Prior Authorization Process & Guidelines

Prior Authorization is not a guarantee of payment as claims will be processed based upon eligibility, benefits, diagnosis and any applicable Oregon Administrative Rules.

Entering this information through our portal is strongly encouraged. If you need to sign up for access to the CIM portal please click CIM User login request. If you need assistance using the Provider portal, please call PhTech at 1 503-584-2169

If you need a referral/PA request form, or have questions about requesting authorization, please contact us 541 471-4208 or toll free at 800 471-0304 or visit our website at http://www.primaryhealthfamily.com

All requests should contain:

  • Member first, and last name and middle initial
  • Member DOB
  • Member OHP ID number
  • Type of request: (Auth Type: Durable medical equipment, Home Health, etc)
  • Referral provider NPI/Name
  • Delivering Provider NPI/Name
  • Facility NPI/Name (if applicable)
  • Indicate if this is an inpatient or outpatient procedure (if applicable) Applicable ICD10s
  • Service (i.e. Procedure code, Rev code, HCPC)
  • Contact information of person completing this form (Name, Phone, Fax, email)

Covered Services are those condition/treatment pairs that are funded on the health Evidence Review Commission (HERC) Prioritized list of health services when such treatments are medically/dentally appropriate. For some diagnoses and services guidelines or rules may apply.

Diagnostic services that are necessary and reasonable to diagnose the member’s presenting condition are covered services regardless of the placement of the condition on the Prioritized list of health services.

You will be notified within 5 working days if you request is invalid. You will have 3 working days to provide the needed information before this is denied as an invalid request.

We can process most requests that have all needed information within a few days. If we need to request information or receive requests where the coding doesn’t work this significantly increases processing time. Please provide all documentation needed for a request at the time of the request.

Urgent or expedited review (3 days) can be used if the standard timeframe could seriously jeopardize the life or health of the member or the member’s ability to regain maximum function. If no reason is indicated for urgent review, this will revert to Standard Review. A scheduled appointment usually doesn’t meet the need for an urgent request.

All scheduled out of area services require prior authorization.

Referrals to Specialist should be initiated by the primary care provider (PCP). Specialists may refer to other specialist, but are expected to notify PCP (medical record sharing). PCPs are expected to review and manage outside referrals.

Referrals to Specialist Should be generated from the PCP to improve coordination of Care. Referrals to Specialists from Urgent care or Emergency room may be denied, unless documentation indicates this is medically appropriate.

All treatments require a funded or covered diagnosis on the prioritized list of health services.

Professional Referrals (Specialists)

Referrals to non-contracted providers require a prior authorization.

Specialists’ referrals must be Primary Care Provider (PCP) driven; there is no member self-referral.  Specialists may refer to another 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.

This process applies to contracted providers

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

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

The following guidelines apply to all other specialties:

  • PrimaryHealth will only issue payment for one office visit (99201-99215) for a non-covered diagnosis without a Prior Authorization. This is to allow a diagnostic evaluation of a non- covered condition. If the diagnosis is still not covered after one visit, a PA will be required for subsequent visits or they will be denied. Whenever possible, the PCP should manage the member’s care.
  • If additional visits are needed to complete a diagnostic evaluation for the purposes of establishing a definitive diagnosis a prior authorization is required with chart notes indicating reason for additional visits.
  • 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.
  • 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.
  • For payment beyond the one diagnostic visit, 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

DME items for PrimaryHealth members. Medicare/Medicaid dual members require prior auth for items dispensed by PrimaryHealth. See chart below.

We are authorizing/ dispensing supplies 3 months at a time.

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.

DME items are subject to coding and billing guidelines in the DME rule book. See tables in rule book. “Column II code is included in the allowance for the corresponding Column I code when provided at the same time and must not be billed separately at the time of billing the Column I code.”

Durable Medical Equipment, Prosthetics, Orthotics and Supplies Administrative Rulebook http://www.oregon.gov/oha/HSD/OHP/Policies/122rb091517.pdf
(*indicates no need for PA.)

Item

Supplier: Medicare Dual
Supplier: Medicaid Only

Spacer reservoir

Pharmacy/DME Provider
(E0570)

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

Nebulizer
(OAR 410-122-0204)

Pharmacy/DME Provider (E0570)

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

Nebulizer Supplies*
(No PA req. once nebulizer is approved.)

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

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

Incontinence Supplies
(OAR 410-122-0630)

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

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

Bath Benches
OAR 410-122-0580

PrimaryHealth (E0245)

PrimaryHealth (E0245)

Commode
(OAR 410-122-0600)

Pharmacy/DME Provider
(if Medicare criteria met)

PrimaryHealth (E0163)

Diabetic Supplies
(OAR410-122-0520)

Pharmacy/DME Provider

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

Dressing Supplies
(410-122- 0625 table 122-0625)

Pharmacy/DME Provider

Pharmacy/DME Provider

CPAP
(OAR 410-122-0202)

Pharmacy/DME Provider

Pharmacy/DME Provider

Catheters and related Supplies
(OAR 410-122-0560)

Pharmacy/DME Provider

PrimaryHealth for intermittent catheterization –
Otherwise use Pharmacy or DME Provider

Walkers/Wheelchairs (not specialty)
(410-122-0375)
(OAR 410-122-0320)

Pharmacy/DME Provider

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

OOral or Enteral nutritional supplements
(OAR 410-148-xxxx. http://www.oregon.gov/oha/HSD/OHP/Policies/148rb100115.pdf )

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

External insulin pump (OAR 410-122-0525
Continuous glucose monitoring (guideline 108)

Pharmacy/DME Provider

Pharmacy/DME Provider

* 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)

Compression Stockings: OAR 410-122-0658
Compression stockings will be issued to PrimaryHealth members for the following additional diagnoses:

  • Ulceration due to chronic venous insufficiency;
  • Varicose veins with ulcer or inflammation
  • Phlebitis/ thrombophlebitis;
  • Deep vein thrombosis (DVT) prophylaxis during pregnancy and postpartum or
    immobilization due to surgery, trauma, or debilitation;
  • Funded lymphedema conditions; and
  • Edema following a covered surgery, fracture, burns or other trauma

Two gradient compression stockings/sleeves per affected limb may be provided at dispensing.

PrimaryHealth will also authorize compression stocking for the following Dx:

  • Venous stasis
  • Venous insufficiency (without stasis ulcer(s))
  • DVT prophylaxis for a person with history of DVT

One pair of stockings shall be authorized initially. Additional pairs may be dispensed at a rate of one pair each 6 months if the member is compliant with use of the stockings. Custom stockings or specialty items require additional review.

Breast Pumps: We follow the Oregon Administrative Rules (OAR) 410-122-0250. Request needs to be in the name of the person using the pump (mother of the baby). Generally, needs to be post-partum. Exclusively breast feeding and has a medical need for the breast pump.

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 (7 days at a time with concurrent review. Max 20 days) If
    additional days may be needed APD needs to assess for long term care services.
  • Skilled Nursing Facility In-house providers acting as primary care during member
    stay requires documented PCP consent and prior authorization
  • Hospice – we will no longer be requiring PA for local Hospice requests. However, we may request required documentation in a retrospective review or at time of claims payment.
  • 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, 58605, 58611, 58671, 58670)
  • Cesarean Section (59510, 59514, 59515, 59618, 59620, 59622) (member request for C-section requires PA) (* Maternal request for c-section requires prior auth.)
  • D&C (58120)
  • Vasectomy (55250)
  • 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, 32097, 32098, 47000, 47001, 41100, 41105, 41108, 47100, 56821)
  • Cataract Surgery (66982, 66983, 66984, 66820, 66821, 66825, 66982, 66984)
  • Insertion or removal of an implantable, venous access device by an DMAP provider
    (36555, 36556, 36557, 36558, 36560, 36561, 36563, 36565, 36566, 36568, 36569, 36570, 36571, 36575, 36576, 36578, 36580, 36581, 36582, 36583, 36584, 36585, 36590, 36591, 36592 to 37193)
  • 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) (54160, 54161)
  • Earwax removal; (69210) when performed in the ENT office for related ear conditions (even if it is a non-covered diagnosis)
    or minor treatment for actinic keratosis (17000, 17003, 17004)
  • Dermatology biopsy or minor treatment for actinic keratosis (17000, 17003, 17004) This should be done at PCP office if possible

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

  • Endoscopic Procedures: Esophagus (43180, 43191, 43192, 43193, 43194, 49195, 43496, 43197, 43198, 43200, 43201, 43204, 43205, 43211, 43216, 43217, 43212, 43220, 43213, 43214, 43226, 43227, 43229, 43231, 43232)
  • Endoscopic Procedures: EGD (43235, 43236, 43237, 43239, 43240, 43241, 43242, 43243, 43244, 43245, 43246, 43247, 43248, 43249, 43251, 43253, 43254, 43255, 43259, 43233, 43266, 43270)
  • Explore parathyroid glands (60500, 60505)
  • Colposcopy (57420, 57421, 57452, 57454, 57455, 57456, 57460, 57461, 57500, 57511, 58100, 58110, 58120)
  • Colonoscopy (44388, 44389, 44390, 44391, 44392, 44394, 44401, 44402, 44403, 44404, 44405, 44406, 44407, 44408, 45378, 45379, 45380, 45381, 45382 45384, 45385, 45386, 45388, 45389, 45390, , 45393)
  • MRI of extremities (73718, 73719, 73720, 73721, 73722, 73723, 73220, 73221)

