Humana Prior Authorization Template 2026: Free Templates + Gold Card & EviCore Guide

Understanding Humana Prior Authorization Requirements 2026

Humana has made significant changes to its prior authorization program in 2026. By January 1, 2026, Humana eliminated approximately one-third of prior authorization requirements for outpatient services, removing PA requirements for colonoscopies, transthoracic echocardiograms, and select CT scans and MRIs. These changes reduce administrative burden for providers handling high-volume routine diagnostic services.

In 2026, Humana also launched a gold card program that waives prior authorization requirements for providers who have demonstrated consistent track records of submitting coverage requests meeting medical criteria with quality outcomes. This represents a meaningful shift in how Humana approaches PA for high-performing practices.

For a comprehensive understanding of prior authorization denials across all major payers, including Humana, see our complete prior authorization denial guide. If a Humana PA has already been denied and you need to appeal, our Humana appeal letter template covers the full dispute process.

The key challenge with Humana prior authorization: Humana uses a delegated model where EviCore by Evernorth manages specialty prior authorizations across cardiology, musculoskeletal, radiology, and other high-cost service categories. Knowing which submission channel to use—Availity versus EviCore—is the most common source of delay.

What's Changed in 2026: Humana Prior Authorization Updates

January 1, 2026: One-Third of Outpatient PAs Eliminated Humana removed prior authorization requirements for a significant portion of outpatient services, particularly diagnostic procedures. Services removed from the PA requirement list include:

• Colonoscopies
• Transthoracic echocardiograms
• Select computed tomography (CT) scans
• Select magnetic resonance imaging (MRI) scans

Verify current PA requirements using Humana's Prior Authorization Search Tool or by checking the published Prior Authorization and Notification (PAL) list at Humana.com/PAL.

CMS-0057-F: Medicare Advantage PA Decision Timelines (January 1, 2026) Under the CMS Interoperability and Prior Authorization Final Rule (CMS-0057-F, effective January 1, 2026), Humana Medicare Advantage plans must issue PA decisions within:

• 7 calendar days for standard prior authorization requests
• 72 hours for expedited (urgent) prior authorization requests

These timelines are federally mandated. Humana's internal commitment to process 95% of complete electronic PAs within one business day applies across commercial and Medicare Advantage plans.

Gold Card Program (2026 Launch) Humana's gold card program waives prior authorization requirements for providers who demonstrate consistent quality outcomes and appropriate coverage request submission. For details on gold card eligibility and enrollment, contact your Humana provider relations representative or the Customer Care line at 800-457-4708.

Which Humana Services Require Prior Authorization in 2026?

Humana publishes separate PA lists for commercial and Medicare Advantage plans.

How to check:

1. Use the Humana Prior Authorization Search Tool — search by CPT code, description, or drug name
2. Download the published PAL (Prior Authorization and Notification List) at Humana.com/PAL
3. Call Customer Care at 800-457-4708 to confirm for specific plan types

General categories typically requiring Humana PA in 2026:

• Inpatient hospital admissions (non-emergency)
• Skilled nursing facility (SNF) admissions
• Inpatient rehabilitation facility (IRF) care
• High-cost specialty drugs (particularly biologics and oncology agents)
• Durable medical equipment above dollar thresholds
• Specialty outpatient procedures (cardiology, musculoskeletal, radiology — managed by EviCore for many plan types)
• Home health services (some plans)
• Behavioral health services (fax 469-913-6941)

Humana Prior Authorization Submission Channels 2026

For pharmacy prior authorizations, use a separate submission channel — see Humana's pharmacy prior authorization page.

Step-by-Step: How to Submit a Humana Prior Authorization via Availity

1. Log in to Availity Essentials at availity.com with your NPI credentials
2. Navigate to Authorizations → Submit Authorization Request
3. Select Humana as the payer
4. Enter the patient's Humana member ID, date of birth, and plan details
5. Enter CPT/HCPCS codes and ICD-10 diagnosis codes for the requested service
6. Complete the clinical questionnaire — for some services, real-time approval is possible at this step
7. Attach supporting clinical documentation (office notes, lab results, failed prior therapy records if applicable)
8. Submit and record the authorization reference number for tracking

If Availity's questionnaire does not result in a real-time decision, the request routes to Humana's clinical review team and you will receive a decision within the applicable timeline.

Humana Prior Authorization Request Template

Use the following structure when submitting written prior authorization requests to Humana. This is not a standalone form — submit via Availity or fax with this information organized clearly.

