagnostic authorizations. It also says that from January 1, 2026 it decides at least 95% of complete electronic requests within one business day, according to its August 2026 update.

The same update says Humana will launch a gold card program in 2026 that waives prior authorization for some services for clinicians with a record of requests that meet medical criteria. The update doesn’t give a launch date.

New members and appeals

For basic Medicare benefits, Humana doesn’t require prior authorization in a new member’s first 90 days for an active course of treatment that started before they enrolled. It may still review those services when it pays for them. To get the claim paid, Humana asks for the modifier in its payment policy CP2023011 or medical records showing an active course of treatment. Under federal rules, a coordinated care plan may not require prior authorization for an active course of treatment during a patient’s first 90 days after switching plans. An approval for a course of treatment stays valid as long as it is medically necessary, under CMS-4201-F.

A reconsideration must be filed within 60 calendar days after the denial notice is received. Humana decides a standard service request within 30 days and an expedited request within 72 hours. A request for a Part B drug is decided within 7 days. A denial it upholds goes to the CMS independent review entity automatically. The full steps are in the guide to appealing a prior authorization denial.

Silna’s part in Humana Medicare authorizations

For each request, Silna checks the patient’s plan type and which reviewer takes the service, then sends the request to Humana, Cohere or Evolent with the clinical documents and follows up until a decision comes back. It tracks each approval’s end date, and its insurance monitoring flags a patient who changes plans. As of October 2026, G2 reviewers rate it 4.8 out of 5 across 66 verified reviews.

Request a Silna walkthrough of your Humana Medicare caseload

Key terms

Medicare Advantage HMO and PPO

Private Medicare plans with a provider network; an HMO generally keeps care in network, and a PPO also covers care outside it at a higher cost.

Private fee-for-service plan

A Medicare Advantage plan type that, on Humana’s list, needs a notification for listed services instead of a prior authorization.

D-SNP

A dual eligible special needs plan, for people who have both Medicare and Medicaid.

Reconsideration

The first appeal of a Medicare Advantage denial, decided by the plan.

Independent review entity

The outside reviewer, under contract to CMS, that receives a denial the plan upholds.

Frequently Asked Questions

Which Humana Medicare services go to Cohere?

Therapy, cardiac, spine and pain, joint and foot surgery, EGD and several other procedures. Cohere also reviews CT, MRI, MRA and PET in every state except Florida, Georgia, North Carolina, South Carolina and Virginia, where Humana reviews them.

Where do I fax a Humana Medicare prior authorization request?

To 800-266-3022, on Humana’s Authorization/Referral Request Form, for a service scheduled in advance that Humana reviews. Behavioral health requests go to 469-913-6941.

Is Humana’s Medicare list the same for every plan type?

No. For a private fee-for-service member, a provider sends Humana a notification for a listed service and can ask for an advance coverage determination before the service.

How long does a Humana member have to appeal a denial?

Sixty calendar days from receiving the denial notice. A denial Humana upholds then goes to the CMS independent review entity without a separate filing.

Has Humana launched its gold card program?

Not as of Humana’s August 2026 update, which still described the program as one it will launch in 2026, without a date.

This article is general educational information and does not give medical, legal or insurance advice. Humana updates its Medicare list during the year, so check the current list before you send a request.

About the author

Jeffrey Morelli

Jeffrey Morelli is the Co-Founder and CEO of Silna Health, the first Care Readiness Platform built to remove the administrative barriers that delay care. Silna automates benefit checks, eligibility, and prior authorizations across 1,000+ payors, and is backed by $27M from Accel and Bain Capital Ventures. Before Silna, Jeff spent a decade in San Francisco building and scaling products for highly regulated industries, including leading go-to-market at Truework (Series C, acquired by Checkr).

Last updated: October 25, 2026.