Medical Policy, Reimbursement Policy, Pharmacy Policy, & Provider Information

Providence Health Plan, Providence Health Assurance, and Providence Health Plan Partners

Select a topic below to access policies or more information:

Prior-authorization, Non-covered, and DME and Supplies Lists and Fax Forms
The following lists are intended to provide guidance regarding coverage of healthcare services and are not all inclusive. Additional exclusions may apply based on benefit and contract terms.
- Prior-authorization List
- How to use the prior-authorization list
- Non-covered and Limited Services List
- How to use the non-covered list
- Durable Medical Equipment List
- How to use the DME List

Please see the “Pharmacy Policies” section below for information regarding drugs that require authorization.

Vendor Sites for Prior Authorization Requests and Delegated Criteria
Beginning July 1, 2024, Carelon Medical Benefits Management may request additional clinical information for radiology pre-authorization requests. If requested, providers will need to submit documentation from the patient’s medical record to demonstrate that services are clinically appropriate.

For general questions or questions regarding criteria, please call 503-574-7500. InterQual, Level of Care Utilization (LOCUS), Child and Adolescent Level of Care Utilization System (CALOCUS), Child and Adolescent Service Intensity Instrument (CASII), American Society of Addiction Medicine (ASAM) criteria, can be disclosed to members and practitioners, upon request.

General Prior-authorization Requirements
Effective March 1, 2023, American Imaging Management/AIM Specialty Health and Beacon Health Options changed their names to Carelon. AIM transitioned to Carelon Medical Benefits Management, and Beacon Health Options transitioned to Carelon Behavioral Health. If you have questions about this change, please call 800-878-4445 or click here to learn more.

Prior-authorization Medical Fax Form
- PA Fax Form
- Transplant PA Fax Form
***Effective January 1, 2024, Yamhill Community Care Organization (YCCO) will be internally assuming all aspects of care management, utilization management, and grievance system activities. These services are currently contracted to PH Tech and Providence Plan Partners.

For any questions, please contact YCCO Customer service at 503-488-2800 or toll free at 855-722-8205.***

Prior-authorization Pharmacy Fax Form
- Drug Prior Authorization Request Form
Prior-authorization Behavioral Health Fax Forms

For new members, authorizations will be held until member eligibility can be verified.
Ambulatory Surgery Center Access - Physician Attestation
- Ambulatory Surgery Center Access - Physician Attestation Form
Clinical Edit Inquiry Form
- Clinical Edit Inquiry Form - Fax Version
Clinical Edit Inquiry Form instructions

**Before sending in a Clinical Edit Inquiry form, review all applicable Payment Policies and Medical Director Edits.

This form can be completed by participating providers.
1. Completely fill out the ‘Sender information’ box at the top of the form.
2. Include the following as instructed on the form:
  - Chart notes for date of service that support all procedures.
  - Letter of explanation for the inquiry
  - Check the box to identify which edit is being appealed. If the edit you are appealing is not listed, enter the edit code in the blank box.
  - Pay close attention to which fax number is listed above the edit code that applies to ensure that the form is sent to the correct area.
Non- participating providers that are disputing a clinical edit would need to send information to the claim support team fax # 503-574-8146

eviCore High Tech Imaging Prior Authorization Code List
Coding Policies and Alerts
Billing, Payment, and Coding Policy Alerts
Billing, Payment, and Coding Policies
Medical, Reimbursement, and Pharmacy Policy Alerts
Medical, Reimbursement, and Pharmacy Policy Alerts
Company Medical Policies
**SPECIAL NOTICE**

Medical Policy Committee: External Provider Review

PHP/PHA Medical Policy Committee is looking to expand our group of external providers who serve as clinical subject matter experts (SMEs) through the policy development and annual review processes. We are seeking provider participation across various clinical specialties who will review and provide feedback on our medical policies. The medical policy specialties include (but are not limited to) pain management, behavioral health, endocrinology, genetics, orthopedics, neurology, urology, cardiology, oncology and general surgery. A complete list of medical policies is below.

