Overview

Click on the payer options below to view more information about the processes for missing information, peer to peer consultations, denials, and appeals.

Avera

Click on the options below to view more information about the authorization process for Avera members!

Missing Information Peer-to-Peer Consults Denials and Appeals

There are two main reasons why you may receive outreach for missing information:

The request was submitted without clinical documentation attached.
There are attachments submitted, but all information needed for review is not included.

Cohere will reach out to the submitter requesting the specific information and/or clinical documentation needed to continue the decisioning process.

You may include clinical documentation in your request using the following methods:

Upload to the Cohere portal during the submission of your request.
Fax clinical documentation to Cohere at (570)-798-5240.

Our goal is to reduce the need for peer-to-peer consults. However, we know that in some situations, the best way to get patients the care they need quickly is to connect the submitting and reviewing physicians for a brief conversation.

The peer-to-peer process for Avera is as follows:

Peer to peer consults only take place after decisioning.
A peer to peer consult will be offered in the denial decision letter.
Peer to peer consults will not be offered as part of outreach for missing information.
Peer to peer consults must be scheduled, and completed with Cohere, within 14 days of the decision date if the service has not been completed and an appeal has not been filed.
- To schedule a P2P with Cohere, contact (800) 249-8035.

What if I don't agree with this decision?

If you do not agree with the final decision, you have the right to file an appeal. You must file the appeal within 180 calendar days of the date on this notice.

Avera Health Plans will only pay for medically necessary services according to eligibility, plan benefits, exclusions, limitations, and maximums as stated in your Certificate of Coverage. Even though a service may be medically necessary, it may or may not be eligible for payment because the service is not a "covered service;" other plan exclusions, restrictions, or limitations may apply. For verification of benefits, please contact the customer care team at (605) 322-4545.

How to file an appeal:

Appeal forms are available from Avera's customer care team or on their website averahealthplans.com. You can mail the appeal form or written request to:

Attn: Complaint and Appeals Coordinator
Avera Health Plans
5300 S. Broadband Ln
Sioux Falls, SD 57108-2221

You can also email the appeal form to Avera at complaintappeals@averahealthplans.com.

BlueCross BlueShield of South Carolina

Click on the options below to view more information about the authorization process for BlueCross BlueShield of South Carolina submissions!

Missing Information Peer-to-Peer Consults Denials and Appeals

There are two main reasons why you may receive outreach for missing information:

The request was submitted without required clinical documentation attached.
The submitted attachments are incomplete and do not include all the necessary information for review.

Please note that the missing information outreach process is managed and conducted by Blue Cross Blue Shield of South Carolina. See the options below for how to provide updated clinical documentation to support your pending prior authorization review.

Upload the missing information directly to the original authorization request through the Cohere portal.
Send missing information via fax using the correct fax number found here.

If you have questions about missing information, please contact BlueCross BlueShield of South Carolina directly at (803) 264-4730.

All Peer-To-Peer (P2P) requests are conducted by BlueCross BlueShield of South Carolina. Please refer to the denial letter for instructions on how to request a P2P with Blue Cross Blue Shield of South Carolina or visit Peer To Peer Request | Medical Forms Resource Center.

For more information on denials, appeal rights, or filing an appeal, please refer to the information provided in the denial letter.

BlueCross BlueShield of Tennessee

Click on the options below to view more information about the authorization process for BlueCross BlueShield of Tennessee members!

Missing Information Peer-to-Peer Consults Denials and Appeals

There are two main reasons why you may receive outreach for missing information:

The request was submitted without clinical documentation attached.
There are attachments submitted, but all information needed for review is not included.

Cohere will reach out to the submitter requesting the specific information and/or clinical documentation needed to continue the decisioning process.

For commercial cases, missing information outreach will not occur for retro-authorizations that exceed three days.

At Cohere, our goal is to reduce the need for peer-to-peer consults. However, we know that in some situations, the best way to get the patients the care they need quickly is to connect our physicians with yours for a brief conversation.

Cohere's Approach:

Minimize the need for peer-to-peer consults with automatic approval of clinically appropriate prior authorization requests.
Have productive conversations with providers to help the patient get the care they need.

