General FAQs
Is Cohere connected to Humana's claims system?
Our system is completely integrated into Humana’s authorization and claims payment systems, so you do not need to reconcile between the two.
What Humana business lines are/are not accepted?
Cohere currently serves the following Humana lines of business: | Cohere does not accept the following insurances: |
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*Humana Medicare HMO (Gold) is in scope for Cohere, which means you can submit with Cohere today, unless the patient’s primary care provider has been delegated prior authorization OR is located in California, Florida, or Hawaii. These members will continue to get authorizations through their primary care provider.
Do we need to submit a request if the patient has Humana as their secondary insurance?
Humana does not require authorizations if that is the patient's secondary insurance.
Can we use the Medicaid number instead of the Humana ID number?
We do not currently accept Medicaid authorization submissions. Currently, you are only able to search for patients by Humana ID. However, we are working on developing the ability to allow for additional search criteria.
What is the denials & appeals process for Humana?
You have the right to appeal any decision not to provide you or pay for an item or service (in whole or in part). To get more information about appeals, including status updates, grievances or questions, please contact Humana's Customer Care Specialist at (800) 448-6262. Cohere is unable to discuss determination details over the phone.
For both lines of business, you can submit an appeal with Humana immediately after a Cohere denial has been issued.
How to Submit Appeals
Line of business | How to submit | Appeal window |
Medicare | Must be submitted by mail, fax, or phone | Within 60 days of receiving the denial letter |
Commercial | Must be submitted in writing | Within 60 days of receiving the denial letter |
*If you are outside the appeal window you may not appeal and therefore must submit a new request to Cohere.
Resubmitting to Cohere
When resubmitting a request to Cohere, the following timeline and criteria must be followed:
Resubmitting for Level of Care
If your authorization was denied, you are able to resubmit with a different level of care (inpatient vs. outpatient) and this will be reviewed as a new authorization.
Frequently Asked Questions:
Q: Can you fax me a copy of the denial?
A: 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.
Q: Who may file an appeal?
A: The requesting provider or someone named to act on their behalf with Humana may file an appeal. To appoint an authorized representative, you must send a signed "Humana Appointment of Authorized Representative" form with, or before, your appeal. Members may also initiate an appeal.
What is the peer-to-peer consultation process for Humana requests?
The information in this FAQ is only applicable to Humana authorizations.
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 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, not issue a denial.
Peer-to-peer conversations can be done with an MD, DO, PA, NP, PT, OT, ST, or a Chiropractor/Podiatrist. Unfortunately, we are unable to accommodate peer-to-peers with a PTA, OTA, STA, practice manager, office nurse, or office MA.
What makes us different
Conversations are scheduled before an adverse determination is made.
Physicians 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.
Cohere’s panel of peer-to-peer physicians are board-certified physicians who are experienced both on the giving and receiving end of peer-to-peer consultations. We will match a peer-to-peer physician with the same specialty as the ordering physician.
How it works
When an authorization is queued for a peer-to-peer request, we will make 3 attempts to contact someone at your office and schedule. All outreach attempts will be through the method indicated below (fax, phone, and/or email) unless that method is unavailable to us.
1st & 2nd attempt
Who receives the outreach? The requester who submitted the authorization
How is the outreach attempted? Fax & email; depending on the contact information available to our team.
When are the attempts made? At the SAME time* *if both outreach attempts are made in the same way (email/fax), the second attempt will be sent:
4 hours after the 1st outreach for Medicare standard
1 hour after the 1st outreach for Commercial/ Medicare Expedited
3rd attempt
Who receives the outreach? The requester who submitted the authorization
How is the outreach attempted? Phone
When are the attempts made?
Medicare standard: 4 hours after 1st & 2nd outreach
Commercial standard: 1 hour after 1st & 2nd outreach
Expedited: 1 hour after 1st & 2nd outreach
On the 3rd attempt, we will offer the option of scheduling a peer-to-peer. Once a denial has been issued, we can no longer offer a peer-to-peer. At that time, you must go through the Humana appeals process. |
To schedule a peer-to-peer, please contact our support team: |
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How do I submit diagnostic and arterial endovascular intervention requests for Humana Medicare Advantage patients?
The following details apply to Humana Medicare Advantage patients when submitting for Peripheral Arterial Disease. Providers and Authorization Specialists are encouraged to become familiar with the Medical Necessity Criteria of the revised Guideline Humana Medicare Advantage Policy HUM-1182-002.
