Missing Information
Missing Information
Including clinical documentation in a WISeR authorization is required.
If no supporting clinical information is attached, the request cannot be submitted. If you attempt to submit without including documentation you will see a message prompting you to upload the required files to proceed.
If all required documentation for your request is not included, you will see a message prompting you to consider including additional documentation. You can go back and add additional attachments or dismiss and continue your authorization.
If there are attachments submitted, but all information needed for review is not included, you may receive one outreach attempt via phone by Cohere for missing information.
For detailed documentation lists of what to include in your requests, click here.
Peer to Peers
Peer to Peers
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.
For WISeR requests, a Peer-to-Peer consult can be requested and performed on a resubmission request (see the Denials & Appeals section below for more information on resubmission requests.)
In addition to resubmitting your request, you may request a peer-to-peer conversation during your resubmission process. A WISeR clinician with relevant specialty expertise will conduct the discussion.
To request a peer-to-peer conversation, contact us at 1(855)-430-6299.
Denials, Resubmissions, and Appeals
Denials, Resubmissions, and Appeals
Resubmission Requests
You may resubmit your request at any time. There is no limit to the number of resubmissions under the WISeR Model.
A resubmission allows you to address the issues identified in the decision, such as incomplete documentation or insufficient evidence that the requested item(s) or service(s) meet Medicare’s medical necessity and coverage requirements.
The following requirements must be met when submitting a resubmission:
A resubmission must be for the same member and codes as the original request.
A resubmission must include the same Ordering Provider NPI as the original request.
A resubmission can be requested within 120 days of the original decision.
A unique, 14-digit tracking number (UTN) is assigned for billing and provided in the decision letter. If you are requesting a resubmission on a non-affirmed authorization, please provide the UTN in your resubmission request.
When resubmitting, please:
Use a new cover sheet (do not reuse the original).
Include all previously submitted materials plus any new or updated information addressing the specific gaps noted in the determination letter (e.g, additional imaging, updated clinical findings, or further rationale supporting that the service meets Medicare’s medical necessity criteria).
Confirm the request aligns with the requirements in the applicable Local or National Coverage Determination cited in the determination letter.
Ensure all required data elements are complete (beneficiary information, diagnosis/ procedure codes, provider identifiers, supporting clinical documentation).
Initiate Your Resubmission Via:
Provider Portal (preferred): Cohere Health
Fax: (404) 835-8325
Mail: PO Box 1290 Portsmouth, NH 03802
Peer to Peer Discussion:
In addition to resubmitting your request, you may request a peer-to-peer conversation during your resubmission process. A WISeR clinician with relevant specialty expertise will conduct the discussion.
To request a peer-to-peer conversation, contact us at 1 (855)-430-6299.
Appeals
If you choose to render the non-affirmed services and submit the claim(s), the claim(s) will be denied and all rights to the appeal process will apply.