COMPANY MEDICAL POLICIES

Specialty/Category

Allergy/Immunology
- Allergy Testing
Audiology
Bariatric
- Bariatric Surgery
Behavioral Health/ Psychiatrics
Cardiology
Complementary and Alternative Medicine
- Complementary and Alternative Medicine (CAM) Treatments
Definitions and Manuals
- Definition of Investigational
- Definition of Medical Necessity
Dental/Oral Surgery
Durable Medical Equipment
Emergency Services
- Ambulance Transport
Endocrinology
- Advanced Diabetes Management Technology
EENT
- Automated Evacuation of Meibomian Gland
- Balloon Dilation of the Sinuses or Eustachian Tubes
Gastroenterology
General Surgery
Genetics
Infectious Disease
- Covid 19 Testing
- Respiratory Viral Panels
Investigational Technologies
- New and Emerging Technologies and Other Non-Covered Services
Lab Tests
Nephrology
- Apheresis (Therapeutic Pheresis)
Neurology/Neurosurgery
Obstetrics and Gynecology
Oncology/Hematology
Opthalmology
- Corneal Collagen Cross-Linking
Orthopedics
Pain Management
Physical Medicine
- Chiropractic Care
Plastic Surgery
Podiatry
- Foot Care Guidelines
Pulmonology
- Bronchial Thermoplasty
Research
- Clinical Trials
Sleep Physicians
Solid Organ Transplants
- Organ Transplantation
Spine Surgery (Neurosurgery/Orthopedic Surgery)
Urology
- Benign Prostatic Hyperplasia Treatments
- Urinary Dysfunction Treatments
Vascular Surgery
- Varicose Veins
Wound Care
Alphabetical
Medicare Medical Policies
**SPECIAL NOTICE**

Medical Policy Committee: External Provider Review - Medicare Medical Policies

PHP/PHA Medical Policy Committee is looking to expand our group of external providers, in particular those with expertise in the clinical care of elderly or disabled patients, to serve as clinical subject matter experts (SMEs) through the policy development and annual review processes. We encourage provider participation across various clinical specialties who will review and provide feedback on our Medicare Advantage medical policies. Specialties include (but are not limited to) pain management, behavioral health, endocrinology, genetics, orthopedics, neurology, urology, cardiology, oncology and general surgery. A complete list of Medicare Advantage medical policies is below.

MEDICARE MEDICAL POLICIES

Specialty/Category

Allergy/Immunology
- Allergy Testing
Audiology
- Bone-Anchored Hearing Aids
- Vestibular Function Testing
Bariatric
- Bariatric Surgery
Behavioral Health/ Psychiatrics
Cardiology
Complementary and Alternative Medicine
- Complementary and Alternative Medicine (CAM) Treatments
Definitions and Manuals
- Definition of Medically Reasonable and Necessary (Medical Necessity)
- PHA Medicare Medical Policy Development and Application
Dental/Oral Surgery
Durable Medical Equipment
Emergency Services
- Ambulance Transport
Endocrinology
- Advanced Diabetes Management Technology
EENT
- Automated Evacuation of the Meibomian Gland
- Balloon Dilation of the Sinuses or Eustachian Tubes
Gastroenterology
General Surgery
Genetics
Infectious Disease
- Covid 19 Testing
- Respiratory Viral Panels
New and Emerging Technologies
- New and Emerging Technologies and Other Non-Covered Services
Lab Tests
Nephrology
- Apheresis (Therapeutic Pheresis)
Neurology/Neurosurgery
Obstetrics and Gynecology
- Pelvic Congestion Syndrome Treatment
- Premature Rupture of Membranes (PROM) Testing
Oncology/Hematology
Orthopedics
Pain Management
Plastic Surgery
Podiatry
- Foot Care Guidelines
Pulmonology
- Bronchial Thermoplasty
Research
- Clinical Trials, Studies and Registries
Sleep Physicians
Solid Organ Transplants
- Organ Transplantation
Spine Surgery (Neurosurgery/Orthopedic Surgery)
Urology
- Urinary Dysfunction Treatments
Vascular Surgery
- Varicose Veins
Wound Care
Alphabetical
Provider Satisfaction Survey

Provider Satisfaction Survey

Providence cares about the experience of our providers. Please click the link below to provide feedback on your experience as a provider working with Providence Health Plan. We look forward to hearing from you.

Thank you!

