Prior Authorization Process & Guidelines

This document is intended as a guide for PrimaryHealth providers. Please call the PHJC office if you have any questions.

There are two ways to request a referral or prior authorization 1), if you have access to our online provider portal please submit your requests through the portal. 2) You may complete the PHJC 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 or Toll Free (800)471-0304. You may also download it here: Referral Form.

Referrals and authorizations are not valid until eligibility, benefits and diagnosis have been verified and referral number is assigned by PrimaryHealth. Additional guidelines may apply. PrimaryHealth never covers codes that are excluded by OHA. Upon request, PrimaryHealth will provide you with information used in making a determination. You may also talk to our staff regarding the decision, or request an appeal or reconsideration of our decision.

Please note OHP guidelines allow up to 14 days to approve or deny a request. You will be notified of our decision. Authorization status can be verified by accessing the on line portal. Please allow 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 indicate the reason for urgency. A scheduled appointment is not necessarily urgent. Retroactive Requests for prior authorization and referrals will be considered up to 30-days following the date of service.

For all dual eligible members (members who have traditional Medicare or a Medicare Advantage Plan as primary) prior authorization will not be required by PrimaryHealth. Please see special rules regarding durable medical equipment.

Prior Authorization 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)

This process applies to contracted providers. Referrals to non-contracted providers require a prior authorization.

Prior authorization/Referral is required for specialty providers in the following categories:

  • Allergy
  • Pain specialist
  • Podiatry
  • Ophthalmology-Please refer to vision section

Specialists’ referrals must be Primary Care Provider (PCP) driven; there is no member self-referral. Though specialists may refer to other specialist without PCP approval. PCPs should be notified of all specialist referrals (medical record sharing). Providers (PCPs) are expected to review and manage outside referrals.

The following guidelines apply to all other specialties:

  • PrimaryHealth will only issue payment for two office visits (99201-99215) 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.
  • Providers/PCPs may undergo periodic chart audits to ensure that this process is being utilized as intended.
  • 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 a referral 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. Chiropractors and Acupuncturists will be addressed under Wellness Benefit.
  • PCPs should be notified of all specialist to specialist referrals (through medical record sharing).
  • Providers/PCPs may undergo periodic chart audits to ensure that this process is being utilized as intended.
  • 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 a referral 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.
  • Chiropractors and Acupuncturists will be addressed under Wellness Benefit.

Durable Medical Equipment

All DME items require prior authorization (*see exception below).  PAs 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 (A4627)

PrimaryHealth (A4627)

Nebulizer

Pharmacy/DME Provider (E0570)

PrimaryHealth (E0570)
(*Exception: high volume nebulizer from DME or pharmacy)

Nebulizer Supplies*
(No PA req.)

Pharmacy/DME Provider (A7003, A7015, A7005, A7013)

Pharmacy/DME Provider
(A7003, A7015, A7005, A7013)

Incontinence Supplies

PrimaryHealth  (T4521-T4535, T4537, T4541, T4543-T4544, A4335, A4927)

PrimaryHealth  (T4521-T4535, T4537, T4541, T4543-T4544, A4335, A4927)

Bath Benches

PrimaryHealth (E0245)

PrimaryHealth (E0245)

Commode

Pharmacy/DME Provider
(if Medicare criteria met)

PrimaryHealth (E0163)

Diabetic Supplies
Pharmacy/DME Provider

PrimaryHealth (E0607, E2100, A4258, A4235, A4253, A4259, A4245, S8490, A4215)

Dressing Supplies
Pharmacy/DME Provider
Pharmacy/DME Provider
CPAP
Pharmacy/DME Provider
Pharmacy/DME Provider

Catheters and related Supplies

Pharmacy/DME Provider

PrimaryHealth for intermittent catheterization –
Otherwise use Pharmacy or DME Provider

Walkers/Wheelchairs (not specialty)

Pharmacy/DME Provider

PrimaryHealth [E0135, E0143, E0149, K0004 (for K0001), K0006, K0007]

Oral or Enteral nutritional supplements

Pharmacy/DME Provider

Pharmacy/DME Provider

Auto blood pressure monitor

Pharmacy/DME Provider

Pharmacy/DME Provider

Syringe with needle for self-injectable medications (ie: Vitamin B, Testosterone)

Pharmacy/DME Provider

Pharmacy/DME Provider

*Exception: Contracted; Physical Therapists, Orthopedists, Podiatrists and Primary Care Providers treating PrimaryHealth members, will be permitted to place a boot, brace, or splint costing up to $250 without obtaining prior authorization provided member has a covered diagnosis and item is dispensed in accordance with OHP DME rules.  (No excluded codes)

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
  • Skilled Nursing Facility In-house providers acting as primary care during member stay requires documented PCP consent and  prior authorization
  • Hospice
  • Infusion Services (except blood and blood products- for contracted providers)
  • 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

Local Area (Jackson and Josephine County)/Contracted Facilities: Notification to PrimaryHealth within 24-hours or next business day is required for hospital admission: includes inpatient, ambulatory surgery & observation-to-inpatient status. No notification is required for Observation status.

Out of Area/Non-Contracted Facilities: Notification is required within 24-hours or the next business day for ALL admissions including observation. 

Emergency Care

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

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

Post-Stabilization Services

Post-Stabilization Services:  Post-stabilization services are covered services to maintain a stabilized condition until the PCP is available.  Post-stabilization care is different than follow-up care.  Post-Stabilization services are not limited to the Emergency Room and may be delivered in a clinic setting.  Documentation for claims payment must show a clear and time-sensitive link between the initial emergency and the post-stabilization service that was delivered.

Elective Surgery and Diagnostics
(regardless of place of service)

Most elective surgeries require prior authorization.  However, the exceptions listed below DO NOT require PA:

  • Tubal Ligation ( 58600-58611, 58671)
  • Cesarean Section (59510-59525, 59618-59622)
  • D&C  (58120)
  • Vasectomy (55250-55450)
  • Biopsy (Diagnostic) (30100, 64795, 37200, 42800, 42804, 42806, 40490, 53200, 65410, 93505, 68100, 31576, 31510, 31535, 31536, 43605, 54100, 54105, 20200, 20205-20206, 52007, 52204, 52224, 52250, 42100, 45800, 54865, 32096-32098, 47000-47001, 41100, 41105, 41108, 47100, 56821)
  • Cataract Surgery (66982-4,  66820, 66821, 66825,, 66982, 66984)
  • Insertion or removal of an implantable venous access device by an DMAP provider (36555-36590)
  • Circumcision performed on an infant in PCP office under 8 weeks of age. (NOTE:  Circumcision performed on child older than 8 weeks and/or outside of PCP office setting requires PA)
  • Earwax removal; (69210) when performed in the ENT office for related ear conditions (even if it is a non-covered diagnosis)
  • Dermatology biopsy or minor treatment for actinic keratosis (17000)

Many diagnostic procedures, even some that require anesthesia, do not require prior authorization, including:

  • Endoscopic Procedures: Esophagus  (43180-43232, 43211, 43212, 43213, 43214)
  • Endoscopic Procedures: EGD (43235-43259, 43233, 43266, 43270)
  • Explore parathyroid glands (60500, 60505)
  • Colposcopy (57420, 57421, 57452, 57454, 57455, 57456, 57460, 57461, 57500,57511, 58100-58120)
  • Colonoscopy (44388-44394, 44397, 44401-44408, 45355, 45378-45387, 45388-45390, 45391, 45392, 45393, 45398)

The following diagnostic procedures require prior authorization:

  • Allergy Testing (95004-95071)
  • Genetic Testing (other than prenatal)(including but not limited to: 81170-81355, 87900-87999)
  • MRI, MRA   77058-77059,  , 75557-75565, 72195-72197,70551-70553, 71550-71552, 72141-72158, 70544-70549, 72159, 72198, 71555, 73725, 74185, 73225
  • PET Scan (78811-78999, 78600-78650)
  • Diagnostic Laparoscopy (49320-49329, 50541-50549, 44186-44238, 38570-38589, 44180, 43647-43659, 43279-43289)
  • Sleep Study (95783-95803)
  • CT Colonography or CT Angiography (70496-70498, 71275, 74174-74175, 72191, 73206, 73706)
  • Cortrosyn Stimulation Test (80400)

Mental Health

Mental health services are provided and coordinated by Options of Southern Oregon

No prior authorization or referral is required for outpatient mental health services within the Options network.

For inpatient placements, please refer to “medical facility admissions.”

For residential placements please contact Options directly. http://www.optionsonline.org or phone: (541) 476-2373.

Substance Used Disorder

Substance use disorder 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 at Choices.  All medication assisted chemical dependency treatment requires prior authorization.  (Example: Medication Assisted Treatment)

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.

Physical and Occupational Therapy

No prior authorization is required for PT/OT Evaluation. Ongoing therapy after the first visit requires PA. Two units of OHP funded treatment on the same date as the evaluation will be covered.

Speech Therapy

No prior authorization is required for Speech Evaluation. Ongoing therapy after the first visit requires PA. Two units of OHP funded treatment on the same date as the evaluation will be covered.

Pulmonary Rehabilitation

No referral is required for Pulmonary Rehabilitation

Treatments and Education

Treatments requiring PA include:

  • Hyperbaric oxygen therapy
  • Treatments that are not listed on the Health Services Commission (HSC) are not included and require prior authorization.

Educational services for covered conditions (in accordance with OHP Guidelines) do not require PA. Requests can be sent through the PA process for education for non-covered conditions.

Retroactive Requests

Retroactive requests for prior authorizations/referrals will be considered up to 30-days following the date of service.

Vision

All routine vision services require prior authorization.

  • If glasses are approved, no prior authorization is required for the use of polycarbonate lenses for members’ age 0-20 years.
  • 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 Optical.
  • Routine vision ( 92014, 92340) Children up to age 20 and pregnant women.
  • No PA required for office visits for diabetic eye exams, to evaluate cataracts and glaucoma, or for office visits and injections for macular degeneration (Except aflibercept (Eylea J0178)- Requires PA).

Vaccines

  • All routine childhood, adolescent and adult vaccines recommended within CDC guidelines are covered and do not require prior authorization.
  • If vaccines are ordered outside CDC guidelines, PA is required (Example, Zostavax for age <60).
  • All childhood vaccines may be administered at any setting that participates in Vaccines For Children (VFC) program.

Dental Services

PrimaryHealth works with the following organizations to provide dental benefits to our members.  Please contact them directly for PA requests. The organization that provides dental care for each member is listed on the member card. You may also call PrimaryHealth to find out which organization 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
Hours: 8am-5pm, Mon-Fri

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

Wellness Benefit

All services require prior authorization at this time.
Services include:

  • Acupuncture
  • Chiropractor