Provider Documents and Forms
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
Click here to read more…
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.
Referral Form – NEVADA ONLY:
Nevada Referring Providers submit this form to initiate home health services.
Centene-Ambetter PA/RA Request Form:
Centene-Ambetter PA-RA Request Form
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.
Re-Authorization Request Form:
In-network providers submit this form for a re-authorization request, if needed.
Start of Care Confirmation Form:
Form confirming start of care or resumption of care. Upload this form along with completed OASIS assessment.
Fax Confirmation Form:
Form to confirm fax numbers for authorization and re-authorization requests.
Out of Network Service Notification:
Out-of-network providers submit this form to receive payment for PPO members.
Claims Payment Materials
Electronic Funds Transfer (EFT) Enrollment:
Form to enroll in EFT payments. The tango payer ID is 26748
Form to dispute denial of a claim.
Provider Information Updates
In-network providers submit this form to update agency information (TIN, NPI, address, etc.)
Please contact the tango team with any questions at: Phone: (888) 705-5274.
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 email@example.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.