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<h2>Ablation</h2>










































































































































<h3>Preauthorization requirements</h3>










































































































































<ul>








<li>Ablation for bone, liver, kidney and prostate disease</li>








</ul>










































































































































Preauthorization for ablation procedures is required for all patients with Humana commercial, Medicare or Illinois Dual Medicare-Medicaid coverage, unless otherwise noted below. Preauthorization is not required for patients with Medicare Advantage (MA) private fee-for-service (PFFS) coverage. However, notification is requested for these plans, as it helps coordinate care for your patients.










































































































































For ablation procedures, contact Evolent (formerly New Century Health). Specific services and areas not delegated to Evolent will be reviewed by Humana.&nbsp;















How to submit a preauthorization request to Evolent
Choose from the following options to submit a request for preauthorization:
<ul>
<li>Delegated lines of business: Medicare health maintenance organization, preferred provider organization plans and Illinois dual 
 Medicare-Medicaid.</li>
<li>Online:&nbsp;Submit through&nbsp;<a href="https://my.newcenturyhealth.com/">Evolent’s provider portal</a>.</li>
<li>Phone:&nbsp;844-926-4528, option 5, Monday – Friday, 8 a.m. – 8 p.m., Eastern time.</li>
<li>Fax:&nbsp;213-596-3783 or <a href="mailto:efax-carepro-oncology@newcenturyhealth.com">efax-carepro-oncology@newcenturyhealth.com</a></li>
</ul>
<ul>

</ul>










































































































































For commercial and PFFS patients










































































































































Please call our clinical intake team at 800-523-0023, 24 hours a day, 7 days a week.










































































































































For patients in Puerto Rico










































































































































For commercial coverage, please submit preauthorization requests by telephone at 








 800-611-1474 (providers) or 800-314-3121 (members) or by fax to 800-658-9457.










































































































































For MA coverage, submit preauthorization requests by telephone at 866-488-5995 (providers) or 866-773-5959 (members) or by fax to 800-594-5309.

<h2>Advanced imaging</h2>


























































<h3>Preauthorization requirements</h3>


























































<ul>









<li>Advanced imaging</li>









<li>Cardiac computed tomographic angiography (CCTA)</li>









<li>Cardiac positron emission tomography (cardiac PET) scan</li>









<li>Computed tomography (CT) scan</li>









<li>Computed tomographic angiography (CTA)</li>









<li>Magnetic resonance angiography (MRA)</li>









<li>Magnetic resonance imaging (MRI)</li>









<li>Peripheral angiography</li>









<li>Positron emission tomography (PET) scan</li>









<li>Positron emission tomography + computed tomography (PET + CT) scan</li>









</ul>


























































All preauthorization requests are reviewed by Cohere Health, a nationally recognized benefit management organization. Preauthorization for diagnostic/cardiac imaging is required for all patients with Humana commercial, Medicare or Illinois dual Medicare-Medicaid coverage. Cohere Health does not review Puerto Rico preauthorizations.


























































Please note:&nbsp;Preauthorization is not required for patients with Medicare Advantage (MA) private fee-for-service (PFFS) coverage. However, notification is requested for these plans, as it helps coordinate care for your patients.


























































<h3>How to submit a preauthorization request to Cohere Health</h3>


























































You can submit a preauthorization request form by following the options below:


























































Online:


























































<ul>









<li>Cohere Health’s portal (online):</li>









</ul>


























































&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;o&nbsp;&nbsp; <a data-ispdf="false" data-iscta="false" target="_blank"></a><a data-ispdf="false" data-iscta="false" target="_blank"></a><a data-ispdf="false" data-iscta="false" target="_blank"></a><a data-ispdf="false" data-iscta="false" href="http://www.coherehealth.com/provider/register" target="_blank">Information and to request a new account</a>.&nbsp; 








&nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; o&nbsp;&nbsp; <a data-ispdf="false" data-iscta="false" target="_blank"></a><a data-ispdf="false" data-iscta="false" target="_blank"></a><a data-ispdf="false" data-iscta="false" target="_blank"></a><a data-ispdf="false" data-iscta="false" target="_blank"></a><a data-ispdf="false" data-iscta="false" href="http://www.coherehealth.com/provider/resources" target="_blank">Additional provider information and resources</a>.&nbsp;


























































<ul>









<li><a data-ispdf="false" data-iscta="false" target="_blank"></a><a data-ispdf="false" data-iscta="false" target="_blank"></a><a data-ispdf="false" data-iscta="false" target="_blank"></a><a data-ispdf="false" data-iscta="false" href="https://login.coherehealth.com" target="_blank">Portal login</a> (preauthorization request)</li>









<li>Phone:&nbsp;833-283-0033, Monday – Friday, 8 a.m. – 8 p.m., Eastern time.</li>









<li>Fax:&nbsp;857-557-6787 









 









</li>









</ul>


























































Please note: All urgent or expedited requests can be submitted and monitored on the Cohere Health portal at <a></a><a data-ispdf="false" data-iscta="false" target="_blank"></a><a data-ispdf="false" data-iscta="false" href="https://next.coherehealth.com" target="_blank">Next.Coherehealth.com</a>.


























































For patients in Puerto Rico


























































For commercial coverage, submit preauthorization requests by telephone at 800-611-1474 (providers) or 800-314-3121 (members) or by fax to 800-658-9457.


























































For MA coverage, submit preauthorization requests by telephone at 866-488-5995 (providers) or 866-773-5959 (members) or by fax to 800-594-5309.


























































Please note: For MA PFFS-covered patients, please contact Cohere Health if you would like an ACD for these services.

<h2>Behavioral health services</h2>
Preauthorization requirements
<ul>
<li>Inpatient hospitalization</li>
<li>Inpatient rehabilitation</li>
<li>Partial hospitalization</li>
<li>Residential treatment</li>
<li>Transcranial magnetic stimulation (TMS)</li>
<li>Applied behavioral analysis (ABA) therapy</li>
</ul>
Preauthorization requests for behavioral health and substance use services for Humana commercial, Medicare and dual-eligible patients (except Illinois) are managed by Humana’s Behavioral Health Utilization Management (UM) team. Certain services may not be covered under the member’s plan.
Medicaid-specific services may require authorization. For state specific information, please visit: 

<a href="https://provider.humana.com/medicaid/florida-medicaid" data-ispdf="false" data-iscta="false">Humana Healthy Horizons® in Florida</a>
<a href="https://provider.humana.com/medicaid/kentucky-medicaid" data-ispdf="false" data-iscta="false">Humana Healthy Horizons® in Kentucky</a>
<a href="https://provider.humana.com/medicaid/louisiana-medicaid" data-ispdf="false" data-iscta="false">Humana Healthy Horizons® in Louisiana</a>
<a href="https://provider.humana.com/medicaid/ohio-medicaid" data-ispdf="false" data-iscta="false">Humana Healthy Horizons® in Ohio</a>
<a href="https://provider.humana.com/medicaid/south-carolina-medicaid" data-ispdf="false" data-iscta="false">Humana Healthy Horizons® in South Carolina</a>
Administrative Services Only (ASO) clients can purchase a behavioral health services product, such as managed behavioral health or integrated medical and behavioral health, which includes management of preauthorization through Humana’s Behavioral Health UM team. For ASO clients with outsourced behavioral health management or those who have purchased a network access-only product, Humana or its clinical affiliates do not provide utilization services.
How to submit a preauthorization request to Availity
You can submit a preauthorization request form by following the options below:
<ul>
<li>Online:&nbsp;Sign into&nbsp;<a href="https://www.availity.com/">Availity Essentials</a>™&nbsp;to start a request. If you are not registered for Availity Essentials, go to&nbsp;<a href="https://www.availity.com/">www.availity.com</a>. To find out more about registration, review our&nbsp;<a href="https://docushare-web.apps.external.pioneer.humana.com/Marketing/docushare-app?q=eVLks5ADFSheuPHzUSyqYA%3d%3d" target="_blank" data-ispdf="true" data-iscta="false">Availity Essentials registration guide</a>.</li>
<li>Phone:&nbsp;Call 844-825-7898 (Medicare), 844-825-7899 (commercial) 
 Monday – Thursday, 8 a.m. – 7:30 p.m., Eastern time, and Friday, 
 8 a.m. – 7 p.m., Eastern time. For all urgent/expedited requests, submit via phone.</li>
<li>Fax:&nbsp;469-913-6941</li>
</ul>
Behavioral Health Authorization Request Forms
Behavioral Health Authorization Request Form for inpatient, sub-acute and residential requests
Physicians, clinicians and other healthcare providers can use this form to submit authorization requests for their patients with Humana’s behavioral health benefits for inpatient, sub-acute and residential requests. Instructions are included on the form. Once complete, please&nbsp;fax&nbsp;it to Humana’s Behavioral Health UM team at&nbsp;469-913-6941. Please include supporting clinical documentation (e.g., medical records, progress notes, assessments, lab reports, etc.) with your fax form.
<a href="https://docushare-web.apps.external.pioneer.humana.com/Marketing/docushare-app?file=4728932" target="_blank" data-ispdf="true" data-iscta="false">Behavioral Health Commercial/Medicare Authorization Request Form – Inpatient</a>
<a href="https://docushare-web.apps.external.pioneer.humana.com/Marketing/docushare-app?file=5106036" data-ispdf="true" data-iscta="false">Behavioral Health Commercial/Medicare Authorization Request Form – Outpatient</a>
Medical necessity criteria
MCG 
 
 If you received a denial letter pertaining to your recent authorization request and the criteria cited in your letter was MCG, you may want to&nbsp;<a href="https://humanabh.access.mcg.com/index" target="_blank" data-ispdf="false" data-iscta="false">review the online MCG criteria</a> (registration required) used to determine behavioral health medical necessity in your authorization request. 
 
 ASAM 
 
 If you received a denial letter pertaining to your recent authorization request and the criteria cited in your letter was American Society of Addiction Medicine (ASAM), you can reference the&nbsp;<a href="https://sitefinitystorage.blob.core.windows.net/sitefinity-production-blobs/docs/default-source/quality-science/asam-paper-criteria---edtitable-final-form.pdf?sfvrsn=5b7e2a32_11" target="_blank" data-ispdf="false" data-iscta="false">ASAM Criteria</a>&nbsp;used to determine behavioral health medical necessity in your authorization request. 
 
 We’re here to help
Did you follow the Medicare guidance but still need resolution? Email&nbsp;<a href="mailto:BHinquiries@humana.com">BHinquiries@humana.com</a> (Please include reference numbers, provider name, Humana member ID, date of birth and a description of your inquiry.)
<a href="https://docushare-web.apps.external.pioneer.humana.com/Marketing/docushare-app?file=5086523" target="_blank" data-ispdf="true" data-iscta="false">This pamphlet </a>is provided for informational uses only and is posted to comply with IL HB 2595.

<h2>Cardiac Services</h2>













<h3>Preauthorization requirements</h3>













<ul>





<li>Aortic repair</li>





<li>Atrioventricular node ablation</li>





<li>Cardiac ablation</li>





<li>Cardiac catheterization</li>





<li>Cardiac implantable device</li>





<li>Cardiac implantable device (defibrillators)</li>





<li>Cardiac implantable device (pacemakers)</li>





<li>Cardio MEMS</li>





<li>Carotid artery stenting (CAS)</li>





<li>Carotid endarterectomy</li>





<li>Catheter-based angiogram, lower extremity arteries</li>





<li>Electrophysiology study (EPS)</li>





<li>Endovascular aortic repair</li>





<li>External wearable devices</li>





<li>Internal loop recorders</li>





<li>LAAC</li>





<li>Myocardial perfusion imaging single-photon emission computed tomography (MPI-SPECT)</li>





<li>Patent foramen ovale (PFO) and atrial septal defect (ASD) closure</li>





<li>Percutaneous coronary intervention (PCI)/angioplasty</li>





<li>Percutaneous intervention: angioplasty/atherectomy/stenting</li>





<li>Percutaneous thoracic aortic repair</li>





<li>Stress echocardiogram</li>





<li>Surgical revascularization/thromboendarterectomy/peripheral vascular bypass</li>





<li>Surgical thoracic aortic repair</li>





<li>Transcatheter aortic valve replacement/implantation (TAVR)</li>





<li>Transcatheter mitral valve repair</li>





<li>Transesophageal echocardiogram (TEE)</li>





<li>Transthoracic echocardiogram (TTE)</li>





</ul>













All preauthorization requests are reviewed by Cohere Health, a nationally recognized benefit management organization. Cohere Health does not review preauthorization requests for Puerto Rico plans or Medicaid plans except for Illinois dual eligible.













Please note:&nbsp;Preauthorization is not required for patients with Medicare Advantage (MA) private fee-for-service coverage. However, notification is requested for these plans, as it helps coordinate care for your patients.













How to submit a preauthorization request to Cohere Health













You can submit a preauthorization request form by following the options below:













1.&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;Online:&nbsp;Enroll with&nbsp;<a href="https://coherehealth.com/provider/register/" target="_blank" data-ispdf="false" data-iscta="false">Cohere Health’s portal</a>&nbsp;before submitting online requests for preauthorization.













2.&nbsp;&nbsp;&nbsp;&nbsp; Phone:&nbsp;Call 866-825-1550, Monday – Friday, 8 a.m. – 8 p.m., Eastern time.













3.&nbsp;&nbsp;&nbsp;&nbsp; Fax:&nbsp;857-557-6787













Cohere Health will evaluate the medical necessity of the service and request needed medical records. A physician may contact the requesting physician to discuss the preauthorization request. Submit all requests with supporting clinical documentation.













For patients in Puerto Rico 



















For commercial coverage, submit preauthorization requests by telephone at 800-611-1474 (providers) or 800-314-3121 (members) or by fax to 800-658-9457.













For MA coverage, submit preauthorization requests by telephone at 866-488-5995 (providers) or 866-773-5959 (members) or by fax to 800-594-5309.

Chemotherapy agents, supportive drugs and symptom management drugs

<h2>Chiropractic therapy</h2>




<h3>Preauthorization requirements</h3>




Preauthorization for chiropractic services is required for all fully insured Humana commercial members in the following markets:




<ul>



<li>Kentucky:&nbsp;Commonwealth of Kentucky outside the 410xx ZIP code and Indiana counties of Clark, Floyd, Harrison, Jefferson, Scott and Washington (ZIP codes 471xx and 472xx) and northern counties in ZIP code 410xx</li>



<li>Illinois:&nbsp;Entire state of Illinois and Indiana (ZIP codes 463xx and 464xx)</li>



<li>Ohio:&nbsp;Entire state of Ohio and the Indiana counties in ZIP codes 470xx, 473xx, and northern Kentucky counties in ZIP code 410xx</li>



<li>Arizona:&nbsp;Entire state of Arizona</li>



<li>Georgia:&nbsp;Entire state of Georgia</li>



<li>South Florida:&nbsp;Broward, Miami-Dade and Palm Beach counties</li>



</ul>




Preauthorization requests for chiropractic therapy, including manipulative therapy, are reviewed by WholeHealth Networks (WHN), a utilization management company. WHN will review for medical necessity of the service and will request any needed medical records.




WHN does not review preauthorization requests for physicians and other healthcare providers who participate in an independent practice association (IPA) or other risk network with delegated services. Those providers need to refer to their IPA or risk network for guidance on processing preauthorization requests. 



 



 Please note: Preauthorization is not required for services provided by nonparticipating healthcare providers for patients with preferred provider organization (PPO) coverage.




<h3>How to submit a preauthorization request to WholeHealthPro</h3>




You can submit a preauthorization request form by following the options below:




1.&nbsp;&nbsp;&nbsp;&nbsp; Online:&nbsp;Enroll with&nbsp;<a href="http://www.wholehealthpro.com/" target="_blank" data-ispdf="false" data-iscta="false">www.wholehealthpro.com</a>&nbsp;and submit a request.
2.&nbsp;&nbsp;&nbsp;&nbsp; Phone:&nbsp;866-430-8647, 24 hours a day, 7 days a week
3.&nbsp;&nbsp;&nbsp;&nbsp; Fax:&nbsp;888-492-1025




Please note: In addition to records specific to the dates of service under review, you can submit other documentation that may be helpful in developing a more complete and accurate clinical picture of the patient’s condition.

<h2>Endoscopy services</h2>


















<h3>Preauthorization requirements</h3>


















<ul>




<li>Capsule endoscopy</li>




<li>Colonoscopy (repeat only)</li>




<li>Diagnostic esophagogastroduodenoscopy (EGD) or esophagoscopy</li>




<li>Laparoscopic hiatal hernia repair</li>




</ul>


















All preauthorization requests are reviewed by Cohere Health, a nationally recognized benefit management organization. Cohere Health does not review preauthorization requests for Puerto Rico plans or Medicaid plans except for Illinois dual eligible.


















Please note:&nbsp;Preauthorization is not required for patients with Medicare Advantage (MA) private fee-for-service coverage. However, notification is requested for these plans, as it helps coordinate care for your patients.


















<h3>How to submit a preauthorization request to Cohere Health</h3>


















You can submit a preauthorization request form by following the options below:


















1.&nbsp; &nbsp; &nbsp;&nbsp;Online:&nbsp;Enroll with&nbsp;<a href="https://coherehealth.com/provider/register/" target="_blank" data-ispdf="false" data-iscta="false">Cohere Health’s portal</a>&nbsp;before submitting online requests for preauthorization


















2.&nbsp;&nbsp;&nbsp;&nbsp; Phone:&nbsp;833-283-0033, Monday – Friday, 8 a.m. – 8 p.m., Eastern time.


















3.&nbsp;&nbsp;&nbsp;&nbsp; Fax:&nbsp;857-557-6787


















Cohere Health will evaluate the medical necessity of the service and request needed medical records. A physician may contact the requesting physician to discuss the preauthorization request. Submit all requests with supporting clinical documentation.


















&nbsp;


















For patients in Puerto Rico


















For commercial coverage, submit preauthorization requests by telephone at 800-611-1474 (providers) or 800-314-3121 (members) or by fax to 800-658-9457.


















For MA coverage, submit preauthorization requests by telephone at 866-488-5995 (providers) or 866-773-5959 (members) or by fax to 800-594-5309.

<h2>Facility-based sleep studies (PSG) for adults</h2>
































<h3>Preauthorization requirements</h3>
































Preauthorization for PSG is required for all adult patients with Humana commercial coverage and most patients with Humana Medicare and dual Medicare-Medicaid coverage. 





 





 Please note:&nbsp;Preauthorization is not required for patients with Medicare Advantage (MA) private fee-for-service (PFFS) coverage. However, notification is requested for these plans, as it helps coordinate care for your patients.
































All preauthorization requests are reviewed by Cohere Health, a nationally recognized benefit management organization. Preauthorization for PSG is required for all adult patients with Humana commercial coverage and &nbsp;most patients with Humana Medicare or dual Medicare-Medicaid coverage. Cohere Health does not review Puerto Rico preauthorizations.
































Please note:&nbsp;Home-based sleep studies do not require preauthorization and, in most cases, in-home studies have $0 cost sharing for Humana-covered patients. Home sleep testing may not be appropriate in all situations. Humana's Sleep Studies Medical Coverage Policy is accessible&nbsp;<a>here</a>.
































<h3>How to submit a preauthorization request to Cohere Health</h3>
You can submit a preauthorization request form by following the options below:
Online:
<ul>
<li>Cohere Health’s portal (online):</li>
</ul>
&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;o&nbsp;&nbsp;&nbsp;<a></a><a href="http://www.coherehealth.com/provider/register">Information and to request a new account.</a>&nbsp; 
&nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; o&nbsp;&nbsp;&nbsp;<a></a><a href="http://www.coherehealth.com/provider/resources">Additional provider information and resources</a>.&nbsp;
<ul>
<li><a></a><a href="https://login.coherehealth.com/">Portal login</a>&nbsp;(preauthorization request)</li>
<li>Phone:&nbsp;833-283-0033, Monday – Friday, 8 a.m. – 8 p.m., Eastern time.</li>
<li>Fax:&nbsp;857-557-6787</li>
</ul>
<ol>


</ol>
































Please note: All urgent or expedited requests can be submitted and monitored on the Cohere portal at <a>Next.Coherehealth.com</a>.&nbsp;
































For patients in Puerto Rico 



































For commercial coverage, submit preauthorization requests by telephone at 800-611-1474 (providers) or 800-314-3121 (members) or by fax to 800-658-9457.
































For MA coverage, submit preauthorization requests by telephone at 866-488-5995 (providers) or 866-773-5959 (members) or by fax to 800-594-5309.
































Please note: For MA PFFS-covered patients, please contact Cohere Health if you would like an ACD for this service.

Facility-based sleep studies (PSG) for adults

<h2>Molecular diagnostic/genetic testing – Availity</h2>















<h3>Preauthorization requirements</h3>















Preauthorization of molecular diagnostic and genetic testing (MD/GT) is required for patients with Humana commercial (including individual products), Medicaid and Medicare Advantage (MA) health maintenance organization (HMO) and preferred provider organization (PPO) plans. In Puerto Rico, preauthorization is required for all commercial plans. The terms prior authorization, precertification, preadmission and preauthorization all refer to the preauthorization process. All remaining preauthorization requirements remain in effect.















Humana does not review preauthorization requests for patients with group MA HMO plans in Arizona, California, Florida, Illinois or Nevada, as healthcare professionals who participate in an independent practice association (IPA) or other risk network with delegated services should refer to their IPA or risk network for guidance on processing these preauthorization requests:















Please note:&nbsp;Preauthorization is not required for patients with Humana MA private 




 fee-for-service plans. However, notification is requested, as it helps coordinate care for your patients. 




 




 Preauthorization is not required for services provided by nonparticipating healthcare providers for MA PPO patients. Notification is requested, as it helps coordinate care for your patients.















<h3>Exclusions to preauthorization</h3>















While most genetic tests and molecular diagnostics require preauthorization, the following categories do not:















<ul>




<li>Routine prenatal screening (Please note: Noninvasive prenatal testing requires preauthorization.)</li>




<li>Routine inpatient newborn screenings</li>




<li>Human leukocyte antigen (HLA) testing for transplant</li>




<li>Chromosomal analysis for leukemia and lymphoma</li>




<li>Infectious disease testing considered to be the standard of care</li>




</ul>















For all other tests, please contact Humana to request preauthorization.















<h3>Additional resources</h3>















To learn more about Humana's clinical policies for MD/GT, use our&nbsp;<a href="https://apps.humana.com/tad/tad_new/home.aspx?type=provider">Medical Coverage Policies tool</a>&nbsp;and search for the term &quot;genetic&quot; or the applicable CPT code.















<h3>Humana's genetic guidance program</h3>















The genetic guidance program is a utilization management initiative designed to share information with physicians and their Humana-covered patients about the use and appropriateness of MD/GT. Board-certified genetic counselors are available to discuss genetic testing services and preauthorizations.















<h3>How to submit a preauthorization request to Availity</h3>
You can submit a preauthorization request form by following the options below:
1.&nbsp;&nbsp;&nbsp;&nbsp; Online:&nbsp;Submit a request via&nbsp;<a href="https://availity.com/" target="_blank" data-ispdf="false" data-iscta="false">Availity Essentials</a>™.
2.&nbsp;&nbsp;&nbsp;&nbsp; Phone:&nbsp;800-523-0023, Monday – Friday, 8 a.m. – 7 p.m., Eastern time
3.&nbsp;&nbsp;&nbsp;&nbsp; Fax:&nbsp;855-227-0677,&nbsp;
&nbsp;&nbsp;&nbsp;&nbsp;·&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; <a href="https://docushare-web.apps.external.pioneer.humana.com/Marketing/docushare-app?file=1986712" target="_blank" data-ispdf="true" data-iscta="false">Request form – English</a>
&nbsp;&nbsp;&nbsp;&nbsp;·&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; <a href="https://docushare-web.apps.external.pioneer.humana.com/Marketing/docushare-app?file=2831582" target="_blank" data-ispdf="true" data-iscta="false">Request form – Spanish</a>
<ul>


</ul>















<h3>Information needed when requesting preauthorization</h3>















The physician should have relevant clinical information available when requesting preauthorization, including:















<ul>




<li>Patient's Humana member ID number</li>




<li>Ordering physician name and National Provider Identifier (NPI) or Tax Identification Number (TIN)</li>




<li>Telephone and fax numbers of the ordering physician</li>




<li>Name, telephone number and fax number of the lab/facility performing the test</li>




<li>Patient diagnosis or clinical indication (ICD code)</li>




<li>Current Procedural Terminology (CPT®) code and test name</li>




<li>Indication/reason for test</li>




<li>Signs, symptoms and duration</li>




<li>Prior related diagnostic and/or genetic tests and their results</li>




<li>Laboratory studies and results</li>




<li>Family medical/genetic history</li>




<li>Medications and duration (if related)</li>




<li>Prior treatments or other clinical findings (when relevant)</li>




<li>How the test results will be used in the patient's care</li>




<li>For Puerto Rico only: Local laboratory name, provider NPI or TIN (i.e., Puerto Rico lab or facility that will collect the sample)</li>
<li>Date test was performed or is anticipated to be performed</li>
</ul>

<h2>Radiation Oncology Services</h2>








<h3>Preauthorization requirements</h3>








Preauthorization for radiation oncology services is required for all patients with Humana commercial, Medicare or Illinois dual Medicare-Medicaid coverage (unless otherwise noted below). Preauthorization is not required for patients with Medicare Advantage (MA) private fee-for-service (PFFS) coverage. However, notification is requested for these plans, as it helps coordinate care for your patients.








For radiation oncology services, contact Evolent (formerly New Century Health). Specific services and areas not delegated to Evolent will be reviewed by Humana.








<h3>Preauthorization requests for the following procedures are reviewed by Evolent:</h3>








<ul>



<li>Conventional and conformal radiotherapy (2D/3D)</li>



<li>Intensity-modulated radiotherapy (IMRT)</li>



<li>Brachytherapy</li>



<li>Neutron therapy</li>



<li>Proton beam therapy</li>



<li>Stereotactic radiosurgery/stereotactic body radiation therapy (SRS/SBRT)</li>



</ul>








<h3>How to submit a preauthorization request to Evolent</h3>








Choose from the following options to submit a request for preauthorization:








<ul>



<li>Delegated lines of business: Medicare health maintenance organization, preferred provider organization plans and Illinois dual 



 Medicare-Medicaid.</li>



<li>Online:&nbsp;Submit via&nbsp;<a></a><a data-ispdf="false" data-iscta="false" href="https://my.newcenturyhealth.com/" target="_blank">Evolent’s provider portal</a>.</li>



<li>Phone:&nbsp;844-926-4528, option 4, Monday – Friday, 8 a.m. – 8 p.m., 



 Eastern time.</li>



<li>Fax:&nbsp;213-596-3783 or&nbsp;mail to:&nbsp;<a href="mailto:efax-carepro-oncology@newcenturyhealth.com" target="_blank" data-ispdf="false" data-iscta="false">efax-carepro-oncology@newcenturyhealth.com</a> 



 



</li>



</ul>








<h3>For commercial and PFFS patients</h3>








Please call our clinical intake team at 800-523-0023, 24 hours a day, 7 days a week.








<h3> 



For patients in Puerto Rico</h3>








For commercial coverage, submit preauthorization requests by telephone at 800-611-1474 (providers) or 800-314-3121 (members) or by fax to 800-658-9457.








For MA coverage, submit preauthorization requests by telephone at 866-488-5995 (providers) or 866-773-5959 (members) or by fax to 800-594-5309.








&nbsp;

<h2>Orthopedic Surgery, Pain management and Therapy</h2>


Preauthorization requirements


Preauthorization for orthopedic surgery, pain management, therapy services, cardiac interventions, cardiac devices, some cardiac imaging, endoscopy services and surgical services is required for all patients with Humana commercial, Medicare or Illinois dual 


 Medicare-Medicaid coverage (unless otherwise noted below).


Musculoskeletal services and surgeries


<ul>


<li>Epidural injections (outpatient only)</li>


<li>Facet injections</li>


<li>Foot surgeries: bunionectomy and hammertoe</li>


<li>Genicular nerve ablation and genicular nerve blocks</li>


<li>Neuromuscular stimulators</li>


<li>Orthopedic surgeries: hip, knee, and shoulder arthroplasty</li>


<li>Orthopedic surgeries: hip, knee, and shoulder arthroscopy</li>


<li>Pain infusion pump</li>


<li>Percutaneous lumbar intravertebral disc injection</li>


<li>Physical and occupational therapy</li>


<li>Radiofrequency ablation for the sacroiliac (SI) joint</li>


<li>SI joint injections</li>


<li>Spinal cord stimulators</li>


<li>Spinal fusion, decompression, kyphoplasty and vertebroplasty</li>


<li>Viscosupplementation (knee)</li>


<li>Xiaflex® (Dupuytren’s contracture)</li>


</ul>


Cardiology interventions


<ul>


<li>Aortic repair</li>


<li>Atrioventricular node ablation</li>


<li>Cardiac ablation</li>


<li>Cardiac catheterization</li>


<li>Cardiac implantable device</li>


<li>Cardiac implantable device (defibrillators)</li>


<li>Cardiac implantable device (implantable carotid sinus stimulator)</li>


<li>Cardiac implantable device (pacemakers)</li>


<li>Cardio MEMS</li>


<li>Carotid Artery Stenting (CAS)</li>


<li>Carotid endarterectomy</li>


<li>Catheter-based angiogram, lower extremity arteries</li>


<li>Electrophysiology study (EPS)</li>


<li>Endovascular aortic repair</li>


<li>External wearable devices</li>


<li>Internal loop recorders</li>


<li>LAAC</li>


<li>Myocardial perfusion imaging single-photon emission computed tomography (MPI-SPECT)</li>


<li>Patent foramen ovale (PFO) and atrial septal defect (ASD) closure</li>


<li>Percutaneous coronary intervention (PCI)/angioplasty</li>


<li>Percutaneous intervention: angioplasty/atherectomy/stenting</li>


<li>Percutaneous thoracic aortic repair</li>


<li>Peripheral revascularization (atherectomy, angioplasty)</li>


<li>Stress echocardiogram</li>


<li>Surgical revascularization/thromboendarterectomy/peripheral vascular bypass</li>


<li>Surgical thoracic aortic repair</li>


<li>Transcatheter aortic valve replacement/implantation (TAVR)</li>


<li>Transcatheter mitral valve repair</li>


<li>Transesophageal echocardiogram (TEE)</li>


<li>Transthoracic echocardiogram (TTE)</li>


</ul>


Endoscopy services


<ul>


<li>Capsule endoscopy</li>


<li>Colonoscopy (repeat only)</li>


<li>Diagnostic esophagogastroduodenoscopy (EGD) or esophagoscopy</li>


<li>Laparoscopic hiatal hernia repair</li>


</ul>


Surgeries


<ul>


<li>Abdominoplasty</li>


<li>Bladder slings</li>


<li>Blepharoplasty</li>


<li>Breast procedures</li>


<li>Cochlear and auditory brainstem implants</li>


<li>Cutaneous vascular lesion removal</li>


<li>Decompression of peripheral nerve (i.e., carpal tunnel surgery)</li>


<li>Gastric pacing</li>


<li>Neurostimulators</li>


<li>Obesity surgeries</li>


<li>Oral, orthognathic, temporomandibular joint (TMJ) surgeries</li>


<li>Otoplasty</li>


<li>Penile implant</li>


<li>Rhinoplasty</li>


<li>Surgical hyperhidrosis treatment</li>


<li>Surgical nasal/sinus endoscopic procedures and balloon sinuplasty (excludes diagnostic nasal/sinus endoscopies)</li>


<li>Varicose vein: surgical treatment and sclerotherapy</li>


</ul>


All preauthorization requests are reviewed by Cohere Health, a nationally recognized benefit management organization. Cohere Health does not review preauthorization requests for Puerto Rico plans or Medicaid plans except for Illinois dual eligible.


Please note:&nbsp;Preauthorization is not required for patients with Medicare Advantage (MA) private fee-for-service coverage. However, notification is requested for these plans, as it helps coordinate care for your patients.


How to submit a preauthorization request to Cohere Health


You can submit a preauthorization request form by following the options below:


1.&nbsp;&nbsp;&nbsp;&nbsp; Online:&nbsp;Enroll with&nbsp;<a href="https://coherehealth.com/provider/register/" target="_blank" data-ispdf="false" data-iscta="false">Cohere Health’s portal</a>&nbsp;before submitting online requests for preauthorization.


2.&nbsp;&nbsp;&nbsp;&nbsp; Phone:&nbsp;833-283-0033, Monday – Friday, 8 a.m. – 8 p.m., Eastern time.


3.&nbsp;&nbsp;&nbsp;&nbsp; Fax:&nbsp;857-557-6787.


Cohere Health will evaluate the medical necessity of the service and request needed medical records. A physician may contact the requesting physician to discuss the preauthorization request. Submit all requests with supporting clinical documentation.


&nbsp;


For patients in Puerto Rico


For commercial coverage, submit preauthorization requests by telephone at 800-611-1474 (providers) or 800-314-3121 (members) or by fax to 800-658-9457.


For MA coverage, submit preauthorization requests by telephone at 866-488-5995 (providers) or 866-773-5959 (members) or by fax to 800-594-5309.

Orthopedic Surgery, pain management and therapy

<h2>Surgical services</h2>






























































Preauthorization requirements






























































<ul>





<li>Abdominoplasty</li>





<li>Bladder slings</li>





<li>Blepharoplasty</li>





<li>Breast procedures</li>





<li>Cochlear and auditory brainstem implants</li>





<li>Cutaneous vascular lesion removal</li>





<li>Decompression of peripheral nerve (i.e., carpal tunnel surgery)</li>





<li>Gastric pacing</li>





<li>Neurostimulators</li>





<li>Obesity surgeries</li>





<li>Oral, orthognathic, temporomandibular joint (TMJ) surgeries</li>





<li>Otoplasty</li>





<li>Penile implant</li>





<li>Rhinoplasty</li>





<li>Surgical hyperhidrosis treatment</li>





<li>Surgical nasal/sinus endoscopic procedures and balloon sinuplasty (excludes diagnostic nasal/sinus endoscopies)</li>





<li>Varicose vein: surgical treatment and sclerotherapy</li>





</ul>






























































All preauthorization requests are reviewed by Cohere Health, a nationally recognized benefit management organization. Cohere Health does not review preauthorization requests for Puerto Rico plans or Medicaid plans except for Illinois dual eligible. 





 





 Preauthorization for diagnostic/cardiac imaging is required for all patients with Humana commercial, Medicare or Illinois dual Medicare-Medicaid coverage.






























































Please note:&nbsp;Preauthorization is not required for patients with Medicare Advantage (MA) private fee-for-service (PFFS) coverage. However, notification is requested for these plans, as it helps coordinate care for your patients.






























































Please note: For MA PFFS-covered patients, please contact Cohere Health if you would like an ACD for this service.






























































How to submit a preauthorization request to Cohere Health
You can submit a preauthorization request form by following the options below:
1.&nbsp;&nbsp;&nbsp;&nbsp; Online:&nbsp;Enroll with&nbsp;<a href="https://coherehealth.com/provider/register/" target="_blank" data-ispdf="false" data-iscta="false">Cohere Health’s portal</a>&nbsp;before submitting online requests for preauthorization.
2.&nbsp;&nbsp;&nbsp;&nbsp; Phone: 833-283-0033, Monday – Friday, 8 a.m. – 8 p.m., Eastern time.
3.&nbsp;&nbsp;&nbsp;&nbsp; Fax:&nbsp;857-557-6787.






























































Preauthorization requests for the following procedures are reviewed by Evolent (formerly New Century Health):






























































<ul>





<li>Breast cancer biopsy (excisional)</li>





<li>Breast lumpectomy</li>





<li>Lung biopsy and resection&nbsp;</li>





<li>Prostate surgeries (prostatectomy)</li>





<li>Simple mastectomy and gynecomastia surgery (excludes radical and modified)</li>





<li>Thyroid surgeries (thyroidectomy and lobectomy)</li>
</ul>






























































How to submit a preauthorization request to Evolent
Choose from the following options to submit a request for preauthorization:
<ul>
<li>Delegated lines of business: Medicare health maintenance organization (HMO), preferred provider organization (PPO) plans and Illinois dual 
 Medicare-Medicaid.</li>
<li>Online:&nbsp;Submit via&nbsp;<a href="https://my.newcenturyhealth.com/">Evolent’s provider portal</a>.</li>
<li>Phone:&nbsp;844-926-4528, option 5, Monday – Friday, 8 a.m. – 8 p.m., Eastern time.</li>
<li>Fax:&nbsp;213-596-3783 or <a href="mailto:efax-carepro-oncology@newcenturyhealth.com">efax-carepro-oncology@newcenturyhealth.com</a></li>
</ul>




For patients in Puerto Rico






























































Commercial coverage, submit preauthorization requests by telephone at 800-611-1474 (providers) or 800-314-3121 (members), or by fax to 800-658-9457.






























































MA coverage, submit preauthorization requests by telephone at 866-488-5995 (providers) or 866-773-5959 (members) or by fax to 800-594-5309.

Submit prior authorizations for Humana Medicare or commercial patients

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Orthopedic Surgery, pain management and therapy

Surgical services

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