Prior authorization through Cohere required

Geisinger Health Plan requires prior authorization through Cohere for Cardiology services for members enrolled in its Commercial HMO and PPO, Medicare Advantage, GHP Family Medicaid and CHIP products. Cohere applies proprietary clinical criteria, utilization management decision‑support tools, and evidence‑based guidelines when adjudicating requests. For details on which services require prior authorization, refer to the payer portal.

• Submit PA requests via the Cohere prior authorization system.
• Cohere will use its proprietary clinical criteria and decision‑support tools to determine medical necessity.

Medicaid PA requests may be evaluated case‑by‑case

For the PA Medicaid business segment, any requests that do not meet the PARP criteria may be evaluated on a case‑by‑case basis. Providers should submit full clinical information with the PA request to support a case‑by‑case review when PARP criteria are not met.

• Case‑by‑case review available only for PA Medicaid segment when PARP criteria are not satisfied.

Submit applicable procedural and device codes with PA requests

When requesting authorization, submit the applicable procedural and device codes listed in this policy to support the request; the coding lists are provided for informational purposes to support authorization submission and do not guarantee coverage or payment.

• Include relevant CPT and HCPCS codes from the policy (see device and procedure code groups).
• Note: inclusion of a code in the list does not imply coverage or reimbursement; Medicare business segment may have specific CPT/HCPCS coverage rules.

Risk of denial or nonpayment without Cohere prior authorization

Failure to obtain prior authorization through Cohere for Cardiology services for members in Commercial HMO/PPO, Medicare Advantage, GHP Family Medicaid and CHIP may result in denial or non‑coverage per plan requirements.

• Providers risk claim denial or nonpayment if Cohere prior authorization is not obtained when required.