Cohere’s panel of peer-to-peer physicians are board-certified physicians who are experienced in both giving and receiving peer-to-peer consultations. We will match a peer-to-peer physician with the same specialty as the ordering physician.

Peer-to-Peer Details by Line of Business	Peer-to-Peer Details by Line of Business
Commercial Requests	A peer-to-peer consultation will be offered in a denial letter. For commercial cases, peer-to-peer consultations will not be offered for retro-authorizations that exceed three days.
Medicaid Requests	Peer-to-peer conversations for Medicaid cases can be requested at any point after submission. A peer-to-peer conversation will also be offered in the denial letter.

If your request is denied, you have the right to appeal the decision. For commercial (group risk) appeals, you have 30 days to submit an appeal. The appropriate team (based on line of business and service(s) requested) will review your appeal request within:

7 days for appeals submitted electronically (via email or fax) or
30 days for appeals submitted any other way (i.e., mail)

For more information on how to submit appeals, please refer to your payer's website.

Geisinger

Click on the options below to view more information about the authorization process for Geisinger members!

Missing Information Peer-to-Peer Consults Denials and Appeals

There are two main reasons why you may receive outreach for missing information:

The request was submitted over the phone and therefore had no clinicals attached.
There are attachments submitted, but all information needed for review is not included.

Authorization requests without complete clinical documentation will still be reviewed but may ultimately be denied if the necessary information is not included. Geisinger will reach out to the user that submitted the request to obtain missing information for any applicable authorizations.

You may include clinical documentation in your request using the following methods:

Upload to the Cohere portal during the submission of your request.
Fax clinical documentation directly to Geisinger using your current process:
- Geisinger Medical Management: (800) 544-3907.

When requesting a peer-to-peer consultation for Cardiovascular, Pain, & Musculoskeletal (MSK) requests:

Contact Cohere regarding adverse benefit determinations based on medical necessity at (855) 460-8026 Monday through Friday from 8am to 8pm EST.

When requesting a peer-to-peer consultation for all other service requests:

Contact a Geisinger Health Plan medical director regarding adverse benefit determinations based on medical necessity. Providers should contact the Medical Management Department at 1-800-544-3907 Monday through Friday from 8am to 5pm EST.

For information on claims, appeals, and grievances, please contact:
- Geisinger Customer Care Team: (800) 447-4000.

HealthPartners

Click on the options below to view more information about the authorization process for HealthPartners members!

Missing Information Peer-to-Peer Consults Denials and Appeals

There are two main reasons why you may receive outreach for missing information:

The request was submitted without clinical documentation attached.
There are attachments submitted, but all information needed for review is not included.

Cohere will reach out to the submitter requesting the specific information and/or clinical documentation needed to continue the decisioning process.

Our goal is to reduce the need for peer-to-peer consults. However, we know that in some situations, the best way to get the patients the care they need quickly is to connect our physicians with yours for a brief conversation.

Cohere's Approach:

Minimize the need for peer-to-peer consults with automatic approval of clinically appropriate prior authorization requests.
Have productive conversations with providers to help the patient get the care they need.

Peer-to-Peer Details by Line of Business	Peer-to-Peer Details by Line of Business
Medicare Requests	Before issuing a denial, Cohere will reach out to the submitter to let them know to contact Cohere to schedule a P2P. Providers have the opportunity to withdraw the case prior to Cohere issuing a denial. This prevents a “denial” notice from being issued to the patient and allows the provider to manage communication. If appropriate, the provider can then submit a new request.
Commercial and Medicaid Requests	Peer to peer conversations for Medicaid and Commercial cases must take place after decisioning. A peer to peer conversation will be offered in the denial letter. Please see below for more information on denial letters.

If your request has been denied, Cohere is unable to reopen the case. Please do not resubmit another authorization request for the same case.

You have the right to appeal any decision not to provide you or pay for an item or service (in whole or in part). For both lines of business, all appeals must be filed directly to HealthPartners and can be submitted immediately after a Cohere denial has been issued.

Who do I contact if my request is denied?	Who do I contact if my request is denied?
Medicare	Please contact HealthPartners directly at MemberRightsBenefits@HealthPartners.Com
All other coverage	Please contact HealthPartners using the phone number provided on the back of the Member’s ID card.

Frequently Asked Questions

Where can I find a denial letter?

If a request is denied, both the patient and ordering provider will receive a denial letter via mail. Denial letters are also available via the Cohere Portal.

Can you fax me a copy of the denial?

If a "denied" decision has been made, you are able to print a copy of the denial letter from within the Cohere portal by clicking the printer icon that appears on the authorization when hovering your mouse over the status. You can also request your denial letter be emailed/faxed to you.

Who may file an appeal?

The requesting provider or someone they name to act on their behalf with Health Partners (authorized representative) may file an appeal.

Humana

Click on the options below to view more information about the authorization process for Humana members! We have built a comprehensive document with all of this information for your access, available here.

Missing Information Peer-to-Peer Consults Denials and Appeals

There are two main reasons why you may receive outreach for missing information:

The request was submitted without clinicals attached.
There are attachments submitted, but all information needed for review is not included.

In accordance with Humana policy, Cohere is required to attempt three (3) outreaches to obtain missing information for any applicable requests. The outreach method will depend on the reason for missing information.

Requests will move forward in the decisioning process 4 hours after the last outreach (for accelerated) and 24 hours (for standard). To meet turnaround time (TAT) requirements, please monitor your request in the portal, as well as email, fax, and phone. Our team may reach out for additional information promptly, and timely responses help prevent delays or denials.

Peer to Peer consults are now offered in every Missing Information outreach. If you would like to schedule a peer to peer, please send us your availability at coherehealth.com/p2p. For emergent requests please call us.

There are 3 possible timelines of outreach that may occur, standard, accelerated, or expedited. These timeframes are determined based on several criteria:

Date of service is before Cohere’s required decision date, and is within 3 business days.
The required decision date, as mandated by federal or state guidelines (AKA turnaround time), is within 3 business days.

Please see this article to learn more about Humana peer-to-peer consults.

Please see this article to learn more about Humana Denials and appeals.

Medical Mutual (MMO)

Click on the options below to view more information about the authorization process for Medical Mutual submissions.

Missing Information Peer-to-Peer Consults Denials and Appeals

There are two main reasons why you may receive outreach for missing information:

The request was submitted without clinical documentation attached.
There are attachments submitted, but all information needed for review is not included.

Commercial Therapy, Chiropractic, Radiology, Cardiology, Sleep, and Gastrointestinal requests:

Cohere will reach out to the submitter requesting the specific information and/or clinical documentation needed to continue the decisioning process.
Peer to peer consults will not be offered as part of outreach for missing information.
Peer to peer consults only take place after decisioning.
A peer to peer consult will be offered in the denial decision letter.

Medicare Advantage Radiology requests:

Cohere will reach out to the submitter requesting the specific information and/or clinical documentation needed to continue the decisioning process.
Before issuing a denial, a peer to peer consult will be offered as a part of the missing information outreach. See below for more information on Peer to Peer consults.

Commercial Therapy, Chiropractic, Radiology, Cardiology, Sleep, and Gastrointestinal requests:

Peer to peer consults only take place after decisioning.
A peer to peer consult will be offer in the denial decision letter.
Peer to peer consults will not be offered as part of outreach for missing information.
Peer to peer consults must be scheduled and completed within 14 days of the decision date if the service has not been completed and an appear has not been filed.

Medicare Advantage Radiology requests:

For medicare advantage radiology requests, before issuing a denial, Cohere will reach out to the submitter to let them know to contact Cohere to schedule a P2P.

First level appeals can be submitted via Cohere for Diagnostic Imaging (Radiology), Physical Therapy, Occupational Therapy, Speech, Chiropractic, Cardiology, Sleep, and Gastrointestinal Commercial requests.

For diagnostic imaging, sleep, and cardiology requests specific to devices (DME), the validity dates will be 180 days (6 months).

Submit your appeals via email, mail, or fax using our Cohere form.

Mail:

Cohere Health - Appeals Department

226 Causeway St.

Boston, MA, 02114

Email: mmosupport@coherehealth.com

Fax: (570) 684-4168

Oak Street Health

Click on the options below to view more information about the authorization process for Oak Street Health submissions.

Missing Information Peer-to-Peer Consults Denials and Appeals

There are two main reasons why you may receive outreach for missing information:

The request was submitted without clinical documentation attached.
There are attachments submitted, but all information needed for review is not included.

Cohere will reach out to the submitter requesting the specific information and/or clinical documentation needed to continue the decisioning process.

You may include clinical documentation in your request using the following methods:

Upload to the Cohere portal during the submission of your request.
- Documentation can also be added after submission, until your authorization is decisioned.
Fax clinical documentation to Cohere at (570) 314-9200.
- If you need to fax clinical documentation for concurrent reviews, please fax to (855) 473-3399

Cohere will perform two (2) missing information outreach attempts to the submitter.

Cohere's approach:

Minimize the need for peer-to-peer consults with automatic approval of clinically appropriate prior authorization requests.
Have productive conversations with provders to help the patient get the care they need.

Steps to schedule a peer-to-peer consultation:

Before issuing a denial, Cohere will reach out to the submitter to let them know to contact Cohere to schedule a P2P at (855) 473-3399.
- You will be given a scheduling block (e.g., window between 8 am-12 pm) during which you will receive a call from an Oak Street Health MD to start the P2P.
If you would like to proactively schedule a P2P, you can do so in one of the following ways:
- Call the Oak Street Health Cohere support phone number: (855) 473-3399
  - Press 1 for existing authorization
  - Press 4 for peer-to-peer
- Email the Oak Street Health Cohere email address: osh.support@coherehealth.com
- Submit a P2P request form at coherehealth.com/p2p.

Oak Street Denials & Appeals
- Most Oak Street Health denials and appeals will follow payer process (e.g., denials and appeals for patients contracted with Humana will follow Humana's process).

Oak Street Health Aetna

Click on the options below to view more information about the authorization process for Oak Street Health Aetna submissions.

Missing Information Peer-to-Peer Consults Denials and Appeals

There are two main reasons why you may receive outreach for missing information:

The request was submitted without clinical documentation attached.
There are attachments submitted, but all information needed for review is not included.

Cohere will reach out to the submitter requesting the specific information and/or clinical documentation needed to continue the decisioning process.

You may include clinical documentation in your request using the following methods:

Upload to the Cohere portal during the submission of your request.
- Documentation can also be added after submission, until your authorization is decisioned.
Fax clinical documentation to Cohere at (570) 572-4968.
- If you need to fax clinical documentation for concurrent reviews, please fax to (570) 572-4970.

Cohere's approach:

Minimize the need for peer-to-peer consults with automatic approval of clinically appropriate prior authorization requests.
Have productive conversations with providers to help the patient get the care they need.

Steps to schedule a peer-to-peer consultation:

Before issuing a denial, Cohere will reach out to the submitter to let them know to contact Cohere to schedule a P2P at 855-975-9643.
- You will be given a scheduling block (e.g., window between 8 am-12 pm) during which you will receive a call from an Oak Street Health Aetna MD to start the P2P.
If you would like to proactively schedule a P2P, you can do so in one of the following ways:
- Call the Oak Street Health Aetna Cohere support phone number: 855-975-9643
  - Press 1 for existing authorization
  - Press 4 for peer-to-peer
- Email the Oak Street Health Aetna Cohere email address: oshaetna.support@coherehealth.com
- Submit a P2P request form at coherehealth.com/p2p.

For Appeals:

What must be included in appeal?

You, your representative or your doctor, can ask for an appeal. Your written request must include:

Your name
Address
Plan Member number
Reasons for appealing
Whether you want a standard or fast appeal (for a fast appeal, explain why you need one).
Any evidence you want us to review, like medical records, doctor supporting statements, or other information that explains why you need the {medical service/item or Medicare Part B drug}.

Submitting an appeal

Submit your appeal by mail, phone, fax, or online.

For a Standard Appeal:

Mailing Address:
- Aetna Medicare Part C Appeals & Grievances
  P.O. Box 14067
  Lexington, KY 40512
Fax: 724-741-4953
Website: www.aetnamedicare.com/complaintsa-gcd

For a Fast Appeal: