Still faxing?

You can now use Cohere to request authorization for all services, including inpatient, outpatient and behavioral health. 

Don't miss out on timesaving benefits, including automatic approvals and guided submission only available when using the Cohere portal to manage authorizations. Registration only takes a few minutes and unlocks access for all users at your practice organization.

Register with Cohere today!

*The request process for  high end radiology services that require authorization through HealthHelp remains the same.

PEBTF referral

• PEBTF referral form

Ambulance

• Non-Emergent Transport Form - Available through Cohere.
• Non-Emergent Ambulance Transportation (NEAT) update

Behavioral health

• Behavioral health professional services questionnaire
• Behavioral health facility services questionnaire
• Behavioral health outpatient prior authorization request form - Available through Cohere.
• Behavioral health services review form
• Behavioral health ABA request form - As of Jan. 1, 2023 Applied Behavioral Analysis no longer requires prior authorization when the provider is in-network, the member’s plan covers autism and there is a diagnosis of Autism Spectrum Disorder. If you're unsure if a prior authorization is required or if the member’s plan has coverage for Autism, call the our care connector team at 888-839-7972. Available through Cohere.
• Behavioral health ECT request form - Available through Cohere.
• Behavioral health psychological testing request form - Available through Cohere.
• Behavioral health TMS request form - Available through Cohere.
• Behavioral health discharge form

DME

• DME ordering through Tomorrow Health - As of Jan. 1, 2021, all DME orders for your GHP patients should be placed through Tomorrow Health.
• DME Precertification Additional Code Form - Available through Cohere.
• DME Precertification Form - Available through Cohere.
• DME Authorization Change Form - Available through Cohere.
• DME Re-Certification Form - Available through Cohere.

Home health

• As of Jan. 16, 2023, you can submit prior authorization requests for home health through Cohere Health. Cohere’s online portal is an easy way to get authorization requests reviewed and approved quickly so your patients can get the care they need. Register with Cohere today!

• Home Health Services Request Form - Available through Cohere.

Inpatient

• Inpatient Admission Review Form
• Inpatient Planned Procedure Precertification Form
• Inpatient Rehabilitation Precertification Form
• Inpatient Update Review Form

Medical benefit outpatient drug

• Medical Drug Prior Authorization List (GHP Family-Medicaid)
• Medical Benefit Outpatient Drug Authorization Form
• Medical Drug Prior Authorization List (Commercial/Marketplace/Medicare/CHIP)

Oncology benefits management program

• Chemotherapy Prior Authorization Form - Available through OncoHealth OneUM
• Radiotherapy Prior Authorization Form - Available through OncoHealth OneUM

Outpatient rehabilitation

• As of Jan. 16, 2023, you can submit prior authorization requests for outpatient therapy services through Cohere Health. Cohere’s online portal is an easy way to get authorization requests reviewed and approved quickly so your patients can get the care they need. Register with Cohere today!

• Outpatient Rehabilitation Therapy Services Request Form - Available through Cohere.

Other outpatient services

• As of Oct. 1, 2023, you can submit prior authorization requests for most outpatient services through Cohere Health. Cohere’s online portal is an easy way to get authorization requests reviewed and approved quickly so your patients can get the care they need. Register with Cohere today!
• Outpatient Prior Authorization Form - Available through Cohere.

SNF

• SNF Concurrent Review Form
• SNF Discharge Planning Notification Form
• SNF Precertification Form

Shift care and private duty nursing

• Shift Care Notification Form - For agencies to submit within five (5) days of any changes in the status of a member receiving shift care services.
• Private Duty Nursing/Shift Care Form - For prescribing providers referring members for initial shift care/private duty nursing services to relay patient and provider information to GHP Medical Management. 

Additional forms and resources

• Newborn Information Form
• NOMNC-Sample Instructions
• Open Negotiation Period Form
• Organizational Determination Form
• Prior Authorization List
• Request for Independent External Review of an Adverse Benefit Determination – Members can use this form to request the Pennsylvania Insurance Department review a health care coverage decision made by their plan (Commercial plans only).
• Physician Certification for Expedited Review – Providers can use this form to certify that normal timeframes for the review of health care coverage decisions would seriously jeopardize the life or health of the covered person or would jeopardize the covered person's ability to regain maximum function.