The following diagnostic procedures require prior authorization:

  • Allergy Testing (95004, 95018, 95024, 95027,95028, 95044, 95052, 95056, 95060, 95065,
    95070, 95071)
  • Genetic Testing (other than approved prenatal. See guideline line note D17 for approved
    prenatal testing. http://www.oregon.gov/oha/HPA/CSI-HERC/Pages/Searchable-List.aspx?7687=%7B%22filter%22%3A%22d17%22%7D )(including but not limited to: 81170, 81200, 81201, 81202,81202, 81203, 81205,81206,81207, 81208, 81209, 81210, 81211, 81212, 81213, 81214, 81215, 81216, 81217, 81218, 81220, 81221, 81222, 81223, 81224, 81228, 81229, 81235, 81240, 81241, 81242, 81243, 81244, 81245, 81245, 81246, 81250, 81251, 81252, 81253, 81254, 81255, 81256, 81257, 81260, 81261, 81262, 81263, 81264, 81265, 81266, 81267, 81267, 81268, 81270, 81272, 81275, 81276, 81288, 81292, 812993, 81294, 81295, 81296, 81297, 81298, 81299, 81300, 81301, 81302, 81303, 81304, 81310, 81314, 81315, 81316, 81317, 81318, 81319, 81321, 81322, 81323, 81324, 81325, 81326, 81330, 81331, 81332, 81340, 81341, 81342, 87900, 87901, 87902, 87903, 87904, 87906, 87999)
  • MRI, MRA 77058, 77059, 75557, 75559, 75561, 75563, 75565, 72195, 72196, 72197,70551, 70552, 70553, 71550, 71551, 71552, 72141, 72142, 72143, 72144, 72146, 72147, 72148, 72149, 72158, 70544, 72146, 72147, 72148, 70549, 72159, 72198, 71555, 73725, 74185, 73225
  • PET Scan (78811, 78812, 78813, 78814, 78815, 78816, 78999)
  • Diagnostic Laparoscopy (49320, 49321, 49322, 49323, 49324, 49325, 49326, 49327,
    49329, 50542, 50543, 50544, 50545, 50546, 44186, 44187,44238, 38570, 38571, 38572, 38589, 44180, , 43651, 43652, 43653, 43659, 43279, 43280, 43281, 43282, 43283, 43284, 43285, 43289)
  • Sleep Study (95783,)
  • 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. Two units of OHP funded treatment on the same date as the evaluation will be covered. Ongoing therapy after the first visit requires PA. *Maximum 2 modalities per day and up to 60 minutes per day (OARs: 410- 131-0080(3)(c) and 410-131-0120(6)(b)(B)

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.

*Maximum 2 modalities per day and up to 60 minutes per day (OARs: 410- 131-0080(3)(c) and 410-131-0120(6)(b)(B)

Pulmonary Rehabilitation Cardiac Rehab

No referral is required for Pulmonary Rehabilitation

No referral is required for Cardia Rehabilitation

Treatments and Education

Treatments requiring PA include:

  • Hyperbaric oxygen therapy
  • Treatments that are not listed on the Prioritized list of Health services, require prior authorization.

No PA required for Dialysis treatments done locally (OAR 410-125-0201)

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.
  • Routine vision (92014, 92340) Is a covered service for children up to age 20 and pregnant women.
  • Replacements for lost/stolen glasses require Prior authorization and documentation justifying medical need. Broken frames covered under warranty (90 days) must coordinate with Sweep Optical.
  • 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. Medical eye exams do not include visual exam or glasses
  • Other Medical Eye Exams require 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. Children may also get flu vaccine at pharmacies if they accept OHP rates.
  • Vaccinations for work or travel are not covered by OHP
  • Adults may receive vaccines at their PCP office, Public Health or anywhere that accepts OHP rates, including pharmacies (Walgreens is not a OHP contracted provider)

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

1-855-4DENTAL, #3
(1-855-433-6825, #3)
TTY: 1-800-735-1232
www.willamettedental.com

Hours
Mon – Fri: 8am – 5pm

Wellness Benefit

Services with non-contracted providers require prior authorization.

  • Acupuncture
  • Chiropractor

Additional visits 1-4 Require covered diagnoses and PA

Visits 5+ require PA, validated assessment, expected outcome

Request for visits beyond initial request will also require PA, Validated assessment tool, progress and realistic expected outcome/goal

Contracted providers only: Members may self-refer for evaluation visit only – no Prior authorization needed.