Review Criteria: Differences Among Payers

Cohere guidelines are created from an adaptation of peer-reviewed clinical research, medical society guidelines, and coordinated peer reviews. Medical Necessity Criteria and Site of Service Criteria are derived from this knowledge base within the guidelines and serve as a decision support tool to help approve prior authorizations for the most appropriate treatment, setting, and help assure consistency of care for each individual. These guidelines do not replace payer-specific policies, NCDs or LCDs. 

We know that for providers who may be contracted with more than one insurance payer, remembering the differences among payer requirements and guidelines can be complicated. We want to provide you with a quick overview of the differences in review criteria for Medical Mutual of Ohio and Humana, specifically. 

Payer Edits Continuations Duplications Voids
Humana

You are able to make certain edits to authorizations that are approved, pended, or still a draft (e.g., dates). 

Please visit this page for more information.

For approved or partially approved authorization requests, you can use this feature to add units or procedure codes to a request. Continuations will go through a separate review and will have the same authorization number as the initial request. 

Please visit this page for more information.

If the portal detects duplicate information, you may be prompted to start a continuation. Please see the continuations column for more information.  You are unable to withdraw requests when they are in draft status because they have not yet been submitted. However, you do have the option to delete these requests. To do this, open the request by selecting “more detail” and scroll down to view “delete this service.
Medical Mutual of Ohio After the request is submitted and decisioned, edits cannot be made without calling MMO. However, as long as the status is still pending or open, additional information can be appended to authorizations, or they can be voided entirely.  Continuations for any requests are not accepted. If certain fields in a new authorization are identical to those in another request, you will be informed that it is a duplicate and will be unable to submit it until changes are made. These fields include: performing provider, facility, overlap of procedure codes, overlap of dates, and same encounter type (inpatient/ outpatient) You cannot withdraw or void a request that has already been decisioned. Contact Medical Mutual of Ohio at 800-362-1279 for more details.  
Geisinger Health Plan 

You are able to make certain edits to authorizations that are approved, pended, or still a draft (e.g., dates). 

Please visit this page for more information.

For approved or partially approved authorization requests, you can use this feature to add units or procedure codes to a request. Continuations will go through a separate review and will have the same authorization number as the initial request. 

Please visit this page for more information.
If the portal detects duplicate information, you may be prompted to start a continuation. Please see continuations column for more information. You are unable to withdraw requests when they are in draft status because they have not yet been submitted. However, you do have the option to delete these requests. To do this, open the request by selecting “more detail” and scroll down to view “delete this service.” Additionally, you cannot void decisioned authorizations.