Overview

Required determination timelines are set by standards required by the state and federal governments for different types of requests (standard or expedited).

Additionally, accreditation standards and levels may be set by quality organizations. Generally, guidelines used to measure success are:

The National Committee for Quality Assurance (NCQA)
Local state agency requirements
Payor policies for commercial healthcare.

Medicare Guidelines are set by the Center for Medicare and Medicaid Services (CMS). Cohere’s goal is to surpass these required guidelines with aggressive turnaround time goals that exceed the required standards. This means that regardless of the member’s insurance, Medicare guidelines are the same.

Medicare	Medicare
Standard	14 days
Expedited	72 hours

Avera

At Cohere, we strive to automatically approve as many cases as possible, but in the event that a submission does not meet those criteria, our turnaround times are as follows:

Commercial	Commercial	Commercial
STATE	STANDARD	EXPEDITED
Alabama	<2 business days of receipt of request	< 2 business days of receipt of request
Alaska	< 1 business day	< 1 business day
Arizona	< 14 calendar days of receipt of request	< 5 calendar days of receipt of request
Arkansas	< 15 calendar days of receipt of request	< 72 hours of receipt of request
California	< 5 business days from plan's receipt of information	< 72 hours of receipt of request
Colorado	< 5 business days of receipt of request	< 2 business days of receipt of request or 72 hours, whichever comes first
Connecticut, Washington DC, Florida, Georgia, Louisiana, Montana, Nebraska, Nevada, New Hampshire, West Virginia, Wisconsin, Wyoming	< 15 calendar days of receipt of request	< 72 hours of receipt of request
Delaware	< 5 business days	< 72 hours of receipt of request
Hawaii	< 15 calendar days of receipt of request	< 24 hours after the date the request
Illinois	< 5 calendar days of receipt of request	< 48 hours of receipt of request
Idaho	< 2 business days after receipt	< 2 business days after receipt
Indiana	< 5 business days of receipt of request	< 48 hours of receipt of request
Iowa	< 1 (one) business day of a determination not to certify an admission	< 1 (one) business day of a determination not to certify an admission
Kansas	< 15 calendar days	< 72 hours of receipt of request
Kentucky	< 5 calendar days of receipt of request	< 24 hours of receipt of request
Maine	Within 72 hours or 2 business days, whichever is less	< 24 hours after receipt of request.
Maryland	< 2 working days after receipt of the information necessary to make the determination	< 2 hours after receipt of the information necessary to make the determination
Massachusetts	< 2 working days of obtaining all necessary information	< within 72 hours
Michigan	< 9 days of receipt of request	< 72 hours of receipt of request
Minnesota	< 5 days of receipt of request	< 72 hours of receipt of request
Mississippi	< 7 business days of receipt of request	< 48 hours of receipt of request
Missouri	< 36 hours of receipt of request	< 36 hours of receipt of request
New Jersey	< 15 calendar days of receipt of request	< 24 hours after the date the request was made
New Mexico	< 7 days	< 24 hours
New York	< 3 business days of receipt of the necessary information.	< 48 hours after receipt
North Carolina	< 3 business days of receipt of request	< 3 business days of receipt of request
North Dakota	< 15 days after receipt	< 72 after receipt of the claim
Ohio *Turnaround times are determined by company licensure.	< 10 calendar days of receipt of request	< 48 hours from receipt of request
Oklahoma	< 2 working days after obtaining all required information	< 24 hours after the date the request was made
Oregon	< 2 business days of after receipt of the request	< 2 business days of after receipt of the request
Pennsylvania	< 2 business days of receipt of request	< 2 business days of receipt of request
Rhode Island	< 15 days after receipt of the claim	< 72 hours after receipt of the claim
South Carolina	< 5 business days of receipt of request	< 5 business days of receipt of request
South Dakota	< 15 days after receipt	< 72 hours after receipt of the claim
Tennessee	< 2 business days of receipt of request	< 2 business days of receipt of request
Texas	< 3 business days after receipt of the request	<3 business days after receipt of the request
Utah	< 15 calendar days of receipt of request	< 72 hours of receipt of request
Vermont	< 2 business days after receipt of the request	< 48 hours after receipt of the request
Virginia	< 2 business days of receipt of request	< 2 business days of receipt of request
Washington	< 15 days after receipt of request	< 24 hours after the date the request

*Utilization reviews must be completed within specific time frames to meet compliance requirements. Time frames begin based on the date the request is received, regardless of department. Time frames end when the required verbal/written notification is provided and documented.*

BlueCross BlueShield of South Carolina

Through our collaboration, Blue Cross Blue Shield of South Carolina and Cohere, aim to automatically approve as many cases as possible. However, if a submission does not meet the criteria for automatic approval, Blue Cross Blue Shield of South Carolina completes the review and assumes full responsibility for ensuring compliance with all state and federal timeliness standards, as well as, for some products additional accreditation requirements established by quality organizations. Blue Cross Blue Shield of South Carolina is committed to not only meeting these standards but also exceeding them to deliver the highest level of service and care.

