provider materials
Provider documents and forms.
announcements
Update on Humana Home Health Network Services
Humana has contracted with Professional Health Care Network (tango) for home health network management services, effective July 1, 2021 for the following Medicare Advantage (MA) networks.
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authorization of services
Prior Authorization Request / Referral Form – Colorado / New Mexico only:
Colorado and New Mexico In-network Providers submit this form for an initial authorization request.
Colorado and New Mexico Referring Providers submit this form to initiate home health services.
Download
Referral Form – Nevada only:
Nevada Referring Providers submit this form to initiate home health services.
Download
Centene-Ambetter PA/RA Request Form:
Centene-Ambetter PA-RA Request Form.
Download
Resumption of Care Request Form:
A Resumption of Care (ROC) assessment is required any time the patient is admitted as an inpatient for 24 hours or more for other than diagnostic tests.
Download
Re-Authorization Request Form:
In-network providers submit this form for a re-authorization request, if needed.
Download
Start of Care Confirmation Form:
Form confirming start of care or resumption of care. Upload this form along with completed OASIS assessment.
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Fax Confirmation Form:
Form to confirm fax numbers for authorization and re-authorization requests.
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Out of Network Service Notification:
Out-of-network providers submit this form to receive payment for PPO members.
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provider information updates
Information Change:
In-network providers submit this form to update agency information (TIN, NPI, address, etc.)
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Our Utilization Management (UM) department applies nationally recognized utilization criteria and regionally developed medical policies and standards of care for utilization management reviews. Criteria are available to providers and practitioners upon request by calling (888) 705-5274, faxing (877) 612-7066, emailing casemanagement@tangocare.com or by mail at 7600 N. 16th St. #140, Phoenix, AZ 85020. Once the request is received, our staff will respond with the requested criteria via fax, email or mail.