Please consider the following when submitting these types of authorizations:
Laser Atherectomy for in-stent restenosis is eligible for prior authorization (i.e., before the procedure) with upload of documentation including:
degree of stenosis
prior intervention and
office notes.
Prospective submission for authorization of the following CPT codes may require pending for manual review and peer-to-peer discussions. Codes can be submitted for retrospective review and should include procedural information as required by the Medical Necessity criteria.
CPT 37225 (femoral-popliteal angioplasty and atherectomy)
CPT 37227 (femoral-popliteal angioplasty, stenting and atherectomy)
CPT 37229 (tibial angioplasty and atherectomy)
CPT 37231 (tibial angioplasty, stenting and atherectomy)
CPT 0238T (iliac atherectomy)
CPT 0505T
CPT 0620T
Codes for intravascular lithotripsy C9764, C9765, C9766, C9767, C9772, C9773, C9774, C9775
Humana accepts retro authorizations up to 364 days after the date of service.
Pending authorizations: what is the review process and who can I contact?
In some cases, you may have questions about a pending authorization that is being reviewed. Cohere Health does have a clinical team that can review authorizations, but in order to streamline and improve your workflow, you can also submit many services through Cohere that are reviewed by a clinical team outside of Cohere. For example, you may see the message, "Pending review by Humana".
In the reference table below, you will see a variety of “pending review” messages that may occur for Humana members. Please use this resource if you need to get in contact with the team reviewing this authorization while the request is pending.
Therapy FAQs
If a patient has therapy in a facility that differs from the request, should we submit another request? Will it be denied if there's already another authorization?
Yes, please submit another authorization request. Cohere will not automatically deny an authorization if there is another similar authorization already in the system.
If we get an auth and the number of units shows none, is it unlimited visits for the date range?
No, your request will include the number of visits that were approved. If you have an auth that says “none” for visits, please resubmit the request or contact us so we can help.
Is the requesting provider the ordering physician or therapist?
The requesting provider is the ordering physician and the performing or rendering provider is the PT office. The physical therapist can initiate the authorization request once the order is received.
What should we enter in the "ordering provider" field if the patient is direct access?
In direct access states, the physical therapist should be entered as both the ordering and rendering provider.
Which services related to therapy are not delegated to Cohere Health for authorization?
Services not delegated to Cohere include services provided by chiropractors, even when submitting codes that are within Cohere’s scope. Additionally, inpatient rehabilitation, cardiac rehabilitation, and pulmonary rehabilitation are not delegated to Cohere. Physical therapy performed in the home, may be delegated to Cohere if the procedure code is within Cohere’s scope.
Please refer to this website for more information on Humana's Prior Authorization List (PAL).
Is outpatient therapy performed in a skilled nursing facility or nursing home within Cohere's scope?
Yes. Any outpatient therapy performed in a skilled nursing facility or nursing home that is billed under the Medicare Part B benefit should be authorized through Cohere.
Xiaflex Policy FAQs
Why did Humana add collagenase enzyme (Xiaflex) injection for Dupuytren's Contracture to the 2022 authorization list?
A greater focus on managing collagenase enzyme injection (Xiaflex) for Dupuytren’s Contracture in 2022 was prioritized in response to an observed trend indicating:
Unexplainable variability in treatment patterns across providers
Opportunities to drive providers to choose the most clinically appropriate, indication optimal treatment option for patients (pharmacologic or surgical).
What criteria will Cohere use to review medical necessity and clinical appropriateness?
Cohere will leverage Humana’s Medicare and Commercial Policies to review medical necessity and clinical appropriateness before making any coverage determinations.
What is the turnaround time for a decision?
Requests meeting Cohere’s clinical guidelines may receive immediate auto-approval (in most cases). That is, an approval decision in seconds. Requests not meeting clinical guidelines may pend for manual review by Cohere’s clinical operations team of nurses and physicians.
This means that a “same-day-of-appointment decision” may be possible if the request is auto- approved, but this is not guaranteed and should not be expected.
Where can I review Humana's authorization list in more detail?
The preauthorization list can be reviewed on Humana's website at www.humana.com/pal.
Which indications require authorization?
All medically accepted indications other than treatment for Peyronie’s disease require submission of a preauthorization for the use of Xiaflex.
Are providers required to submit an authorization for the use of Xiaflex to treat Peyronie's disease?
Providers will not be required to submit an authorization for the use of Xiaflex to treat Peyronie’s disease.