Overview
This article houses some of our most frequently asked questions and their answers for Geisinger specifically.
General FAQs
Once services have been approved, is an authorization required for every recertification period?
No. Prior authorization approvals are given for a set number of visit(s) and time frame. If the member needs additional services, increase number of visits or extended time frames, authorization will be required. An authorization is not required for every recertification period.
When should I contact Cohere vs. Geisinger?
The table below highlights a few key functions relating to the authorization process and where you should direct any questions, issues, or feedback. Click here to view a printable version of this table.
Cohere contact information
General support: (855) 460-8026
Geisinger contact information
Medical management: (800) 544-3907
Customer care team: (800) 447-4000
Provider Account Management: (800) 876-5357
Other Helpful FAQs
If a patient has a question about out-of-pocket costs or their authorizations, should I contact Cohere or Geisinger Health Plan?
Please direct questions about member benefits to Geisinger. Please refer to the patient’s insurance card or Geisinger’s website for the correct contact information.
What should I do if I need to reset my password?
You can reset your password by:
Navigating to the main login screen, clicking “Need Help Signing In?”
Select “Forgot password?”, enter your email or username and click “Reset via Email”
Navigate to the password reset email from Cohere and select “Back to Sign in”
If you are already registered with Cohere for other insurances, do you need to register again for Geisinger?
No, users only need to register once. Registered users will be able to submit authorizations for all eligible payers.
Are we able to submit retro authorizations?
Geisinger does not accept retro authorizations. However, you are able to backdate the authorization to accurately represent that start of care.
Geisinger and Cohere define backdating as an authorization that is submitted after the start of care date, but while care is still in progress and within the accepted time frame of 5 days (home health) and 7 days (outpatient therapy).
Geisinger and Cohere define retro authorizations as authorizations that are submitted after all care is complete.
How long after the start of care do we have to request prior authorization?
This depends on the service being requested.
If you are requesting Home Health services, you have 5 days from the start of care to submit your prior authorization request.
After the start of care, you have 7 days to submit outpatient therapy authorization requests.
Can I submit Geisinger out-of-network requests through Cohere?
Yes, you should submit these requests through the Cohere portal. All out-of-network home health requests will pend for manual review from the GHP clinical team.
What is the process for submitting re-authorization requests?
Re-authorization requests may be submitted at any time and must be uploaded through the Cohere portal. These requests will only be processed during regular business hours.
A re-authorization, continuation, or concurrent review is required to continue services beyond the initial approved services/visits.
Obtaining a re-authorization is the responsibility of the home health agency
Home health agency providers must submit requests for re-authorization at least 48 hours prior to being discharged from home health services.
Home health agency providers must submit an updated clinical status or a new plan of care which includes objective reasons for request for re-authorization or continuation of services.
For wound care requests, the home health agency providers must send in the most recent wound care visit notes with measurements and full color wound photos (HIPAA compliant).
How do I submit a durable medical equipment (DME) request?
This article contains the key information users need to know when submitting requests for DME in the Cohere portal. Click here to print this information. Click here for general information on how to submit a prior authorization request.
All requests will have the service name "DME". The specific name of the equipment being requested will not appear (Ex: wheelchair, orthotics, oxygen, etc).
Enter additional details in the clinical assessment questions. Provide additional information as free text within the clinical assessment questions. This includes modifiers, descriptions for miscellaneous codes, and whether the DME is a rental or will be purchased.
Any requests for DME less than $500 do not require prior authorization. Purchased/ rented DME items with an allowed amount of $500 or less DO NOT require prior authorization except:
Incontinence supplies, when a covered benefit
Equipment repairs
Positive airway pressure services (CPAP and RAD)
ALL miscellaneous codes require prior authorization, regardless of price
Entering provider information. The ordering provider should be entered as the provider ordering the DME. The performing provider is optional.
Entering facility/agency information. Enter the facility/agency as the company providing the DME to the member.
No procedure code limit. Enter as many procedure codes as necessary for your request.
What is the Geisinger program exception process?
Participating providers may request coverage for items or services that are included under the member's benefits package but are not currently listed on the medical assistance program fee schedule. Participating providers may also request an exception for services or items that exceed limits on the fee schedule if the limits are not based in statute or regulation. These exceptions should be requested in advance of providing services. To request program exceptions*, participating providers must follow the Geisinger Family Prior Authorization process.
Direct questions to Geisinger Medical Management by calling 800-544-3907.
*Please note that all program exception requests will pend for review
(Source: GHP Family Provider Manual)
Out-Of-Network Excptions Organization determinations Medicare Fee Schedule Unlisted or Miscellaneous Codes
If a provider and/or facility is out-of-network, all codes require authorization, regardless of whether the code is on the prior authorization list. To submit an out-of-network exception request, enter the relevant codes when initiating the request and select the check box below the procedure code field to proceed.
.
These are typically member-driven. An organization determination is any decision made by a Medicare health plan regarding:
Authorization or payment for a health care item or service;
The amount a health plan requires an enrollee to pay for an item or service; or
A limit on the quantity of items or services.
An enrollee, an enrollee's representative, or any provider that furnishes, or intends to furnish, services to an enrollee may request a standard organization determination by filing a request with the health plan. Expedited requests may be requested by an enrollee, an enrollee's representative, or any physician, regardless of whether the physician is affiliated with the health plan.
(Source: CMS.gov).
What is the Medicare fee schedule?
The Medicare fee schedule is a listing of all the fees that Medicare uses to pay doctors and other providers for their services. This listing is used to reimburse doctors or other health care providers.
These are codes labeled as non-specified, not listed, not elsewhere specified (NEC), not otherwise classified (NOC), not otherwise specified (NOS), unclassified, unlisted, or unspecified.
Some unlisted or miscellaneous codes could require prior authorization to determine coverage and benefits. Be sure to check eligibility and benefits to confirm prior authorization requirements. If prior authorization is required, services performed without prior authorization or that do not meet medical necessity criteria may be denied for payment and the rendering provider may not seek reimbursement from the member.
If you submit a prior authorization or predetermination request that includes an unlisted or miscellaneous code, be sure to include a detailed description of the service along with any documentation to support your request. This step helps avoid the need for post-service medical necessity review. The type of information required will vary depending on the type of service or item being billed.
What is Geisinger's UM Process?
When Geisinger is responsible for conducting a review of the medical necessity of a proposed service, the following is our standard medical necessity definition:
Assure that high-quality service is delivered to the member at the appropriate time.
Appropriate and consistent with the diagnosis of the treating Provider and the omission of which could adversely affect the eligible Patient’s medical condition;
The process used for decision-making is based on the appropriateness of care and services and is compatible with standards of medical practice in the community.
Provided in a safe, appropriate, and cost-effective setting given the nature of the diagnosis and the severity of the symptoms;
Geisinger does not offer incentives nor are medical staff compensated to deny medically appropriate services to members.
Not provided solely for the convenience of the Patient or the convenience of the Health Care Agency or hospital; and
Not primarily custodial care unless custodial care is a covered service or benefit under the Patient’s evidence of coverage.
The UM Program seeks to:
Coordinate the delivery of care that is aligned with Health Plans, State, and Federal Regulatory guidelines.
Promote the efficient Utilization of services/resources.
Monitor patterns of Utilization over time to increase consistency in UM decision-making and delivery of care.
Improve continuity of care and patient outcomes through effective care coordination and specificity to each patient.
Initiates needed operational revisions to prevent problematic issues from reoccurring.
Enhance physicians and patient satisfaction by facility access, enhancing awareness of medical necessity and appropriateness of services.
Promotes and ensures the integration of utilization management with quality monitoring and improvement, risk management, and case management activities.
Home Health & Shift Care FAQs
How do I submit home health and shift care authorizations?
Geisinger Health Plan and Cohere Health are excited to announce a more streamlined approach to submitting your home health authorizations within the Cohere portal. Instead of requiring the selection of a specific modality, enter the specific procedure codes.
There is no change to the way you currently bill and submit claims to Geisinger Health Plan.
How to submit a request:
Please specify the number of visits next to each Home Health CPT code or specify the number of units next to each Shift Care CPT code (see tables and screenshots below).
For Home Health only, the CPT code descriptions containing a reference to 15-minute intervals can be ignored. For shift care, each 15 min interval should be submitted as 1 unit.
Examples:
Home Health: a 60-minute skilled nursing care visit, should be submitted as 1 visit.
