A physician explains medical information to a woman and her caregiver.

Submit prior authorizations for Humana Medicare or commercial patients

Find frequently requested services and procedures below to submit prior authorizations for your Humana Medicare or commercial patients.

For all other medical service prior authorization requests and notifications, please contact our clinical intake team at 800-523-0023, open 24 hours a day.

Frequently requested services

Ablation

Ablation

Prior authorization requirements

  • Ablation for bone, liver, kidney and prostate disease

Prior authorization for ablation procedures is required for all patients with Humana commercial, Medicare or Illinois Dual Medicare-Medicaid coverage, unless otherwise noted below. Prior authorization 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. 

How to submit a prior authorization request to Evolent

Choose from the following options to submit a request for prior authorization:

  • Delegated lines of business: Medicare health maintenance organization, preferred provider organization plans and Illinois dual Medicare-Medicaid.
  • Online: Submit through  Evolent’s provider portal
  • Phone: 844-926-4528, option 5, Monday – Friday, 8 a.m. – 8 p.m., Eastern time.
  • Fax: 213-596-3783 or   efax-carepro-oncology@newcenturyhealth.com

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 prior authorization requests by telephone at
800-611-1474 (providers) or 800-314-3121 (members) or by fax to 800-658-9457.

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

Advanced imaging

Advanced imaging

Prior authorization requirements

  • Advanced imaging
  • Cardiac computed tomographic angiography (CCTA)
  • Cardiac positron emission tomography (cardiac PET) scan
  • Computed tomography (CT) scan
  • Computed tomographic angiography (CTA)
  • Magnetic resonance angiography (MRA)
  • Magnetic resonance imaging (MRI)
  • Peripheral angiography
  • Positron emission tomography (PET) scan
  • Positron emission tomography + computed tomography (PET + CT) scan

All prior authorization requests are reviewed by Cohere Health, a nationally recognized benefit management organization. Prior authorization 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 prior authorizations.

Please note: Prior authorization 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.

How to submit a prior authorization request to Cohere Health

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

Online:

  • Cohere Health’s portal (online):

            o     Information and to request a new account
            o     Additional provider information and resources

  • Portal login  (prior authorization request)
  • Phone: 833-283-0033, Monday – Friday, 8 a.m. – 8 p.m., Eastern time.
  • Fax: 857-557-6787

Please note: All urgent or expedited requests can be submitted and monitored on the Cohere Health portal at  Next.Coherehealth.com

For patients in Puerto Rico

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

For MA coverage, submit prior authorization 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.

Behavioral health services

Behavioral health services

Prior authorization requirements

  • Inpatient hospitalization
  • Inpatient rehabilitation
  • Partial hospitalization
  • Residential treatment
  • Transcranial magnetic stimulation (TMS)
  • Applied behavioral analysis (ABA) therapy

Prior authorization 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:

Humana Healthy Horizons® in Florida

Humana Healthy Horizons® in Kentucky

Humana Healthy Horizons® in Louisiana

Humana Healthy Horizons® in Ohio

Humana Healthy Horizons® in South Carolina

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 prior authorization 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 prior authorization request to Availity

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

  • Online: Sign in to  Availity Essentials  ™ to start a request. If you are not registered for Availity Essentials, go to  www.availity.com  . To find out more about registration, review our   Availity Essentials registration guide
  • Phone: 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.
  • Fax: 469-913-6941

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 fax it to Humana’s Behavioral Health UM team at 469-913-6941. Please include supporting clinical documentation (e.g., medical records, progress notes, assessments, lab reports, etc.) with your fax form.

Behavioral Health Commercial/Medicare Authorization Request Form – Inpatient

Behavioral Health Commercial/Medicare Authorization Request Form – Outpatient

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  review the online MCG criteria   (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  ASAM Criteria  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  BHinquiries@humana.com  (Please include reference numbers, provider name, Humana member ID, date of birth and a description of your inquiry.)

This pamphlet  is provided for informational uses only and is posted to comply with IL HB 2595.

Cardiac interventions/devices

Cardiac services

Prior authorization requirements

  • Aortic repair
  • Atrioventricular node ablation
  • Cardiac ablation
  • Cardiac catheterization
  • Cardiac implantable device
  • Cardiac implantable device (defibrillators)
  • Cardiac implantable device (pacemakers)
  • Cardio MEMS
  • Carotid artery stenting (CAS)
  • Carotid endarterectomy
  • Catheter-based angiogram, lower extremity arteries
  • Electrophysiology study (EPS)
  • Endovascular aortic repair
  • External wearable devices
  • Internal loop recorders
  • LAAC
  • Myocardial perfusion imaging single-photon emission computed tomography (MPI-SPECT)
  • Patent foramen ovale (PFO) and atrial septal defect (ASD) closure
  • Percutaneous coronary intervention (PCI)/angioplasty
  • Percutaneous intervention: angioplasty/atherectomy/stenting
  • Percutaneous thoracic aortic repair
  • Stress echocardiogram
  • Surgical revascularization/thromboendarterectomy/peripheral vascular bypass
  • Surgical thoracic aortic repair
  • Transcatheter aortic valve replacement/implantation (TAVR)
  • Transcatheter mitral valve repair
  • Transesophageal echocardiogram (TEE)
  • Transthoracic echocardiogram (TTE)

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

Please note: Prior authorization 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 prior authorization request to Cohere Health

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

  1. Online: Enroll with  Cohere Health’s portal   before submitting online requests for prior authorization.
  2. Phone: Call 866-825-1550, Monday – Friday, 8 a.m. – 8 p.m., Eastern time.
  3. Fax: 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 prior authorization request. Submit all requests with supporting clinical documentation.

For patients in Puerto Rico

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

For MA coverage, submit prior authorization 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

Chemotherapy agents, supportive drugs and symptom management drugs

Prior authorization requirements

Humana requires prior authorization for chemotherapy agents, supportive drugs and symptom management drugs.  View a list of specific drugs for which prior authorization is required .

Depending on the Humana-covered patient’s state of residence, age and enrollment in a clinical trial, the prior authorization request could be reviewed by Humana’s Medication Intake Team (MIT) or one of Humana’s delegated review vendors: New Century Health or OncoHealth.

Humana defines chemotherapy agents, supportive drugs and symptom management drugs as:

  • Infused/injectable drugs used in the treatment of oncologic disorders or supportive care drugs represented by a C, J, Q or a miscellaneous Healthcare Common Procedure Coding System (HCPCS) code
  • Radiotherapeutic agents (e.g., Zevalin® and Xofigo®)
  • Any new-to-market drug that would fall under the two items above

When prescribing chemotherapy agents, supportive drugs or symptom management drugs for the treatment of an oncologic disorder, physicians and other healthcare providers should call MIT, New Century Health or OncoHealth. (See below for more information.) Even if a drug regimen already has been approved, adding any chemotherapy agent, supportive drug or symptom management drug requires a new prior authorization request.

Important note: Physicians and other healthcare providers should contact Humana's MIT (not Evolent or OncoHealth) if any chemotherapy agent, supportive drug, symptom management drug or any other drug listed on Humana's medication prior authorization lists is used in the treatment of:

  • Nononcologic disorders
  • Oncologic disorders for Humana-covered patients younger than 18
  • Oncologic disorders for Humana-covered patients enrolled in a clinical trial

Evolent

Evolent reviews prior authorization requests for Humana-covered patients in these states:

  • Alabama
  • Alaska
  • Arizona
  • Arkansas
  • California
  • Colorado
  • Florida
  • Idaho
  • Illinois
  • Indiana
  • Iowa
  • Kansas
  • Kentucky
  • Louisiana
  • Michigan
  • Minnesota
  • Mississippi
  • Missouri
  • Montana
  • Nebraska
  • Nevada
  • New Mexico
  • North Carolina
  • North Dakota
  • Ohio
  • Oklahoma
  • Oregon
  • South Carolina
  • South Dakota
  • Tennessee
  • Utah
  • Virginia
  • Washington
  • West Virginia
  • Wisconsin
  • Wyoming

How to submit a prior authorization request to Evolent (formerly New Century Health)

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

  • Online: Submit via  Evolent's provider portal
  • Phone: 844-926-4528, option 3, Monday – Friday, 8 a.m. – 8 p.m.,
    Eastern time.
  • Fax: 877-624-0611

OncoHealth

Prior authorization requests for Humana-covered patients in the following states and territory are reviewed by OncoHealth:

  • Connecticut
  • Delaware
  • Georgia
  • Maine
  • Maryland
  • Massachusetts
  • New Hampshire
  • New Jersey
  • New York
  • Pennsylvania
  • Puerto Rico
  • Rhode Island
  • Texas
  • Vermont

How to submit a prior authorization request to Oncohealth

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

  • Online: Submit via  OncoHealth provider portal   (participating cancer-care physicians only). Please note: Physicians must call 888-916-2616 to obtain a username and password
  • Fax: 800-264-6128. Please use a secure cover sheet and our  protocol request form  when sending a fax

How to submit a prior authorization request to Humana's MIT

Humana’s MIT reviews prior authorization requests for commercial, private fee-for-service (PFFS) and Humana-covered patients in Hawaii.

  • Fax: 888-447-3430. Request forms are available  here
  • Phone: 866-461-7273, Monday – Friday, 8 a.m. – 8 p.m., Eastern time

Chiropractic therapy

Chiropractic therapy

Prior authorization requirements

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

  • Kentucky: 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
  • Illinois: Entire state of Illinois and Indiana (ZIP codes 463xx and 464xx)
  • Ohio: Entire state of Ohio and the Indiana counties in ZIP codes 470xx, 473xx, and northern Kentucky counties in ZIP code 410xx
  • Arizona: Entire state of Arizona
  • Georgia: Entire state of Georgia
  • South Florida: Broward, Miami-Dade and Palm Beach counties

Prior authorization 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 prior authorization 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 prior authorization requests.

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

How to submit a prior authorization request to WholeHealthPro

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

1.     Online: Enroll with  www.wholehealthpro.com  and submit a request.

2.     Phone: 866-430-8647, 24 hours a day, 7 days a week

3.     Fax: 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.

Endoscopy services

Endoscopy services

Prior authorization requirements

  • Capsule endoscopy
  • Colonoscopy (repeat only)
  • Diagnostic esophagogastroduodenoscopy (EGD) or esophagoscopy
  • Laparoscopic hiatal hernia repair

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

Please note: Prior authorization 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 prior authorization request to Cohere Health

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

  1. Online: Enroll with  Cohere Health’s portal  before submitting online requests for prior authorization
  2. Phone: 833-283-0033, Monday – Friday, 8 a.m. – 8 p.m., Eastern time.
  3. Fax: 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 prior authorization request. Submit all requests with supporting clinical documentation.

For patients in Puerto Rico

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

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

Facility-based sleep studies (PSG) for adults

Facility-based sleep studies (PSG) for adults

Prior authorization requirements

Prior authorization 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: Prior authorization 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 prior authorization requests are reviewed by Cohere Health, a nationally recognized benefit management organization. Prior authorization for PSG is required for all adult patients with Humana commercial coverage and  most patients with Humana Medicare or dual Medicare-Medicaid coverage. Cohere Health does not review Puerto Rico prior authorizations.

Please note: Home-based sleep studies do not require prior authorization 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  here

How to submit a prior authorization request to Cohere Health

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

Online:

  • Cohere Health’s portal (online):
    • Information and to request a new account.
    • Additional provider information and resources
  • Portal login   (prior authorization request)
  • Phone: 833-283-0033, Monday – Friday, 8 a.m. – 8 p.m., Eastern time.
  • Fax: 857-557-6787

Please note: All urgent or expedited requests can be submitted and monitored on the Cohere portal at  Next.Coherehealth.com

For patients in Puerto Rico

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

For MA coverage, submit prior authorization 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.

Molecular diagnostic/genetic testing

Molecular diagnostic/genetic testing – Availity

Prior authorization requirements

Prior authorization 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, prior authorization is required for all commercial plans. The terms prior authorization, precertification, preadmission and preauthorization all refer to the prior authorization process. All remaining prior authorization requirements remain in effect.

Humana does not review prior authorization 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 prior authorization requests:

Please note: Prior authorization 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.

Prior authorization 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.

Exclusions to prior authorization

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

  • Routine prenatal screening (Please note: Noninvasive prenatal testing requires prior authorization.)
  • Routine inpatient newborn screenings
  • Human leukocyte antigen (HLA) testing for transplant
  • Chromosomal analysis for leukemia and lymphoma
  • Infectious disease testing considered to be the standard of care

For all other tests, please contact Humana to request prior authorization.

Additional resources

To learn more about Humana's clinical policies for MD/GT, use our  Medical Coverage Policies tool   and search for the term "genetic" or the applicable CPT code.

Humana's genetic guidance program

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 prior authorizations.

How to submit a prior authorization request to Availity

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

  1. Online: Submit a request via  Availity Essentials™
  2. Phone: 800-523-0023, Monday – Friday, 8 a.m. – 7 p.m., Eastern time
  3. Fax: 855-227-0677, 
    • Request form – English
    • Request form – Spanish

Information needed when requesting prior authorization

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

  • Patient's Humana member ID number
  • Ordering physician name and National Provider Identifier (NPI) or Tax Identification Number (TIN)
  • Telephone and fax numbers of the ordering physician
  • Name, telephone number and fax number of the lab/facility performing the test
  • Patient diagnosis or clinical indication (ICD code)
  • Current Procedural Terminology (CPT®) code and test name
  • Indication/reason for test
  • Signs, symptoms and duration
  • Prior related diagnostic and/or genetic tests and their results
  • Laboratory studies and results
  • Family medical/genetic history
  • Medications and duration (if related)
  • Prior treatments or other clinical findings (when relevant)
  • How the test results will be used in the patient's care
  • For Puerto Rico only: Local laboratory name, provider NPI or TIN (i.e., Puerto Rico lab or facility that will collect the sample)
  • Date test was performed or is anticipated to be performed

Oncology therapy services

Radiation oncology services

Prior authorization requirements

Prior authorization for radiation oncology services is required for all patients with Humana commercial, Medicare or Illinois dual Medicare-Medicaid coverage (unless otherwise noted below). Prior authorization 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.

Prior authorization requests for the following procedures are reviewed by Evolent:

  • Conventional and conformal radiotherapy (2D/3D)
  • Intensity-modulated radiotherapy (IMRT)
  • Brachytherapy
  • Neutron therapy
  • Proton beam therapy
  • Stereotactic radiosurgery/stereotactic body radiation therapy (SRS/SBRT)

How to submit a prior authorization request to Evolent

Choose from the following options to submit a request for prior authorization:

  • Delegated lines of business: Medicare health maintenance organization, preferred provider organization plans and Illinois dual
    Medicare-Medicaid.
  • Online: Submit via  Evolent’s provider portal
  • Phone: 844-926-4528, option 4, Monday – Friday, 8 a.m. – 8 p.m.,
    Eastern time.
  • Fax: 213-596-3783 or mail to:  efax-carepro-oncology@newcenturyhealth.com

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

For MA coverage, submit prior authorization 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

Orthopedic surgery, pain management and therapy

Prior authorization requirements

Prior authorization 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

  • Epidural injections (outpatient only)
  • Facet injections
  • Foot surgeries: bunionectomy and hammertoe
  • Genicular nerve ablation and genicular nerve blocks
  • Neuromuscular stimulators
  • Orthopedic surgeries: hip, knee, and shoulder arthroplasty
  • Orthopedic surgeries: hip, knee, and shoulder arthroscopy
  • Pain infusion pump
  • Percutaneous lumbar intravertebral disc injection
  • Physical and occupational therapy
  • Radiofrequency ablation for the sacroiliac (SI) joint
  • SI joint injections
  • Spinal cord stimulators
  • Spinal fusion, decompression, kyphoplasty and vertebroplasty
  • Viscosupplementation (knee)
  • Xiaflex® (Dupuytren’s contracture)

Cardiology interventions

  • Aortic repair
  • Atrioventricular node ablation
  • Cardiac ablation
  • Cardiac catheterization
  • Cardiac implantable device
  • Cardiac implantable device (defibrillators)
  • Cardiac implantable device (implantable carotid sinus stimulator)
  • Cardiac implantable device (pacemakers)
  • Cardio MEMS
  • Carotid Artery Stenting (CAS)
  • Carotid endarterectomy
  • Catheter-based angiogram, lower extremity arteries
  • Electrophysiology study (EPS)
  • Endovascular aortic repair
  • External wearable devices
  • Internal loop recorders
  • LAAC
  • Myocardial perfusion imaging single-photon emission computed tomography (MPI-SPECT)
  • Patent foramen ovale (PFO) and atrial septal defect (ASD) closure
  • Percutaneous coronary intervention (PCI)/angioplasty
  • Percutaneous intervention: angioplasty/atherectomy/stenting
  • Percutaneous thoracic aortic repair
  • Peripheral revascularization (atherectomy, angioplasty)
  • Stress echocardiogram
  • Surgical revascularization/thromboendarterectomy/peripheral vascular bypass
  • Surgical thoracic aortic repair
  • Transcatheter aortic valve replacement/implantation (TAVR)
  • Transcatheter mitral valve repair
  • Transesophageal echocardiogram (TEE)
  • Transthoracic echocardiogram (TTE)

Endoscopy services

  • Capsule endoscopy
  • Colonoscopy (repeat only)
  • Diagnostic esophagogastroduodenoscopy (EGD) or esophagoscopy
  • Laparoscopic hiatal hernia repair

Surgeries

  • Abdominoplasty
  • Bladder slings
  • Blepharoplasty
  • Breast procedures
  • Cochlear and auditory brainstem implants
  • Cutaneous vascular lesion removal
  • Decompression of peripheral nerve (i.e., carpal tunnel surgery)
  • Gastric pacing
  • Neurostimulators
  • Obesity surgeries
  • Oral, orthognathic, temporomandibular joint (TMJ) surgeries
  • Otoplasty
  • Penile implant
  • Rhinoplasty
  • Surgical hyperhidrosis treatment
  • Surgical nasal/sinus endoscopic procedures and balloon sinuplasty (excludes diagnostic nasal/sinus endoscopies)
  • Varicose vein: surgical treatment and sclerotherapy

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

Please note: Prior authorization 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 prior authorization request to Cohere Health

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

  1. Online: Enroll with  Cohere Health’s portal  before submitting online requests for prior authorization.
  2. Phone: 833-283-0033, Monday – Friday, 8 a.m. – 8 p.m., Eastern time.
  3. Fax: 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 prior authorization request. Submit all requests with supporting clinical documentation.

For patients in Puerto Rico

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

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

Surgical services

Surgical services

Preauthorization requirements

  • Abdominoplasty
  • Bladder slings
  • Blepharoplasty
  • Breast procedures
  • Cochlear and auditory brainstem implants
  • Cutaneous vascular lesion removal
  • Decompression of peripheral nerve (i.e., carpal tunnel surgery)
  • Gastric pacing
  • Neurostimulators
  • Obesity surgeries
  • Oral, orthognathic, temporomandibular joint (TMJ) surgeries
  • Otoplasty
  • Penile implant
  • Rhinoplasty
  • Surgical hyperhidrosis treatment
  • Surgical nasal/sinus endoscopic procedures and balloon sinuplasty (excludes diagnostic nasal/sinus endoscopies)
  • Varicose vein: surgical treatment and sclerotherapy

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: 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. Online: Enroll with  Cohere Health’s portal  before submitting online requests for preauthorization.
  2. Phone: 833-283-0033, Monday – Friday, 8 a.m. – 8 p.m., Eastern time.
  3. Fax: 857-557-6787.

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

  • Breast cancer biopsy (excisional)
  • Breast lumpectomy
  • Lung biopsy and resection 
  • Prostate surgeries (prostatectomy)
  • Simple mastectomy and gynecomastia surgery (excludes radical and modified)
  • Thyroid surgeries (thyroidectomy and lobectomy)

How to submit a preauthorization request to Evolent

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

  • Delegated lines of business: Medicare health maintenance organization (HMO), preferred provider organization (PPO) plans and Illinois dual
    Medicare-Medicaid.
  • Online: Submit via  Evolent’s provider portal
  • Phone: 844-926-4528, option 5, Monday – Friday, 8 a.m. – 8 p.m., Eastern time.
  • Fax: 213-596-3783 or  efax-carepro-oncology@newcenturyhealth.com

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.

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