BlueCross BlueShield of Tennessee

TAT Table - Commercial and Medicaid	TAT Table - Commercial and Medicaid	TAT Table - Commercial and Medicaid	TAT Table - Commercial and Medicaid
	Pre-Service - Standard	Pre-Service - Expedited	Post-Service
Commercial TN	3 days	24 hours	7 days
ACA & ASO	3 days	24 hours	7 days
Medicaid	3 days	24 hours	7 days

Geisinger

Geisinger requirements for returning a decision on an authorization request can be viewed in the image below. In certain cases, there may be extensions granted based on a variety of factors.

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HealthPartners

At Cohere, we strive to automatically approve as many authorizations as possible. In the event that a submission does not meet criteria for auto-approval, our turnaround time guidelines for HealthPartners are as follows:

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Humana

At Cohere, we strive to automatically approve as many cases as possible, but in the event that a submission does not meet those criteria, our turnaround times are as follows:

Commercial	Commercial	Commercial
STATE	STANDARD	EXPEDITED
Alabama	<2 business days of receipt of request	< 2 business days of receipt of request
Alaska	< 1 business day	< 1 business day
Arizona	< 14 calendar days of receipt of request	< 5 calendar days of receipt of request
Arkansas	< 15 calendar days of receipt of request	< 72 hours of receipt of request
California	< 5 business days from plan's receipt of information	< 72 hours of receipt of request
Colorado	< 5 business days of receipt of request	< 2 business days of receipt of request or 72 hours, whichever comes first
Connecticut, Washington DC, Florida, Georgia, Louisiana, Montana, Nebraska, Nevada, New Hampshire, West Virginia, Wisconsin, Wyoming	< 15 calendar days of receipt of request	< 72 hours of receipt of request
Delaware	< 5 business days	< 72 hours of receipt of request
Hawaii	< 15 calendar days of receipt of request	< 24 hours after the date the request
Illinois	< 5 calendar days of receipt of request	< 48 hours of receipt of request
Idaho	< 2 business days after receipt	< 2 business days after receipt
Indiana	< 5 business days of receipt of request	< 48 hours of receipt of request
Iowa	< 1 (one) business day of a determination not to certify an admission	< 1 (one) business day of a determination not to certify an admission
Kansas	< 15 calendar days	< 72 hours of receipt of request
Kentucky	< 5 calendar days of receipt of request	< 24 hours of receipt of request
Maine	Within 72 hours or 2 business days, whichever is less	< 24 hours after receipt of request.
Maryland	< 2 working days after receipt of the information necessary to make the determination	< 2 hours after receipt of the information necessary to make the determination
Massachusetts	< 2 working days of obtaining all necessary information	< within 72 hours of receipt
Michigan	< 9 days of receipt of request	< 72 hours of receipt of request
Minnesota	< 5 days of receipt of request	< 72 hours of receipt of request
Mississippi	< 7 business days of receipt of request	< 48 hours of receipt of request
Missouri	< 36 hours of receipt of request	< 36 hours of receipt of request
New Jersey	< 15 calendar days of receipt of request	< 24 hours after the date the request was made
New Mexico	< 7 days	< 24 hours
New York	< 3 business days of receipt of the necessary information.	< 48 hours after receipt
North Carolina	< 3 business days of receipt of request	< 3 business days of receipt of request
North Dakota	< 15 days after receipt	< 72 after receipt of the claim
Ohio *Turnaround times are determined by company licensure.	< 10 calendar days of receipt of request	< 48 hours from receipt of request
Oklahoma	< 2 working days after obtaining all required information	< 24 hours after the date the request was made
Oregon	< 2 business days of after receipt of the request	< 2 business days of after receipt of the request
Pennsylvania	< 2 business days of receipt of request	< 2 business days of receipt of request
Rhode Island	< 15 days after receipt of the claim	< 72 hours after receipt of the claim
South Carolina	< 5 business days of receipt of request	< 5 business days of receipt of request
South Dakota	< 15 days after receipt	< 72 hours after receipt of the claim
Tennessee	< 2 business days of receipt of request	< 2 business days of receipt of request
Texas	< 3 business days after receipt of the request	<3 business days after receipt of the request
Utah	< 15 calendar days of receipt of request	< 72 hours of receipt of request
Vermont	< 2 business days after receipt of the request	< 48 hours after receipt of the request
Virginia	< 2 business days of receipt of request	< 2 business days of receipt of request
Washington	< 15 days after receipt of request	< 24 hours after the date the request

Medical Mutual (MMO)

At Cohere, we strive to automatically approve as many cases as possible, but in the event that a submission does not meet those criteria, our turnaround times are as follows :

Commercial	Commercial	Commercial
STATE	STANDARD	EXPEDITED
Alabama	<2 business days of receipt of request	< 2 business days of receipt of request
Alaska	< 1 business day	< 1 business day
Arizona	< 14 calendar days of receipt of request	< 5 calendar days of receipt of request
Arkansas	< 15 calendar days of receipt of request	< 72 hours of receipt of request
California	< 5 business days from plan's receipt of information	< 72 hours of receipt of request
Colorado	< 5 business days of receipt of request	< 2 business days of receipt of request or 72 hours, whichever comes first
Connecticut, Washington DC, Florida, Georgia, Louisiana, Montana, Nebraska, Nevada, New Hampshire, West Virginia, Wisconsin, Wyoming	< 15 calendar days of receipt of request	< 72 hours of receipt of request
Delaware	< 5 business days	< 72 hours of receipt of request
Hawaii	< 15 calendar days of receipt of request	< 24 hours after the date the request
Illinois	< 5 calendar days of receipt of request	< 48 hours of receipt of request
Idaho	< 2 business days after receipt	< 2 business days after receipt
Indiana	< 5 business days of receipt of request	< 48 hours of receipt of request
Iowa	< 1 (one) business day of a determination not to certify an admission	< 1 (one) business day of a determination not to certify an admission
Kansas	< 15 calendar days	< 72 hours of receipt of request
Kentucky	< 5 calendar days of receipt of request	< 24 hours of receipt of request
Maine	Within 72 hours or 2 business days, whichever is less	< 24 hours after receipt of request.
Maryland	< 2 working days after receipt of the information necessary to make the determination	< 2 hours after receipt of the information necessary to make the determination
Massachusetts	< 2 working days of obtaining all necessary information	< within 72 hours
Michigan	< 9 days of receipt of request	< 72 hours of receipt of request
Minnesota	< 5 days of receipt of request	< 72 hours of receipt of request
Mississippi	< 7 business days of receipt of request	< 48 hours of receipt of request
Missouri	< 36 hours of receipt of request	< 36 hours of receipt of request
New Jersey	< 15 calendar days of receipt of request	< 24 hours after the date the request was made
New Mexico	< 7 days	< 24 hours
New York	< 3 business days of receipt of the necessary information.	< 48 hours after receipt
North Carolina	< 3 business days of receipt of request	< 3 business days of receipt of request
North Dakota	< 15 days after receipt	< 72 after receipt of the claim
Ohio *Turnaround times are determined by company licensure.	<10 calendar days after receipt of all necessary info.	< 48 hours from receipt of request
Oklahoma	< 2 working days after obtaining all required information	< 24 hours after the date the request was made
Oregon	< 2 business days of after receipt of the request	< 2 business days of after receipt of the request
Pennsylvania	< 2 business days of receipt of request	< 2 business days of receipt of request
Rhode Island	< 15 days after receipt of the claim	< 72 hours after receipt of the claim
South Carolina	< 5 business days of receipt of request	< 5 business days of receipt of request
South Dakota	< 15 days after receipt	< 72 hours after receipt of the claim
Tennessee	< 2 business days of receipt of request	< 2 business days of receipt of request
Texas	< 3 business days after receipt of the request	<3 business days after receipt of the request
Utah	< 15 calendar days of receipt of request	< 72 hours of receipt of request
Vermont	< 2 business days after receipt of the request	< 48 hours after receipt of the request
Virginia	< 2 business days of receipt of request	< 2 business days of receipt of request
Washington	< 15 days after receipt of request	< 24 hours after the date the request

Medicare Advantage	Medicare Advantage	Medicare Advantage
State	Standard	Expedited
Ohio	< 2 business days of receipt of request	< 48 hours of receipt of request
Kentucky	< 5 calendar days of receipt of request	< 24 hours of receipt of request

Oak Street Health Aetna

At Cohere, we strive to automatically approve as many cases as possible, but in the event that a submission does not meet those criteria, our turnaround times are as follows: