Overview
This article provides an overview of all steps of submitting a prior authorization request in the Cohere portal. Follow these steps when submitting your requests.
Introduction
Cohere Health simplifies healthcare by enabling patients, physicians, and health plans to collaborate on getting the right care, at the right time, at the right place, and at the right cost. Our focus is to enable an efficient, transparent patient journey where patient goals and achieving optimal clinical outcomes are central to decision-making.
If you're looking for information on how to submit a referral request (for office visit CPT codes), please click here.
Step 1: Log in to the Cohere Portal
Using the platform will make you much more likely to receive an auto-approval than non-platorm submission methods like fax of phone. Submitting requests online allows you to ensure you submit all of the necessary information required for approval.
To submit a request online, you will first need to log in by going to next.coherehealth.com and entering your email and password. If you are unsure if you have an account, please try signing in to the portal first, and then contact the applicable support team using the information in this article.
If you or others at your organization do not have an account, please select the "Register for an Account" option here: coherehealth.com/provider/resources.
For more information on how to register for a Cohere account and how to log in to the Cohere portal, click here.
Step 2: Navigate the Cohere Dashboard
After signing in, you will land on the Cohere dashboard, where you can see authorization requests and their statuses for the patients at your practice. You can filter the requests that are shown on the dashboard by several different criteria, including:
Authorization status
The user that submitted the authorization
Use the search bar at the top of the page to search by patient name, member ID, tracking ID, or authorization ID.
If you submit authorizations for multiple payers, you will also be able to filter by payer.
You also have the option to sort the requests by either the most recently created or edited request or by the date of service.
You can also access the support drop down menu and your account from the dashboard. The support drop down includes a link to the Cohere Learning Center as well as a link to connect with one of our live chat agents. | The "My account" drop down allows you to view your organization's management page, opt in to paperless notifications, or logout. |
Demo: Navigating the Cohere Dashboard
Step 3: Start Auth Request
Start your authorization by clicking on the blue "Start auth request" button in the top right corner. Then, enter the patient's health plan member ID and date of birth. If you ever have any issues finding a patient, please use our support drop-down for additional resources or to reach out for help.
Once the correct patient is returned, you will see either two or three options for how to proceed. For eligible patients, we can start either a prior authorization request or a referral request directly from the patient search. The "start referral" button will only be available for eligible patients. We can also navigate to the patient summary from this screen. More information about the patient summary can be found in the step 12 of this article.
Non-eligible (example) patient: | Eligible (example) patient: |
To start a prior authorization request, click the "Start auth request" button.
Demo: Start Authorization Request
Step 4: Tell Us About Your Request - Request Details
In this step, we will enter some basic information about the request.
First, indicate whether the request is going to be inpatient or outpatient.
If you're looking for more information on how to submit an inpatient request, click here.
Next, you will enter a start date, or the date the requested service will take place.
If you do not know the date of service, you can enter today's date as a placeholder.
Next, enter in the primary diagnosis. You can search either by name or diagnosis code.
If you have any additional diagnoses, you can enter them in the optional secondary diagnosis field.
Lastly, you will enter in the procedure codes. Once again, this field is searchable by name or the CPT/HCPCS code.
Once you are ready to move forward in the submission process, click "Continue."
TIP: If needed, you can click on the "Save and exit" button on the bottom left side of the screen to save these details as a draft that you can access through both the dashboard and the patient summary. This button will be available on multiple steps of the submission process.
Demo: Request Details
Step 5: Select Services
In some cases, the portal will prompt you to indicate the type of diagnosis or procedure to be sure the portal recommends the most clinically appropriate path. Select the options that best match based on the details of the request; if you're not sure what to select from the available options, we recommend reaching out to the ordering provider.
Once you have selected the appropriate options, you can select "Continue."
Step 6: Enter Provider Details
In this step, you will capture the provider and facility details for your request.
The "Care setting" field has "outpatient" selected, since that is what we selected at the start of the request.
In the "Place of service" drop-down, you will see different options depending on the level of care, type of service, and payer of the patient you are submitting a request for. Please select the most appropriate option.
Next, you will enter the provider and facility details.
The provider and facility field are searchable by NPI, tax ID number (TIN), or name.
The portal will alert you if the provider or facility you select is out-of-network for the patient.
If the provider or facility you are searching for is missing, you are able to manually add them directly from the portal. Please ensure you are not duplicating a provider or facility that already exists in the system. This can cause your request to be inaccurately flagged as out-of-network.
In order to properly perform a member network check and ensure proper claims payments, you may be required to enter both ordering and performing provider details. If you do not have these details, we recommend contacting the performing facility.
Once you have entered in these details, you can click "Continue."
Demo: Entering Provider Details
For more information on performing provider requirements, out-of-network exceptions, and provider and facility information, click on the tabs below:
Performing provider requirement Out-of-network exceptions* Provider and Facility Information
Performing provider requirement
“Cohere is requiring that I enter the performing provider, but I don’t have that information, what do I do?”
When using the Cohere portal, we recommend filling out all details with the information available to you. In order to properly perform a member network check, and avoid claims payment issues, the performing provider may be required for your authorization request. This section contains suggestions on how to obtain these details and which services will require you to obtain this information before submitting.
Steps to obtain performing provider details
In some cases you may not have this information, in which case we recommend the following steps:
Click “Save & exit” if you are in the middle of submitting an authorization and do not have this information available. This will save your request as a draft that you can access later.
Contact the ordering provider to obtain this information
Contact the performing facility and obtain this information
You may need to explain to the facility that you are unable to submit the authorization without this information.
Wait to submit the request until you have this information.
Ensure you are following payer policy in regards to submitting a retro authorization as some payers do not allow these to be submitted.
Out-of-network exceptions
Our portal will alert you if the provider or the facility you select is out-of-network for the patient as some payers may not allow use of an out-of-network provider or facility. However, we will present you with information on how to complete this request including how to indicate an out out-of-network exception.
Definitions:
Delegated: A request or procedure will be reviewed and decisioned by the indicated insurance payer.
Geisinger Health Plan (GHP)
Network checks always run for every GHP request. However, asking for an exception is always optional.
Humana
Non-delegated requests: for non-delegated requests, you will not be able to see the network status nor ask for an out-of-network exception.
Non-HMO delegated requests: For requests with out-of-network benefits, you will be able to see the network status and will also have the option to ask for an out-of-network exception.
HMO delegated requests: You will be able to see the network status and will be required to ask for an exception if the request is out-of-network.
*NOTE: Oak Street Health follows the same guidelines as Humana for both HMO and non-HMO delegated requests.
Medical Mutual (MMO)
For Therapy, Chiropractic, Radiology, Cardiology, Sleep and Gastrointestinal requests: You will not be able to see the network status nor ask for an out-of-network exception.
For commercial HMO delegated requests: If the provider or facility is out of network, you will be required to ask for an out of network exception.
For non-commercial HMO delegated requests (including MA-HMO, EPO, PPO): The portal will not indicate if the request is out of network. You will be able to provide a waiver request for your authorization. Requests will require prior-authorization except in the cases that they are delegated to another vendor.
Avera
To be eligible for in-network benefits, all medical care and services must be obtained from an Avera Health Plans participating provider. It is your responsibility to verify that the facility and physician participate with Avera Health Plans. You may do this by viewing Avera's provider directory at www.AveraHealthPlans.com, or you can call the Avera Customer Care Center at (888) 322-2115 from 8am-5pm CST, Monday-Friday.
BlueCross BlueShield of Tennessee
Commercial requests: OON requests will be voided, unless the member has OON coverage. Cohere will notify the submitter with a fax.
Medicaid requests: OON requests will always receive a medical necessity review. When applicable, Cohere will provide an alternative provider closest to the member's location.
BlueCross BlueShield of South Carolina
Network checks are automatically conducted for every request regarding the performing provider, provider group, and facility fields. If any of the providers you have selected are out-of-network (OON), you can still proceed with the submission through Cohere. You may proceed with submission regardless of the OON status.
However, if you wish to request an out-of-network exception, please contact Blue Cross Blue Shield of South Carolina directly at 800-868-2510 to initiate the exception request process.
Provider information (Address, TIN, NPI)
To ensure the correct policies are used to review your authorization and determination letters are sent to the ordering provider, you can now manually enter or update the provider and facility information and it will also be saved for future submissions*.
*Only you will be able to access or edit records that you create.
Steps for provider information entry:
When you enter a provider or facility that is not in the portal, you will be able to select "Enter information manually".
Enter the provider or facility information, validate the address, and save the information. Only validated mailing addresses can be saved and you may need to enter a suite/ unit number.
If you need to make changes to the manually entered information, you can click the pencil icon next to the name.
Ordering provider field
If you are requesting services in a state that does not require a provider order, you should enter your "Performing facility or agency" information in this field.
If you are requesting services in a state that does require a provider order, you should enter only the details of that provider and no other details including placeholder or generic information.
Ensure you are selecting the most accurate provider details
When entering provider information into an authorization users may need to specify the NPI, TIN, and Address for each provider and facility. All of these pieces of information are important and need to be selected accurately in order for your authorization to get the most accurate result.
The following are best practices to ensure you are always selecting the most accurate information for your request:
Search for facility by name: It is possible that an NPI can include several facilities within it and the portal will only display the first facility attached to that NPI. Searching for the facility name will guarantee that the exact facility attached to your NPI is selected.
Select the most accurate address: It is possible when selecting an address that there are multiple of the same address with very small differences.
As an example: 226 Causeway Street vs. 226 Causeway Street Suite 403
Both of these options have the same “address” but have small specific differences that set them apart from each other. When selecting an address be thorough to ensure you are selecting the most accurate option for your provider.
Changes to provider or facility information that populates in the portal
If the provider or facility information listed in the Cohere portal is not correct, you can contact the insurance payer of the patient to update these details. This will prevent outdated or incorrect information from populating in the portal, as these payers are the source of these details. Please note, Cohere is no longer able to update these when you call our support teams.
Geisinger: Please contact Geisinger's Provider Account Management team at (800) 876-5357.
Step 7: Authorization Check Results
When we get to this page, we see a notice at the top, in green, that we have entered services that require authorization by Cohere. We need to fill in the remainder of the details:
First, we'll be asked to confirm our start and end dates.
The start date will autofill based on what was initially entered when we started our request, but if you have more than one service date, you will need to indicate the end date, meaning that all visits or service dates will take place during this time frame.
The number of units or visits refers to how many times each service will take place.
The numbers that autofill here is generally what is deemed clinically appropriate.
These numbers can be changed, but that may cause your request to pend for medical necessity review.
All codes you entered in step 4 will autofill into the appropriate procedure, but you do have the option to make changes to these fields in this step.
For example, you could add another physical therapy-related CPT code under the physical therapy section.
You are also able to remove codes here by hovering over them and clicking "Remove"
Toward the bottom of each request form, you will see the option to expedite the request.
You should only expedite the request if the "standard turnaround times could seriously jeopardize the life or health of the enrollee" or their "ability to regain maximum function." If either or both of these are determined to be the case, you can select the appropriate reason(s) to expedite the request.
Expediting a request when it does not meet the criteria will delay your request. Only select these options when appropriate.
Standard Requests Expedited Requests
Standard cases follow the typical process of submission for all other procedures not deemed life threatening or resulting in limb loss.
Standard cases have a turnaround time of 14 calendar days given by federal and state guidelines.
The expedite option is appropriate when applying standard turnaround times could seriously jeopardize either:
The life or health of the enrollee OR
The enrollee’s ability to regain maximum function (e.g., loss of limb)
Expedited cases have a turnaround time of 3 calendar days (72 hours). You can find more information on how to submit an expedited request below. Please avoid submitting an expedited request on a Friday or holiday weekend, as the 72 hour window applies to calendar days, not business days.
At Cohere Health, we strive to complete cases prior to the allotted time because we understand the importance of treating all patients in a timely manner.
In the event that a case is submitted as a standard request, but the procedure date is nearing, you do have the option to request that the case be reviewed sooner. Cohere will escalate this to our clinical team based on the date of service.
Finally, we can see at the very bottom of the page that one code entered does not require authorization and is noted in gray.
For these types of codes, we have the option to download and/or print a confirmation for our records.
Click "Continue."
Demo: Authorization Check Results
Step 8: Add Attachments
About Clinical Documentation
Including clinical documentation with every request will help expedite the review of your request. Without this information, our technology and the clinical reviewers will be unable to process the request before seeking out this important information from the submitter.
For revery request, regardless of service, clinical documentation must include patient identifiers.
If any clinical documentation is missing from the request, the submitter will be contacted to obtain this information.
Failure to provide needed information for review can result in delays, and in some cases even denials.
If, for some reason, you are unable to upload relevant clinical documentation directly to the portal, you are also able to fax documents to support the details in your request.
Click here for more information on how to fax documents to Cohere.
However, if you do have the necessary documentation on your computer, uploading attachments is convenient and easy, and saves you the trouble of faxing supporting documentation in your requests.
Once attached, you can click "Continue."
How to Upload Clinical Documentation
After entering diagnosis and procedure codes, provider and facility details, and units/visits in the portal, you will be prompted to upload clinical documentation.
If you have the clinical attachments for this request on your computer, you can conveniently upload them directly to the portal. To do this, follow these steps:
Choose a file from your computer
100MB is the maximum file size that is accepted
The following file types are supported: ".jpeg", ".jpg", ".pdf", ".rtf", ".tif", ".tiff"
Uploading Clinical Documentation After Initial Submission
In the event that you need to upload clinical documentation after submission, you are able to do so in some cases. For more information on when and how to do this (including allowable edits by payer), please view our Editing Prior Authorizations article.
Faxing Clinical Documentation
If, for some reason, you are unable to upload clinical documentation directly to the portal, you are also able to fax any relevant attachments for review. Please view this article to obtain the applicable fax number (varies by payer). It is essential that fax forms are sent to the correct fax number, so please be sure to verify that you have the correct number before sending.
Step 9: Answer Clinical Assessment Questions (CAQs)
The next step is to answer the CAQs.
These questions are designed to capture key information about the patient's specific clinical situation, and will vary based on the payer, diagnosis, and services requested for approval.
The answers to these questions will typically be found within the patient's chart, but if you need help answering these, we recommend reaching out to the ordering provider.
Again, if you need to save your request as a draft and come back to it later, you can do so at this time by clicking "Save and exit."
Please note that this CAQs may not populate for every request.
Once all questions have been answered, click "Continue."
Best Practices
The guidance included in this document should be followed regardless of the services you are requesting.
Step 10: Review Recommendation - Evidence-Based Suggestions
Our portal may prompt you on this step with evidence-based suggestions as a way to help make your request eligible for approval.
What is an evidence-based suggestion?
Evidence-based suggestions are simple messages that indicate how to align your request with Cohere's clinical guidelines.
In our example, you can see the suggestion stating that we should reduce our physical therapy visits to that which is deemed more clinically appropriate (from 60 units to 10).
You are never required to accept these suggestions, but if you do your request should then be eligible for approval.
What are the different types of evidence-based suggestions?
The table below provides a brief description of each type of suggestion, when you could encounter them, and if there is an action required.
Type | Action | When will you experience it? | Description |
Platform | No action required | Pre-submission within the Cohere platform | When we suggest making changes to your authorization so your request can become eligible for auto-approval. |
Platform | Action recommended | Post-submission via fax | You will receive an automated fax after you submit your authorization request if there are no attachments included with your request. At this stage, you are not blocked from moving forward, however, you will need to upload documentation for Cohere to review your request. |
Operational | Action recommended | Post-submission | A phone call or email (when possible) directly from our nurse reviewers when we suggest making changes to your authorization so your request can become eligible for auto-approval. |
Redirect | Action required: “Hard stop” | Within the Cohere platform during submission | Based on guidelines, these messages will present when you need to make a change. Examples include:
|
When you have selected an option, click "Continue."
Step 11: Review Before Submitting
This brings us to the final step of our authorization submission process, which is simply to review all the details of the request before submitting it.
If you notice anything here that needs to be changed, you can click any of the blue "Edit" buttons and make any needed changes.
You may see other evidence-based suggestions on this screen. In this example, the suggestion in the purple box on the right side of the screen is recommending that we do not expedite this request.
Again, you are never required to accept these suggestions, but if you do your request should then be eligible for approval.
Once you have confirmed that all of the details are correct, you can click "Submit."
Once you press submit, we immediately begin processing the request.
When possible, based on the information provided, we will issue an auto approval.
Otherwise, an authorization status will appear indicating the current stage of review.
Click "Done" to be redirected to the patient summary.
Step 12: Navigate the Patient Summary
After submitting, you will be redirected to the patient summary that was mentioned earlier in step 3.
You can view the status of the request either here, or on the dashboard.
Here in the patient summary, we can see more details about this patient on the left side of the screen, as well a other requests submitted for this patient.
An authorization number will be provided as soon as it is available.
If the request is not auto approved, it will continue to be processed and the submitter will be contacted if more information is required.
You will also receive a notification once your authorization has been decisioned.
We also want to note that there is a button at the top of the patient summary that allows you to start an authorization request directly associated with this patient instead of doing so from the dashboard.
If you choose to start an auth from patient summary, please double check that you are submitting an authorization for the correct patient!
To navigate to the dashboard from the patient summary, click the "Cohere Health" icon at the top of the page.
Demo Video
Click here to watch a demo video of most inpatient and outpatient requests (excludes home health).
FAQs
Is there a limit to the number of procedure codes and diagnosis codes that I can submit with my request?
Procedure codes: the number of procedure codes you submit may vary by payer.
Diagnosis codes: you can enter one (1) primary diagnosis and up to nine (9) secondary diagnosis codes.
Is it necessary to upload clinical documentation with my request?
While uploading documents may not technically be required for all authorizations, we recommend that you do this every time. In the case that we need to review the request in more detail, this will minimize the need to reach out to obtain that information.
Does each service get its own authorization number?
Yes, each service (regardless of the number of services you submit) is processed individually, has an individual decision, and receives its own authorization number.
What needs to be documented and submitted with my request to ensure I'm meeting evidence-based care?
Required details may vary depending on the payer, line of business, level of care, or other authorization details. Please review the payer's guidelines to understand what needs to be documented and submitted with your request to ensure you are meeting evidence-based care.
How long will it take for the authorization number to populate in the portal after an auto-approval?
It may take up to 5 business days for the authorization number to populate.
Can you start a request, save it, and come back to it later?
Yes! At the bottom left of each screen within the submission workflow, simply press "Save and exit" to save your progress and return at another time.