Start survey
Credentialing Services

Providence Credentialing Services

Credentialing Services Policies and Procedures
Reimbursement Policies

REIMBURSEMENT POLICIES

Medical Services

+ Ambulatory Surgery Center (ASC) Payment Structure

+ Associated Services and Related Claims

+ Birthing Center Services

+ Emergency Department Evaluation & Management Services

+ Facility Routine Supplies and Services

+ High Dollar Drug Reviews

+ Incident to Services

+ Inpatient Hospital Admission and Length of Stay Reviews

+ Inpatient Readmissions

+ Observation Status

+ Outpatient Hospital Services Rendered Prior to an Inpatient Admission

+ Plan-Directed Care

+ Preventable Adverse Events

+ Robotic Surgical Systems

+ Transfers Between Hospitals

+ Scope of License, Scope of Practice, and Provider Qualification

+ Urine Drug Testing

For questions related to medical reimbursement policies please contact our PHP Reimbursement Policy Team at PHPReimbursementPolicy@providence.org

Pharmacy Reimbursement Policies

+ Medical Drug Reimbursement: Outpatient and Inpatient

For questions related to pharmacy reimbursement policies please contact our PHP Pharmacy Policy Team at PHPPharmacySpecialtyTeam@providence.org
Pharmacy Policies
Medical Benefit Drug Search Tool - Click[HERE] -for all lines of business

NDC Required for Medical Claims Reimbursement effective 11/1/2023

Providence Health Plan (PHP) requires providers to submit National Drug Codes (NDCs) on provider drug claims and hospital outpatient facility claims that are reported for reimbursement.
- Pharmacy Reimbursement Policy Medical Drug Reimbursement: Outpatient and Inpatient revised and approved by ORPTC in June 2024.
National Drug Code (NDC) numbers are the industry standard identifier for drugs and provide full transparency to the medication administered. The NDC number identifies the manufacturer, drug name, dosage, strength, package size and quantity.

For purposes of this policy, a valid NDC number, NDC unit of measure and NDC units dispensed for the drug administered will be required for reimbursement of professional drug claims on a1500 Health Insurance Claim Form (a/k/a CMS-1500), the 837-professional transaction, a UB-04 Claim Form or the 837i facility transaction.

More Members Eligible for Copay Maximizer Program

On January 1st, 2024, Providence Health Plan is expanding the opportunity of the Smart RxAssist Copay Maximizer program to all fully insured Oregon non-HSA members. This program optimizes the use of manufacturer copay assistance on specialty medications.
- Captures the maximum benefit of manufacturer copay cards
- Reduces member copay responsibility to $0
- Up to 10-15% reduction in plan sponsor’s specialty drug cost
As fully insured groups renew their PHP plans, the group will become eligible for the Smart Rx Assist program. For groups renewing 1/1/24, members who are on specialty medications that quality for manufacturer copay coupons will be mailed out letters on December 10th, 2024.

Medical Benefit Drug Prior Authorization

Below you will find lists of drugs with their associated medical necessity criteria for coverage. Please select the list of drugs based on the medical plan of your patient (e.g., Commercial, Medicaid, Medicare). You may use the drug prior authorization request form below to request authorization for a drug.

Please note that the presence of drugs on these lists does not indicate that the particular drug will be covered under your patient’s medical or prescription drug benefit. You can verify drug coverage by accessing your patient’s formulary on the Providence Health Plan pharmacy resources page.

Formulary exceptions: There may be times that you prescribe a drug that is not on your patient’s formulary. You may want to consider prescribing a formulary alternative for your patient; however, you may also request a formulary exception for the drug you wish to prescribe by using the drug prior authorization form below.

Drug Prior Authorization Request Form
- Drug Prior Authorization Request Form
- Commercial Maximum Allowable Opioid Dose Request Form
Medical Benefit Drug Search Tool - Click[HERE] -for all lines of business

Medicare Part B
Biosimilar Preferred Product Program

Providence Health Plan (PHP) implemented a biosimilar preferred product formulary strategy for medical benefit drugs effective July 1, 2021. Use the above Medical Benefit Drug Search Tool to easily find preferred Biosimilars.

Infusion Therapy Site of Care (SOC)

Providence Health Plan (PHP) requires site of care prior authorization for the medications listed below when given in an unapproved hospital setting. A separate prior authorization may be required for the drug. Refer to the Commercial Infusion Therapy SOC Policy link below.
- Infusion Therapy SOC Policy - Effective 1/1/2024
- Infusion Therapy SOC Policy - Effective 10/1/2024
- Site of Care Prior Authorization Request Form
Infusion Therapy Site of Care Facility Contracting:
- Approved Site of Care Facility List
- 2024 Outpatient Infusion Services SOC Contract list of Drug Codes - Effective 2/1/2024
- 2025 Outpatient Infusion Services SOC Contract list of Drug Codes - Effective 1/1/2025
Specialty Drugs Shipped from Pharmacies to Providers and Facilities ("White Bagging")
- Specialty Drugs Shipped from Pharmacies to Providers and Facilities - Operational Policy
Self-Administered Drug Exclusion Policy

Self-Administered Drugs definition - Medications which have been identified as being medically appropriate for administration by a patient or caregiver, safely and effectively, without medical supervision.

Certain medications considered to be usually self-administered by the patient or their caregiver are excluded from coverage under the medical benefit without prior-authorization.
- Self-Administered Drug Exclusion Policy - Commercial and Medicaid
- Medicare Part B – Refer to Noridian Healthcare Solutions’ Self-Administered Drugs (SADs) Policy: https://med.noridianmedicare.com/web/jfb/policies/sads
- Self-Administered Drug Exclusion Drug List - Applies to All Lines of Business
Opioid Resources and Guidelines
- PHP has created a list of links designed to empower providers to make evidence based decisions when starting opioid therapy as well provide support when taper is indicated.
- Opioid Resources & Guidelines
Outpatient Rehabilitation
NEW 6.1.2024

Special Announcement: We are pleased to announce that Providence Health Plan, being true to ourselves of “Know me, Care for me, Ease my way”, has made the decision to ease the way for our members aged 18 and younger, by removing select pediatric diagnosis codes from requiring prior authorization review through eviCore for outpatient rehabilitation.

Please see Excluded Pediatric Diagnosis Codes for a complete list

eviCore ASO Expansion

Please be aware that Self-Funded Administrative Only (ASO) group plans require eviCore medical necessity reviews for outpatient rehabilitation. Providers will need to request medical necessity review through eviCore healthcare. Please see below for additional details

Please note that Providence will continue to require a request to eviCore on all Commercial, Fully Insured, and Individual members.

For additional information, including eviCore’s clinical guidelines and a complete list of services requiring medical necessity review, please visit:

https://www.evicore.com/resources/healthplan/providence-health-plan or call the eviCore Client Provider Operations department at (800) 646-0418 (Option #4).

Effective 1/1/2024:
- PEBB
  
  The following ASO plans do not require eviCore:
- Intel
- Marathon Coach
eviCore Web Portal Training Sessions
- eviCore Healthcare Web Portal Training Sessions
Outpatient Rehabilitation Resources
- PHP Outpatient Rehabilitation Information
- PHP Outpatient Rehabilitation CPT Code List
Health Related Social Needs (HRSN)
Health Related Social Needs (HRSN)

3/1/2024 Oregon Health Authority (OHA) implemented a new benefit, Health Related Social Needs (HRSN). This benefit allows certain eligible members that meet certain criteria to receive Climate-Related Supports. PHA’s process requires a member, member representative, provider, or Community Based Organization, to request this support utilizing the HRSN Benefit Request form below.
Climate-Related Supports are climate-related devices and services provided to an eligible member with an HRSN authorization to utilize in their own home or non-institutional, non-congregate primary residence, and for whom which equipment and support are Clinically Appropriate as a component of health services treatment or prevention.
Clinically Appropriate Climate-Related Devices:
Air Conditioners for individuals at health risk due to significant heat,

Heaters for individuals at increased health risk due to significant cold,

Air filtration devices and, as needed, replacement air filters for individuals at health risk due to compromised air quality,

