Prior Authorization Process & Guidelines

This list is intended as a guide for PrimaryHealth providers. Please call the PrimaryHealth office at (541) 471-4208, toll free (800) 471-0304 if you have any questions.

To request a referral or prior authorization, please complete the PrimaryHealth Referral/Prior Authorization Request Form and fax the completed form to (541) 956-5460. If you need the PrimaryHealth referral form, or need instructions on how to use the form, please contact us at (541) 471-4208, Toll Free (800) 471-0304.

Referrals are not valid until eligibility, benefits and diagnosis have been verified and a referral number is assigned by PrimaryHealth. Additional guidelines may apply to surgery, some diagnostics and some injections. Upon request, we will provide you with information about the guidelines/rules used in making our decision. You may also talk to the staff member who made the decision, or request an appeal or reconsideration of our decision. Retroactive referrals will be considered up to 30 days following the date of service.

  • Please note OHP guidelines allow up to 14 days to approve or deny this request. You will be notified of our decision.
  • Please allow at least 5 business days for processing prior to calling the office to inquire about the status of a request.
  • Please send relevant chart notes to expedite processing.
  • If your request is medically urgent, please print a note on the form to alert us to your processing needs.

For all dual eligible members (members who have traditional Medicare or a Medicare Advantage Plan) authorization is not required by PrimaryHealth. This is NOT a guarantee of payment as claims will be processed based upon eligibility, benefits, diagnosis and any applicable Oregon Administrative Rules.

Professional Referrals (Specialists)

No prior authorization is required for office visit referrals to contracted specialty providers in the following “prior authorization exempt” categories. All professional referrals for provider types not listed require prior authorization. Specialist referrals must be PCP driven; there is no member self-referral**. Providers (PCP’s) are expected to review and manage outside referrals. All *the following guidelines apply to all prior authorization exempt specialties:

  • PrimaryHealth will only issue payment for two office visits for a non-covered diagnosis. This is to allow a diagnostic evaluation of a non-covered condition. If the diagnosis is still not covered after two visits, subsequent visits will be denied. It is the responsibility of the provider to ensure that the diagnosis being treated is covered by OHP. Providers can do this by checking MMIS or contacting PrimaryHealth to check the code.
  • **Specialists may refer to other specialists without PCP approval. However, PCPs should be notified of all specialist to specialist referrals (through medical record sharing).
  • Providers/PCP’s may undergo periodic chart audits to ensure that this process is being utilized as intended.
  • This process applies to local, contracted providers in Jackson and Josephine County. Referrals to non-contracted providers require a prior authorization.
  • Surgeries(including those conducted in the office),procedures, certain diagnostic studies, and some injections/ infusions require prior authorization, as noted in this guideline.
  • Specialist who have seen a PrimaryHealth member twice for a non-covered condition but have not yet completed a diagnostic evaluation for the purposes of establishing a definitive diagnosis may request prior authorization from PrimaryHealth for additional visits for the non-covered diagnosis. For payment beyond 2 visits, a referral must be in place with PrimaryHealth for the date of service. PrimaryHealth will review these requests on a case- by-case basis to determine if the referral is medically necessary to diagnose the condition. Provider must abide by the 30-day retro authorization policy for authorization of services that have already been rendered.

Prior Authorization Exempt Specialties*

  • Cardiology
  • OB/GYN
  • Hematology/Oncology
  • Pulmonology
  • Nephrology
  • Endocrinology
  • Orthopedics
  • Neurology
  • Gastroenterology
  • Urology
  • Rheumatology
  • Surgical Specialists

Durable Medical Equipment

All DME items require prior authorization. PA’s must be submitted to PrimaryHealth or a prescription given to the member. PrimaryHealth is the sole supplier for certain specific DME items. For more information on the PrimaryHealth DME program, please see the chart below or call our office at 541-471-4208.

Item

Supplier: Medicare Dual
Supplier: Medicaid Only

Spacer reservoir

PrimaryHealth

PrimaryHealth

Nebulizer & supplies

Pharmacy/DME Provider

PrimaryHealth

Incontinence Supplies

PrimaryHealth

PrimaryHealth

Toileting/Bath Supplies (bath bench, raised toilet seat, bed pan)

PrimaryHealth

PrimaryHealth

Toileting/Bath Supplies (Commode, reusable bed pan, urinal)
Pharmacy/DME Provider (if Medicare criteria met)

PrimaryHealth

Diabetic Supplies
Pharmacy/DME Provider

PrimaryHealth

Dressing Supplies
Pharmacy/DME Provider
Pharmacy/DME Provider
CPAP
Pharmacy/DME Provider
Pharmacy/DME Provider
Catheter Supplies
Pharmacy/DME Provider
PrimaryHealth
Standard Walkers/ Standard Wheelchairs
Pharmacy/DME Provider
PrimaryHealth
Ensure/Nutrition Drink By mouth (Non- glucose control)
PrimaryHealth
PrimaryHealth
Nutritional Drink (enteral feeding/Pediasure/ glucose control)
Pharmacy/DME Provider
Pharmacy/DME Provider
Auto blood pressure monitor
PrimaryHealth
PrimaryHealth
Syringe with needle for self- injectable medications (ie: Vitamin B, Testosterone)
Pharmacy/DME Provider
PrimaryHealth

Scheduled Medical Facility Admissions

Prior Authorization is required for all scheduled admissions to the following facilities/services:

  • Hospital
  • Home Health (Home Health Evaluation does not require authorization)
  • Skilled Nursing Facilities (In-house providers require prior authorization
    documenting PCP notification)
  • Hospice
  • Infusion Services
  • Inpatient Rehabilitation
  • Residential Mental Health Placements

The exceptions listed below in the “elective surgery” section do not require medical facility authorization.

Unscheduled Medical Facility Admissions

Notification to PrimaryHealth within 24-hours or next business day is required for hospital admission: includes inpatient, ambulatory surgery & observation-to- inpatient status.

Emergency Care

Emergency services do not require prior authorization and will be paid based on prudent layperson standards and Oregon Administrative Rules. Treatment provided in the emergency room for conditions that are found to be non-emergent following a triage assessment will be denied.

Urgent Care

PrimaryHealth members may seek urgent care/walk-in services at Asante Urgent Care and Siskiyou Community Health Center Walk-In Clinic. No PA is required. The member should seek care through the PCP office before seeking urgent care services.

Elective Surgery

Regardless of place of service.

All elective surgery requires prior authorization, with the exception of:

  • Tubal Ligation
  • Cesarean Section**
  • D&C
  • Colposcopy
  • Vasectomy
  • Biopsy (Diagnostic)
  • Cataract Surgery
  • Insertion or removal of an implantable venous access device by a DMAP provider in any
    setting (office, hospital, ASC)with CPT codes 36555-36590
  • Endoscopic Procedures: Esophagus 43180-43233[43211,43212,43213,43214]
  • Endoscopic Procedures: EGD 43235-43259[43233,43266,43270]

**Please Note Cesarean Section by Maternal request requires PA**

Mental Health

No prior authorization or referral is required for outpatient mental health services. Mental health services are provided and coordinated by Options of Southern Oregon (541)476-2373. For inpatient/residential placements, please refer to “medical facility admissions.”

Chemical Dependency

Chemical Dependency services are provided and coordinated by Choices Counseling Center (541) 479-8847.

Outpatient Treatment: No prior authorization or referral is required for chemical dependency screening and outpatient treatment. All medication assisted chemical dependency treatment requires prior authorization. (Example: Methadone Replacement Therapy)

Residential Treatment/ Medical Detox: Prior Authorization is required for residential treatment and medical detox services. These services are authorized based on medical necessity. Contact Choices Counseling Center for authorization at (541) 479-8847, fax (541) 471-2679.

Rehabilitation/ Treatments/ Education Services

The following treatments, rehabilitative therapies, and educational services require prior authorization:

  • Blood Transfusions
  • Diabetic Education
  • Nutrition Education (except for clients approved for bariatric surgery evaluation)
  • Occupational Therapy (No referral is required for OT Evaluation)
  • Physical Therapy (No referral is required for PT Evaluation, two units of OHP funded
    treatment will be covered on the same date as the PT Evaluation)
  • Speech Therapy (No referral is required for ST Evaluation)
  • Pulmonary Rehabilitation
  • Ostomy and Wound Care
  • Radiation
  • Audiology (except for hearing screening for newborn-6 mos)
  • Circumcision performed on child older than 8 weeks and/or outside of PCP office setting.

*Note* Dialysis does NOT require PA

Diagnostic Services and Procedures

  • Allergy Testing
  • Genetic Testing (other than routine prenatal)
  • MRI, MRA
  • PET Scan
  • Diagnostic Laparoscopy
  • Sleep Study
  • CT Colonography or CT Angiography

*Note*Colonoscopy does not require prior authorization, and does not require a facility referral at an Ambulatory Surgery Center

Retroactive Requests

Retroactive requests for prior authorizations/ referrals will be considered up to 30-days following the date of service. Requests that have already been billed will not be considered. If billings have already been submitted, a claims appeal must be requested. Please call (541)471-4208 to get more information about how to appeal a claim.

Medications in the Outpatient/ Office Setting

All office Infusions/Injections EXCEPT approved medication categories for office or outpatient administration require a prior authorization

  • Medication Categories not requiring prior authorization
  • Antiemetics
  • Analgesics
  • Antibiotics
  • Contraceptives
  • Anxiolytics
  • Hydration
  • Routine Immunizations within CDC guidelines and not for employment or travel
  • Antihistamines
  • Epinephrine
  • Anesthetic medication used to carry out minor approved office procedures
  • CancerChemotherapyandfilgrastim(Neupogen)(limitedtocontractedproviders)
  • NOTE: pegfilgrastim (Neulasta) requires a PA

Medication Assisted Chemical Dependency Treatment requires a Prior Authorization

For information on prior authorization requirements for medications obtained at pharmacies, please see the PrimaryHealth Medication Formulary. A copy is on our website or you can call (541) 471-4208

Vision

All routine vision services require prior authorization. In general, routine vision exams/glasses are covered only for the following:

  • For clients age 20 or under on a yearly basis
  • For pregnant women on an every two year basis.
  • If glasses are approved, no prior authorization is required for the use of
    polycarbonate lenses for members age 0-20.
  • Except in extreme circumstances, replacements for lost/stolen glasses are not a
    covered benefit. Broken frames covered under warranty (90 days) must
    coordinate with Sweep.
  • Medical vision referrals require review of records. Please send records to
    expedite requests. Note: Unspecified visual disturbances without a co-morbid
    condition is considered routine.
  • Cataract surgery does not require PA. OHP Rules for visual deficit do still apply.
  • NO PA is required for office visits to for diabetic eye exams, to evaluate cataracts
    and glaucoma, or for office visits &injections for macular degeneration.

Vaccines

Other than the exceptions listed, vaccines ordered within CDC guidelines do not require prior authorization.

  • If vaccines are ordered outside CDC guidelines, PA is required. (Example, Zostavax for age <60).
  • Only Flu Shots may be obtained at pharmacies. All other vaccines are administered either at the PCP Clinic, Public Health Department, or other health facility setting (OB/GYN Clinic, Hospital, etc).

    Exceptions:
  1. Synagis (RSV) – Requires PA. Contact PrimaryHealth Member Services Department for guidelines.
  2. Gardasil (HPV) – PrimaryHealth covers only admin fees of HPV vaccine for females ages 9-18. The vaccine costs are covered by VFC. PrimaryHealth pays both the vaccine and administration costs for ages 18-26. HPV Vaccine is not covered for males.

Dental Services

PrimaryHealth works with Dental Care Organizations to provide dental benefits to our members. Each DCO has different guidelines for services requiring PA. Please contact the DCO directly for PA requests. The DCO for each member is listed on the member card. You may also call PrimaryHealth to find out which DCO a member is assigned to. ***General anesthesia for dental services requires PA through PrimaryHealth***

Advantage Dental Services, LLC

1-866-268-9631
TTY: 711 or 800-735-1232
www.AdvantageDentalServices.com

Hours
Mon – Fri: 8am – 5pm

Capitol Dental Care, Inc.

1-800-525-6800 or (503)585-5205
TTY: 1-800-735-2900
www.capitoldentalcare.com

Hours
Mon – Fri: 7am – 7pm

ODS Community Health, Inc.

1-800-342-0526 or (503)243-2987
TTY: 711
www.odscompanies.com/ohp

Hours
Mon – Fri: 7:30am – 5:30pm

Willamette Dental Group

1-855-433-6825, #3
TTY: 1-800-735-1232
www.willamettedental.com

Hours
Mon – Fri: 8am – 5pm