Preauthorization submission information

Ablation

Preauthorization requirements

• Ablation for bone, liver, kidney and prostate disease

Preauthorization for the ablation procedures listed above is required for all patients with Humana commercial, Medicare or Illinois dual Medicare-Medicaid coverage

All preauthorization requests are reviewed by HealthHelp, a nationally recognized benefit management organization. HealthHelp does not review Puerto Rico preauthorizations.

How to submit a preauthorization request to HealthHelp

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

1. Online: Enroll with HealthHelp before submitting online requests for preauthorization.
2. Phone: 866-825-1550, Monday – Friday, 7 a.m. – 7 p.m., Saturday, 7 a.m. – 4 p.m., Central time.
3. Fax: 888-863-4464

Please note, all urgent or expedited requests should be submitted via phone or fax. For additional information (procedure codes, FAQ and clinical guidelines) visit, Health Consult.

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

Advanced imaging

Preauthorization 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 preauthorization requests are reviewed by HealthHelp, 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. HealthHelp does not review Puerto Rico preauthorizations.

Please note: Preauthorization is not required for patients with Medicare Advantage 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 HealthHelp

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

1. Online: Enroll with HealthHelp before submitting online requests for preauthorization.
2. Phone: 866-825-1550, Monday – Friday, 7 a.m. – 7 p.m., Saturday, 7 a.m. – 4 p.m., Central time.
3. Fax: 888-863-4464

Please note, all urgent or expedited requests should be submitted via phone or fax. For additional information (procedure codes, FAQs or clinical guidelines) visit, Health Consult.

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

Behavioral health services

Preauthorization requirements

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

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.

Medicaid-specific services in Florida may require authorization. For information, please visit Humana Healthy Horizons™ in Florida.

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:

• Online: Sign into Availity Essentials to start a request. If you are not registered for Availity Essentials, go to Availity.com. To find out more about registration, review our Availity Essentials registration guide, PDF.
• 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. For all urgent/expedited request, 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. 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, PDF

Behavioral Health Commercial/Medicare Authorization Request Form – Outpatient, PDF

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

We’re here to help

Followed the Medicare guidance and still need resolution? Email BHinquiries@humana.com; include reference numbers, provider name, Humana member’s ID and DOB, and description of your inquiry.

This pamphlet, opens in new window, is provided for informational uses only and is posted to comply with IL HB 2595.

Cardiac Services

Preauthorization 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 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: 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. Online: Enroll with Cohere Health’s portal before submitting online requests for preauthorization.
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 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 Medicare Advantage 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

Preauthorization requirements

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

Depending on the Humana-covered patient’s state of residence, age and enrollment in a clinical trial, the preauthorization 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
• Radio-therapeutic agents (e.g., Zevalin and Xofigo)
• Any new-to-market drug that would fall under Nos. 1 or 2 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 preauthorization request.

Important note: Physicians and other healthcare providers should contact Humana's MIT (not New Century Health or OncoHealth) if any chemotherapy agent, supportive drug, symptom management drug or any other drug listed on Humana's medication preauthorization 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

New Century Health

New Century Health reviews preauthorization 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 preauthorization request to New Century Health

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

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

OncoHealth

Preauthorization 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 preauthorization request 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, PDF when sending a fax.

How to submit a preauthorization request to Humana's MIT

Humana’s MIT reviews preauthorization 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

Preauthorization requirements

Preauthorization 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, Palm Beach and Miami-Dade counties

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.

How to submit a preauthorization request to WholeHealthPro

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

1. Online: Enroll with 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

Preauthorization requirements

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

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: 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. Online: Enroll with Cohere Health’s portal before submitting online requests for preauthorization.
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 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 Medicare Advantage coverage, submit preauthorization 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

Preauthorization requirements

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: Preauthorization is not required for patients with Medicare Advantage private-fee-for-service coverage. However, notification is requested for these plans, as it helps coordinate care for your patients.

All preauthorization requests are reviewed by HealthHelp, 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. HealthHelp does not review Puerto Rico preauthorizations.

Please note: 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 here.

How to submit a preauthorization request to HealthHelp

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

1. Online: Enroll with HealthHelp before submitting online requests for preauthorization.
2. Phone: Call 866-825-1550, Monday – Friday, 7 a.m. – 7 p.m., Saturday, 7 a.m. – 4 p.m., Central time.
3. Fax: 888-863-4464

Please note, all urgent or expedited requests should be submitted via phone or fax. For additional information (procedure codes, FAQs or clinical guidelines) visit, Health Consult.

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

Molecular diagnostic/genetic testing - Availity

Preauthorization requirements

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: 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.

Exclusions to preauthorization

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

• Routine prenatal screening (Please note: Noninvasive prenatal testing does require preauthorization)
• 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 preauthorization.

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 preauthorizations.

How to submit a preauthorization request to Availity

You can submit a preauthorization 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, PDF, request form – Spanish, opens in new window.

Information needed when requesting preauthorization

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

Preauthorization requirements

Preauthorization for oncology therapy 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 private-fee-for-service coverage. However, notification is requested for these plans, as it helps coordinate care for your patients.

For radiation oncology therapy services, Humana has two delegated vendors: HealthHelp and New Century Health for specific services and areas. Specific services and areas not delegated to HealthHelp and New Century Health will be reviewed by Humana.

HealthHelp

Preauthorization requests for the following oncology therapy procedures are reviewed by Humana’s delegated vendor HealthHelp:

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

New Century Health

Preauthorization requests for oncology therapy procedures are reviewed by Humana’s delegated vendor New Century Health for Arizona and Florida Medicare members.

How to submit a preauthorization request to HealthHelp

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

1. Online: Enroll with HealthHelp before submitting online requests for preauthorization.
2. Phone: Call 866-825-1550, Monday – Friday, 7 a.m. – 7 p.m., Saturday, 7 a.m. – 4 p.m., Central time.
3. Fax: 888-863-4464

Please note, all urgent or expedited requests should be submitted via phone or fax. For additional information (procedure codes, FAQs or clinical guidelines) visit, Health Consult.

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

How to submit a preauthorization request to New Century Health

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

• Online: Submit via New Century Health’s provider portal
• Phone: 844-926-4528, option 4, Monday – Friday, 8 a.m. – 8 p.m., Eastern time.
• Fax: 877-624-0611

Orthopedic Surgery, Pain management and therapy

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

• 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 SI Joint
• Sacroiliac (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 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: 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. Online: Enroll with Cohere Health’s portal before submitting online requests for preauthorization.
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 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 Medicare Advantage coverage, submit preauthorization requests by telephone at 866-488-5995 (providers) or 866-773-5959 (members) or by fax to 800-594-5309.

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 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 requests for the following procedures are reviewed by HealthHelp, a nationally recognized benefit management organization:

• 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)

Preauthorization for diagnostic/cardiac imaging is required for all patients with Humana commercial, Medicare or Illinois dual Medicare-Medicaid coverage. HealthHelp does not review Puerto Rico preauthorizations.

Please note: 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. Online: Enroll with Cohere Health’s portal before submitting online requests for preauthorization.
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 preauthorization request. Submit all requests with supporting clinical documentation.

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.

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

How to submit a preauthorization request to HealthHelp

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

1. Online: Enroll with HealthHelp before submitting online requests for preauthorization.
2. Phone: Call 866-825-1550, Monday – Friday, 7 a.m. – 7 p.m., Saturday, 7 a.m. – 4 p.m., Central time.
3. Fax: 888-863-4464

Please note, all urgent or expedited requests should be submitted via phone or fax. For additional information (procedure codes, FAQs or clinical guidelines) visit, Health Consult.

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.

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