Shift Care: 8 hrs of shift care for a code that is 15 minute intervals should be a submitted as 32 units.
Home health codes (Visits)
Modality | Codes to be submitted |
Physical Therapy (PT) | G0151 |
Occupational Therapy (OT) | G0152 |
Speech Therapy (ST) | G0153 |
Social Worker (MSW) | G0155 |
Home Health (HHA) | G0156 |
Skilled Nursing (RN, LPN)* | G0299 |
Shift care codes (Units)
Modality | Codes to be submitted |
RN Services | T1002 |
LPN Services | T1003 |
Home Health Aide or Certified Nursing Assistant | G0156 |
* Code G0299 applies to an RN visit, an LPN visit, and a situation where the level of nursing is unknown.
What information is required for home health requests?
Required information generally includes, but is not limited to, the following:
Medicaid & CHIP Medicare & Commercial
Home Health services referral from a physician/allowed practitioner
The signature or electronic signature by an MD, DO, PA, CNS, or NP
The current date, institution discharge date, or a future start of care date
Patient demographics, including the patient's first and last name and DOB
H&P/Progress Notes/Therapy Notes – these must be within:
90 days prior to the start of care, and/or
30 days after the start of care
They must support the need for services being ordered and include appropriate diagnoses/reasons for home health services such as: intravenous medications, enteral feeding (e.g., PEG), Foley catheter, tracheostomy, wound care, DMEs, medical supplies, caregiver/family teaching and training.
Insurance information for services not in-scope to Geisinger
To qualify for home health services, members must meet all of the following:
Be confined to the home (or meet the homebound exclusion criteria)
Be receiving a plan of care established and reviewed by a physician/allowed practitioner
Be in need of skilled services (such as nursing or therapy)
Require one or more of the following:
Skilled nursing care on an intermittent basis
Physical therapy
Speech-language pathology
Occupational therapy
Medical Social Services and Home Health Aide services can be provided if one of the skilled services above is also being delivered
The signature or electronic signature by an MD, DO, PA, CNS, or NP
The current date, institution discharge date, or a future start of care date
Patient demographics, including first and last name and DOB
H&P/Progress Notes/Therapy Notes – these must be within:
90 days prior to the start of care, and/or
30 days after the start of care
Must support the need for services and list appropriate diagnoses, such as: intravenous medications, enteral feeding (e.g., PEG), Foley catheter, tracheostomy, wound care, DMEs, supplies, caregiver/family teaching
Insurance information for services not in-scope to Geisinger
Documented face-to-face encounter is required (see this article for more information)
Do PTA, OTA, and LPN need to be submitted under their own code or will they fall under the main codes for SN, OT, PT?
You do not need to request these separately. Any request for PT will cover the PTA, OT will cover the OTA, and Nurse will cover the LPN as needed.
How to submit a request:
Enter the number of visits for each procedure code
Please specify the number of visits next to each Home Health CPT code. The CPT code description containing a reference to 15-minute intervals can be ignored.
Example: a 60-minute skilled nursing care visit, should be submitted as 1 visit.
Modality | Codes to be submitted |
Physical Therapy (PT) | G0151 |
Occupational Therapy (OT) | G0152 |
Speech Therapy (ST) | G0153 |
MSW | G0155 |
HHA | G0156 |
Skilled Nursing (RN, LPN)* | G0299 |
* Code G0299 applies to an RN visit, an LPN visit, and a situation where the level of nursing is unknown.
Is a new request required when a patient resumes care following a re-hospitalization?
Yes, this would require a new authorization.
How soon is the signature of the MD required?
The plan of care requires a signature by the provider. If the request is reauthorized, the provider must sign at least every 60 days.
What if more visits are needed?
Do you need to request more visits, or add additional codes to a request while the care is in progress? In certain situations, you may find that more visits are needed for a patient. When this happens you can simply edit the existing authorization to request this increase. Click here to view more details, including screenshots of this process.
We have included an example below.
You initially requested 10 physical therapy visits for your patient.
8 days into treatment you decide that 5 more visits will be needed.
How should you submit authorization for those 5 additional visits???
Log in to the Cohere portal & locate the original request for the 10 visits.
Select "More detail" within the patient summary
Press "Edit request"
Scroll down and edit the number of units to include the new TOTAL. In the example above, this would be 15.
Cohere is currently building the functionality to support an easier workflow for this specific use case and we will communicate with all Geisinger providers when this is available.
Can we use the previous OASIS form for reauthorization?
Yes, you can use a previous OASIS form for reauthorization.
How soon after the patient is discharged or referred to home health do we need to make an initial visit?
Each patient must receive an initial visit 48 hours post-discharge/ referral. This is a CMS requirement, meaning that it is mandated for Medicare FFS plans, however, Geisinger is applying that policy across all lines of business.
The purpose of this requirement and the initial visit, in general, is primarily for patient safety reasons and to ensure the patient is well. This visit CAN be combined with the start of care, but that is not a requirement.
Due to COVID, a public health emergency (PHE) is still in effect, so this initial visit can be done over the phone.
What is the prior authorization process for Geisinger home health referrals?
Organizations that provide any of the services listed in the 2023 Geisinger Health Plan Prior Authorization List for Geisinger Health Plan members across any line of business, will need to begin submitting authorizations through Cohere Health as of May 15th, 2023.
They will need to request all prior authorizations for home health, shift care, and outpatient hospice authorizations through Cohere.
Inpatient hospice auths should be submitted via fax directly to Geisinger Health Plan.
This will apply to all Geisinger Health Plan patients.
The procedure codes included in the updated PAL notice will require prior authorization (in addition to the home health and hospice codes that currently require prior authorization).
All home health and hospice codes that require prior authorization must be authorized through Cohere to pay.
Organizations will benefit from a streamlined online authorization process--better than phone and fax--that offers submission guidance, faster approval, and even instant authorization in some cases.
Please remember that an authorization is not required for the initial visit, which must occur within 48 hours post-discharge/post-referral in accordance with plan policy.
What are the Geisinger Home Health Utilization Management (UM) responsibilities?
Prior-Authorization and Reauthorization Process
Initial authorizations, continuation of care, and resumption of care (ROC) requests are given in thirty (30) day increments and all authorizations require upload/submission of a complete Home Health Agency referral.
Home Health Agencies have the following Utilization Management responsibilities:
Provide and maintain appropriate documentation to establish the existence of medical necessity.
Obtain authorization prior to beginning services/products. Services/products performed without authorization may be denied for payment, and any such denial of payment is not billable to the patient by the Home Health Agency.
Verify the information on the Authorization Form (member name, date of birth, address of where services will be provided, discipline, number of visits/units (as applicable), start and stop date, agency name, contact, and location) upon receipt.
Notify Geisinger if the patient is not homebound and/or refuses services.
Notify Geisinger to report a serious member incident and/or sentinel event.
Notify Geisinger if the services ordered will not meet the patient's needs.
Respond to all requests for contact from Geisinger within
What are the face-to-face (FTF) requirements for Medicare home health?
A physician ordering Medicare home health services must certify a patient’s eligibility for the home health benefit. The certifying physician must document that they, or an allowed nonphysician practitioner (NPP), has had a Face-to-Face (FTF) encounter with the patient related to the primary reason for the home health care. This encounter must occur within 90 days prior to or 30 days after the start of care (SOC).
No specific form is required to document this encounter, it only needs to contain all requirements listed below:
Date of encounter.
Patient’s clinical condition and how it supports the patient’s homebound status and need for skilled services.
The certifying physician must complete and sign the face-to-face documentation.
This is true, even if another provider performs the FTF encounter.
The documentation of the face-to-face encounter must be clearly titled as such.
The encounter must take place either in person, or via two-way audio-visual telehealth, and should be clearly documented as such.
What are the OASIS Requirements?
The Outcome and Assessment Information Set ("OASIS") data collection requirements apply to Medicare-certified home health agencies (HHAs) and to Medicaid home health providers in states where those agencies are required to meet the Medicare Conditions of Participation.
Geisinger requires a copy of the completed OASIS within 5 days of the start of care. The comprehensive assessment requirement currently applies to all patients regardless of pay source, including Medicare, Medicaid, Medicare Advantage, Medicaid managed are, and private pay/including commercial insurance. The comprehensive assessment must include OASIS items for all skilled Medicare, Medicaid, and Medicare or Medicaid managed care patients with the following exceptions: patients under the age of 18, patients receiving maternity services, and patients receiving only a single visit in a quality episode.