It is important to establish medical necessity prior to treatment to prevent claim delays. Government and private insurers have varying criteria for determining if a treatment is medically necessary based on the patient's circumstances. Medicare uses National Coverage Determinations and private Medicare plans (i.e., Medicare Advantage) use Local Coverage Determinations in order to ensure that the criteria for medical necessity are met. Private insurers can set their own criteria, although they're required to provide coverage that's in compliance with state and federal mandates.
Prior to treatment, an office should review and document the following to determine medical necessity:
To complete an electronic prior authorization (ePA) please visit the Coherus COMPLETE Provider Portal.
Document medical necessity of the patient
*NCCN guidelines, refer to Clinical Practice Guidelines of Oncology (NCCN guidelines)
Provider offices may use the services offered by Coherus COMPLETETM that include but are not limited to: