Humana prior authorization for behavioral health and substance use care

1. Which Humana plan is it?

The rules depend on the product, so read the card first.

Product	What it means for prior authorization
Medicare Advantage (HMO, PPO, PFFS) and dual-eligible special needs plans (D-SNP)	Humana's national Medicare Advantage and D-SNP list, plus CMS's rules for Medicare Advantage. Most of this page.
Humana Healthy Horizons (Medicaid) and some state dual plans	A separate list for each state, often longer than the Medicare one. See section 8.
TRICARE East (Humana Military)	TRICARE's rules, through Humana Military. See section 8.
Employer group commercial	Humana finished leaving this business in 2025 (Humana's 2025 annual report). A card that still says Humana on an employer plan needs a call to the number on the back.

The electronic benefits check tells you which plan it is, and our guide to reading a 271 shows where.

2. Which levels of care need prior authorization

From Humana's Medicare Advantage and D-SNP prior authorization and notification list, effective January 1, 2026 and revised June 1, 2026, and its 2026 provider manual. Humana changes the list during the year; the current one is always at Humana.com/PAL.

Level of care	Medicare Advantage (as of October 2026)	Notes
Emergency and urgent care	No prior authorization	Humana's manual says emergent and urgent care don't need prior authorization.
Inpatient, including inpatient psychiatric and hospital detox	On the list	The list's inpatient admissions section includes mental health. The list holds both prior authorization and notification items; Humana's manual says notification alone doesn't produce an approval or a denial.
Partial hospitalization (PHP)	On the list	Named in the behavioral health section, by revenue code (for example 0912 and 0913).
Residential treatment	Ask whether it's covered at all	Medicare's coverage pages list hospital inpatient care, PHP and IOP, but no non-hospital residential benefit. The manual does put behavioral health residential facilities under concurrent review where a plan covers them.
Intensive outpatient (IOP)	Not found on the national list	Some state dual-plan lists include it: Humana's Michigan dual plan list (July 1, 2026) names H0015 and S9480. Check the member's own list.
Outpatient therapy	Not found on the national list	Verify the member's benefit and your network status anyway.
Psychological testing	Not found on the national list	Some Medicaid and dual lists include it, for example Ohio Medicaid's above a yearly limit.
TMS	On the list	CPT 90867, 90868 and 90869, and the device code E0732.

Medicare has covered IOP since January 1, 2024, but only from certain provider types: hospitals, critical access hospitals, community mental health centers, rural health clinics, FQHCs and opioid treatment programs (Medicare Benefit Policy Manual, chapter 6). A freestanding program that isn't one of those should ask Humana how it would cover the service before talking about authorization. Our detox and residential VOB guide covers the inpatient benefits.

3. How to request it

1. Find the member's list at Humana.com/PAL: the national Medicare Advantage and D-SNP list, or the state Medicaid or dual list. Run the benefits check and the questions in our VOB call script for each level you might use.
2. Submit on Availity. Humana's provider tools guide calls Availity the preferred method; for some services you answer a set of questions in the request and, if approved, get the decision right away.
3. Or call 800-523-0023, Humana's prior authorization line (an automated phone system). The same guide says to call it when a request must be expedited because of the patient's condition. Humana's manual also lists a fax number for behavioral health requests.
4. Ask early. Humana asks for requests as soon as possible and at least 14 days before a planned service. Emergency admissions don't wait for approval, but tell the plan as its list requires.
5. Check who reviews it. For some services, Humana's lists name a separate review company with its own portal and phone line. The list tells you which; send those requests where it says.
6. Write down the reference number, the reviewer, what was approved, and the first and last approved day.

4. The criteria Humana uses

• Medicare Advantage follows Medicare's coverage rules. CMS's 2024 rule requires Medicare Advantage plans to follow national and local coverage determinations and the coverage rules in Traditional Medicare's regulations. A plan may use its own criteria only where Medicare's aren't fully established, and only if they rest on current evidence in widely used guidelines or published clinical literature (CMS fact sheet). For PHP and IOP, that means Medicare's own rules in chapter 6 of the Benefit Policy Manual.
• A medical director reviews before any denial. Humana's manual says that before an adverse medical necessity determination, a licensed, board-certified medical director reviews the available clinical documentation. You can ask for the specific guidelines used in a denial.
• Medicaid plans name their sets. Humana Healthy Horizons in Kentucky reviews substance use requests against the ASAM Criteria, 4th edition (from July 1, 2025) and mental health requests against MCG. The Ohio plan applies state rules first, then guidelines such as MCG and ASAM. The Louisiana plan uses LOCUS for adults and CALOCUS for children for some mental health services.

For substance use care, rate all six ASAM dimensions even when the plan doesn't ask; they are the clearest way to show why this level and not a lower one. The dimensions are in our prior authorization guide.

5. Continued-stay reviews

• Which stays. Humana's 2026 manual puts behavioral health partial hospital and residential treatment facilities under concurrent review. For more days, submit a request for continued stay with the most recent medical records.
• How long an approval lasts. Under CMS's 2024 rule, a Medicare Advantage approval for a course of treatment must stay valid as long as it's medically reasonable and necessary, based on the criteria, the patient's history and the treating provider's recommendation.
• New Humana members already in treatment. Humana's list says it doesn't require prior authorization for basic Medicare benefits during a new member's first 90 days for an active course of treatment that began before enrollment, as CMS's rule requires.
• Medicaid example. Humana Healthy Horizons in Ohio's 2026 provider manual requires notice of every inpatient admission within one business day, and decides concurrent requests within three calendar days.

Send the update before the last approved day, built from this week's notes: progress on each goal, updated ratings, attendance, drug screens and the discharge plan. Our general guide has the full list.

6. How long Humana has to decide

Plan	Deadline	Source
Medicare Advantage, standard	7 calendar days from receipt for a service subject to prior authorization, from January 1, 2026 (14 days for other requests). The plan can extend by up to 14 days only with written reasons.	42 CFR 422.568
Medicare Advantage, expedited	72 hours, when waiting could seriously jeopardize the member's life, health or ability to regain maximum function. A physician's request saying so must be expedited.	42 CFR 422.570, 422.572
Humana Healthy Horizons (Medicaid)	72 hours expedited and 7 calendar days standard, from 2026; state contracts can be shorter.	CMS-0057-F

If Medicare Advantage misses the deadline, the missed deadline itself counts as a denial you can appeal. Starting in 2026, every denial must also give a specific reason.

7. Peer-to-peer reviews and appeals

• Peer-to-peer comes before the denial. Humana's 2026 manual says that for Medicare Advantage plans, the peer-to-peer must be completed before the adverse determination is issued. It's a phone conversation between a Humana medical director and the physician or other professional who asked for the authorization. It isn't an appeal, so ask for it while the request is still pending.
• Who joins. Humana's Kentucky Medicaid FAQ leaves it to the provider, as long as the person can answer questions about why the service is needed. Bring the clinician who knows the client, with the ASAM ratings and the treatment history on one page.
• Medicare Advantage appeals. Ask for a reconsideration within 60 calendar days of receiving the denial (42 CFR 422.582). If Humana upholds it, the case goes to the independent review entity CMS contracts with (422.590). Ask for an expedited reconsideration when the client is in care.

Cima EHR's guide to appealing an insurance denial walks through the letter.

8. Humana Medicaid and TRICARE East

Humana Healthy Horizons is Humana's Medicaid brand, and each state plan publishes its own prior authorization list, often with more behavioral health items than Medicare. A few examples from 2026:

• Ohio: the Ohio Medicaid list includes SUD partial hospitalization, residential treatment, TMS, and psychological testing above a yearly limit. The Ohio provider manual also requires prior authorization for inpatient psychiatric admissions.
• Louisiana: the Louisiana Medicaid list includes intensive outpatient (H0015).
• Kentucky: substance use reviews use the ASAM Criteria, 4th edition, and mental health reviews use MCG.

TRICARE East is run by Humana Military. Its behavioral health tip sheet says non-emergency residential SUD admissions (detox and rehabilitation) need a referral and preauthorization, and emergency admissions must be reported within 72 hours. Active duty service members need a referral and preauthorization for mental health and SUD care outside a military facility. For PHP and IOP, Humana Military's documents and TRICARE's PHP page don't agree, so check the beneficiary's plan with Humana Military before admission. Humana Military's continued-stay request form covers PHP, IOP and SUD detox and rehab. Programs getting TRICARE-authorized first can read Cima Consulting's guide to TRICARE IOP and PHP certification.

9. Before you call: a checklist

• The card and the product: Medicare Advantage, D-SNP, Medicaid or TRICARE, and the member's state.
• The right list: the current version from Humana.com/PAL, with its date.
• Coverage before authorization: for a Medicare Advantage member, is your program a provider type Medicare pays for this level (PHP and IOP from hospitals and community mental health centers, for example)? Are you in network?
• The codes: the revenue code and HCPCS or CPT code for the service.
• The clinicals: diagnosis with ICD-10 code, substance use history and last use, withdrawal risk, medications, risk to self or others, treatment history with dates, and the recovery environment.
• The ratings and plan: the ASAM dimensions (or the plan's criteria), the schedule, the expected length of stay and the discharge plan; for PHP, the physician's certification Medicare requires.
• Your log: the date, the person, the reference number and the approved dates. Use the VOB checklist and the printable VOB form.

Quick VOB keeps that log: what the rep said for each level of care, with the reference number, and each authorization tracked to its last day with an email 5 days before it ends. Programs that want the continued-stay reviews on the chart use Cima EHR for IOP and PHP programs. Joining Humana's network first? See Cima Consulting's Humana credentialing guide.

Other insurers: Cigna prior authorization · Aetna prior authorization · prior authorization for any plan

Questions

Does Humana require prior authorization for partial hospitalization?

Yes, for Medicare Advantage and D-SNP members: partial hospitalization is in the behavioral health section of Humana's national list effective January 1, 2026. Humana Medicaid plans list it too, Ohio's for SUD partial hospitalization, for example.

Does Humana require prior authorization for IOP?

We didn't find IOP on Humana's national Medicare Advantage list as of October 2026. Some state lists include it, such as the Michigan dual plan's (H0015, S9480) and Louisiana Medicaid's (H0015). Check the member's own list at Humana.com/PAL, and confirm Medicare covers IOP from your type of program.

What is the Humana prior authorization phone number?

800-523-0023, Humana's prior authorization line, which Humana also says to call for an expedited request. Humana Medicaid plans and Humana Military have their own numbers; use the one on the member's card.

How do I submit a prior authorization to Humana?

On Availity, which Humana calls its preferred method, or by phone at 800-523-0023. Submit at least 14 days before a planned service. If the list names a separate review company for that service, send it there.

Does Humana Medicare require prior authorization for inpatient psychiatric or detox admissions?

Inpatient admissions, including mental health, are on Humana's Medicare Advantage prior authorization and notification list; check whether the member's list asks for authorization or notice. Emergency admissions don't need prior authorization first, but a planned admission on the list that wasn't authorized beforehand isn't eligible for review afterward.

How long does Humana prior authorization take?

For Medicare Advantage, CMS requires a decision within 7 calendar days for a standard request for a service subject to prior authorization, from January 1, 2026, and 72 hours for an expedited one. The plan can extend a standard request by up to 14 days only with written reasons.

Does Humana require prior authorization for TMS?

Yes, on the Medicare Advantage and D-SNP list: CPT 90867 to 90869 and the device code E0732. Several Humana Medicaid and dual lists include TMS too.

Does Humana Military (TRICARE) require prior authorization for behavioral health?

For TRICARE East, Humana Military requires a referral and preauthorization for non-emergency residential SUD admissions, and notice within 72 hours of an emergency admission. Active duty members need a referral and preauthorization for care outside a military facility. Its documents disagree on PHP and IOP, so confirm with Humana Military.

Sources

1. Humana, Medicare Advantage and Dual Eligible Special Needs Plan Prior Authorization and Notification List (effective January 1, 2026, revised June 1, 2026); Humana.com/PAL. humana.com · humana.com
2. Humana, 2026 Provider Manual for physicians, hospitals and healthcare providers (non-delegated). humana.com
3. Humana, Tools and resources for physicians and other healthcare providers (Availity, 800-523-0023). humana.com
4. Humana, Michigan Dual Highly Integrated prior authorization list (July 1, 2026). humana.com
5. Humana Healthy Horizons: Kentucky behavioral health authorization FAQ; Ohio medical necessity guidelines, prior authorization list and 2026 provider manual; Louisiana CPST policy and prior authorization list. humana.com · humana.com · humana.com · humana.com · humana.com · humana.com
6. Humana Military, Behavioral health covered services (TRICARE East); TRICARE, Partial hospitalization. humanamilitary.com · tricare.mil
7. Humana Inc., Annual report on Form 10-K for 2025. sec.gov
8. 42 CFR 422.568, 422.570, 422.572, 422.582 and 422.590 (Medicare Advantage organization determinations and reconsiderations). ecfr.gov
9. CMS, 2024 Medicare Advantage and Part D Final Rule (CMS-4201-F) fact sheet; Interoperability and Prior Authorization Final Rule (CMS-0057-F). cms.gov · cms.gov
10. CMS, Medicare Benefit Policy Manual, chapter 6 (intensive outpatient and partial hospitalization services); Medicare.gov, Mental health and substance use disorder services. cms.gov · medicare.gov

General information, not legal, clinical or billing advice. Quick VOB isn't affiliated with Humana. Humana's lists change during the year and differ by plan and state; check the member's current list at Humana.com/PAL and your contract before each admission.