HUMANA PRIOR AUTHORIZATION REQUEST

Date: [Date]
Submitting Provider: [Name, NPI, Practice Name, Address]
Rendering Provider (if different): [Name, NPI]
Treating Facility (if applicable): [Name, NPI, Address]

--- PATIENT INFORMATION ---
Patient Name: [Last, First]
Date of Birth: [MM/DD/YYYY]
Humana Member ID: [Member ID from card]
Group Number: [Group number from card]
Plan Type: [Commercial / Medicare Advantage / Medicaid / DSNP]

--- REQUESTED SERVICE ---
CPT/HCPCS Code(s): [Code(s) with description]
ICD-10 Diagnosis Code(s): [Primary diagnosis + relevant secondary codes]
Place of Service: [Office / Outpatient / Inpatient / SNF / IRF]
Requested Service Date(s): [Date or date range]
Number of Units / Visits: [If applicable]

--- CLINICAL JUSTIFICATION ---
Primary Diagnosis: [Specific condition with clinical detail]
Symptom Duration: [How long patient has experienced condition]
Conservative Treatments Tried: [List with dates and outcomes — required for many specialty services]
Relevant Lab/Imaging Results: [Summarize key objective findings]
Clinical Guidelines Supporting Request:
  - [Cite specific guideline — e.g., ACP/ACC Guideline 2024 for [condition]]
  - [Or: Humana Clinical Coverage Policy [number], updated [date]]
Urgency: [Standard / Urgent — if urgent, specify clinical reason]

--- ATTACHMENTS ---
[ ] Office/clinic notes (last 90 days)
[ ] Relevant lab results or imaging reports
[ ] Failed conservative treatment records (if applicable)
[ ] Specialist consultation notes (if applicable)
[ ] Letter of medical necessity (attach if required by plan)

Submitting Provider Signature: ___________________
Date: ___________________

Humana Medicare Advantage Prior Authorization Requirements 2026

Medicare Advantage prior authorization at Humana is governed by both CMS federal rules and Humana's MA-specific PA list.

Key MA-specific changes effective January 1, 2026 (CMS-0057-F):

• Standard PA decisions: 7 calendar days maximum
• Expedited PA decisions: 72 hours maximum
• Humana must provide specific clinical reasons for any PA denial
• Humana must send denial notices concurrently to the enrollee and provider
• Concurrent review (reviewing active admissions for continued authorization) cannot retroactively reverse a previously approved admission

The 2026 Humana Medicare Advantage and D-SNP Prior Authorization and Notification List lists all services requiring authorization for MA and Dual Eligible Special Needs Plans, effective January 1, 2026.

For MA timely filing deadlines and appeal windows after a Humana denial, see our Humana Medicare Advantage timely filing guide.

Humana Gold Card Program: What Providers Need to Know

Humana's gold card program, launched in 2026, waives prior authorization requirements for specific items and services when providers meet defined quality criteria. The program applies to providers who:

• Have a proven record of submitting coverage requests that meet Humana's medical criteria
• Deliver high-quality care with consistent outcomes for Humana members

Gold card status means those providers do not need to submit prior authorization for the covered services in the program — the PA requirement is automatically waived.

To inquire about gold card eligibility for your practice, contact your Humana provider relations representative or call Humana Customer Care at 800-457-4708. Humana has committed to publicly reporting PA approval, denial, and appeal metrics annually — these metrics can be used to document your practice's PA approval history when applying.

EviCore-Delegated Prior Authorizations: Specialty Services

For many Humana commercial and Medicare Advantage plans, EviCore by Evernorth manages prior authorization for specialty service categories. Common EviCore-delegated services for Humana plans include:

• Cardiology: stress tests, echocardiograms (note: some echo types removed from PA requirement in 2026 — verify)
• Musculoskeletal / Orthopedic: spine surgery, joint replacement, physical/occupational therapy (some plans)
• Radiology / Imaging: advanced imaging (CT, MRI, PET — verify which remain on PA list)
• Behavioral Health / Substance Use: residential treatment, intensive outpatient (some plans)
• Oncology: some chemotherapy regimens

How to submit an EviCore PA for Humana:

1. Go to evicore.com/provider and select Humana as your health plan
2. Log in with your NPI or create an EviCore provider account
3. Complete the online authorization request with clinical documentation
4. EviCore's portal is available 24/7 and provides real-time status tracking
5. For Humana Kentucky Medicaid (Healthy Horizons): use the Kentucky-specific EviCore resources at evicore.com/resources/healthplan/humana/kentucky

If you are unsure whether EviCore or Availity handles a specific service, check Humana's PA search tool first or call 800-523-0023 before submitting.

What to Do When Humana Denies a Prior Authorization

If Humana denies a prior authorization request, you have several options:

Peer-to-peer review: Contact Humana's clinical reviewer directly within the appeal window to discuss the case. This is often the fastest path to reversal for cases with strong clinical documentation.

First-level appeal (Provider Dispute): Submit a written appeal within the applicable deadline. Commercial plans typically allow 60–180 days from the denial date; Medicare Advantage allows 60 days. See our Humana appeal letter template for a structured format.

External review / Independent Medical Review: After exhausting internal appeals, Humana members and providers have the right to request independent review. For Medicare Advantage, the escalation ladder runs through QIC, ALJ, and federal court. See our guide to the independent review organization appeal process.

For patterns of AI-driven or algorithm-based PA denials — increasingly common with large payers — see our guide to fighting AI insurance denials.

How Muni Appeals Streamlines Humana Prior Authorization

Managing Humana prior authorizations — with EviCore delegation, evolving gold card requirements, and MA-specific CMS-0057-F timelines — is high-complexity administrative work. Muni Appeals automates the clinical documentation assembly and submission workflow, reducing the time your staff spends per PA request.

For practices managing high prior authorization volume with Humana:

• Insurer-specific submission routing (Availity vs. EviCore by service category)
• Clinical documentation checklist built for Humana's medical criteria
• Denial tracking and automatic appeal initiation
• MA-specific CMS-0057-F timeline monitoring

Start Free with Muni Appeals

Frequently Asked Questions

How do I know if a service requires Humana prior authorization in 2026?

Use Humana's Prior Authorization Search Tool to search by CPT code or description. You can also download the Prior Authorization and Notification (PAL) list at Humana.com/PAL. When in doubt, call Customer Care at 800-457-4708 before scheduling the service.

What is the Humana prior authorization fax number?

The general Humana prior authorization fax number is 855-227-0677. For behavioral health authorizations, fax to 469-913-6941. Availity Essentials is the preferred submission method — fax when portal access is unavailable.

How long does Humana take to approve a prior authorization?

Humana has committed to issuing decisions within 1 business day on at least 95% of complete electronic prior authorization requests. For Medicare Advantage plans, CMS-0057-F (effective January 1, 2026) requires standard decisions within 7 calendar days and expedited decisions within 72 hours. For urgent requests across all plan types, call 866-737-5113.

Does Humana still use EviCore for prior authorization in 2026?

Yes. EviCore by Evernorth continues to manage prior authorization for specialty service categories under many Humana commercial and Medicare Advantage plans, including cardiology, musculoskeletal, and some radiology services. Submit EviCore-delegated PAs at evicore.com/provider, not through Availity.

What is Humana's gold card program and how do I apply?

Humana's gold card program, launched in 2026, waives prior authorization requirements for providers with demonstrated track records of submitting clinically appropriate coverage requests with quality outcomes. To inquire about eligibility, contact your Humana provider relations representative or call 800-457-4708.

What services did Humana remove from the prior authorization list in 2026?

As of January 1, 2026, Humana eliminated approximately one-third of outpatient prior authorization requirements. Services removed include colonoscopies, transthoracic echocardiograms, and select CT scans and MRIs. Always verify current requirements using the Humana PA Search Tool, as the PAL list is updated throughout the year.

What happens if I submit a Humana prior authorization to the wrong portal?

If you submit an EviCore-delegated service via Availity, the request may not route correctly and can result in a delayed decision or denial for administrative reasons. Check the service category against the EviCore delegation list before submitting. When in doubt, call 800-523-0023 to confirm the correct submission channel.

How do I appeal if Humana denies a prior authorization for Medicare Advantage?

For Medicare Advantage PA denials, you must file a formal appeal within 60 days of the denial notice. Under CMS-0057-F (effective January 1, 2026), Humana must provide specific clinical reasons for the denial. Use those reasons to structure your appeal with targeted clinical evidence. See our Humana appeal letter template and our Humana Medicare Advantage timely filing guide for deadline specifics.

Ready to Reduce Humana PA Denials?

Humana's 2026 prior authorization changes — including PA reductions, the gold card program, and faster electronic decision timelines — create real opportunities for practices that adapt their submission workflows. The primary risk is routing errors between Availity and EviCore, and inadequate clinical justification for specialty services.

Get Started:

• Insurer-specific PA routing (Availity vs. EviCore by service type)
• Clinical documentation built to Humana's evidence-based medicine criteria
• Automated denial tracking with appeal initiation
• MA-specific CMS-0057-F timeline compliance monitoring

Start Free with Muni Appeals

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This guide reflects Humana prior authorization procedures and regulations as of April 2026. PA requirements, EviCore delegation scope, and gold card program details may vary by plan type and state. Always verify current requirements at provider.humana.com or via the Prior Authorization Search Tool before scheduling services. Medicare Advantage timelines reflect CMS-0057-F requirements effective January 1, 2026.