Mini refrigeration units as needed for individuals for medication storage, and

Portable power supplies (PPSs) for individuals who need access to electricity-dependent equipment (e.g., ventilators, dialysis machines, intravenous equipment, chair lifts, mobility devices, communication devices, etc.) or are at risk of public safety power shutoffs (PSPS) that may compromise their ability to use medically necessary devices.
To receive a Climate-Related Device, members must attest to their ability to safely use the devices to reduce the risk of injury or harm. The safe use of devices requires that a member reside in a non-institutional, non-congregate housing or “recreational vehicle”, that has a reliable source of electricity for operating a device, and that the member or their representative can safely and legally install the device in their place of residence.
In the event the above conditions cannot be met, the HRSN Eligible Member may not be authorized for receipt of the Climate-Related device.
Eligibility for Climate-Related Supports for a PHA HSO Member:
To be eligible for Climate-Related Supports an individual must meet all of the following requirements:
Be enrolled in OHP through Health Share of Oregon-Providence

Be in at least one HRSN Covered Population

Meet at least one of the HRSN Climate Device Clinical Risk Factors

Meet criteria for HRSN Climate Device Social Risk Factor, which includes meeting safe use requirements for the device(s) and not already receiving the same or substantially similar services from a local, state, or federally funded program.
HRSN Covered Populations:
Member must be in one of the following HRSN Covered Populations to be eligible:
Adults and Youth Discharged from an IMD

Adults and Youths Released from Incarceration
Individuals Involved with Child Welfare

Individuals Transitioning to Dual Status

Individuals who are Homeless or At Risk of Homelessness

If you are a member, member representative, provider of a member, or Community Based Organization and would like to submit a request for the HRSN benefit, please use the form provided below and submit the form to Providence via email at: HRSNBenefit@providence.org
HRSN Benefit Request Form
For questions, please email us at: HRSNBenefit@Providence.org
No Surprises Act

Reimbursement to providers and facilities for services subject to the No Surprises Act are paid according to the qualifying payment amount (QPA) as defined by the No Surprises Act. The methodology for calculating the QPA was determined by the Plan to be consistent with the requirements of the No Surprises Act. If the out-of-network provider or facility wishes to initiate a 30 business day negotiation period, they may contact ClearHealth via https://clearhs.com, claimsinquiry@clearhs.com, or by calling (866) 722-3773. Independent Dispute Resolution may be initiated within 4 days after the end of the 30 day negotiation period.
Contact Us

The PHP Medical Policy Team only deals with evidence-based reviews around published medical policies. All inquiries concerning PHP medical policies or new medical devices and technologies may be sent by filling out our online form

Do not submit the Medical Policy Inquiry Feedback form for questions regarding pricing, benefits, claims, EOB statements, or contract issues. Medical policy staff cannot answer or forward these issues. Please contact Customer Service or Provider Relations for assistance with the above.

If you are a member please do not use this form. Please call customer service.

Medical Policy Inquiry Form

Provider Relations can be contacted here: https://healthplans.providence.org/providers/provider-support/provider-relations-representatives/

Customer Service can be reached at: 503-574-7500 or 800-878-4445 (TTY: 711); or at https://healthplans.providence.org/about-us/contact-us/

For questions related to pharmaceuticals please contact our PHP Pharmacy Policy Team at PHPRX@providence.org

For questions related to reimbursement policies please contact our PHP Reimbursement Policy Team at PHPReimbursementPolicy@providence.org

Need help?

Medical Policy, Reimbursement Policy, Pharmacy Policy, & Provider Information

Select a topic below to access policies or more information:

Prior-authorization, Non-covered, and DME and Supplies Lists and Fax Forms

Vendor Sites for Prior Authorization Requests and Delegated Criteria

General Prior-authorization Requirements

Prior-authorization Medical Fax Form

Prior-authorization Pharmacy Fax Form

Prior-authorization Behavioral Health Fax Forms

Ambulatory Surgery Center Access - Physician Attestation

Clinical Edit Inquiry Form

eviCore High Tech Imaging Prior Authorization Code List

Coding Policies and Alerts

Billing, Payment, and Coding Policy Alerts

Billing, Payment, and Coding Policies

Medical, Reimbursement, and Pharmacy Policy Alerts

Medical, Reimbursement, and Pharmacy Policy Alerts

Company Medical Policies

COMPANY MEDICAL POLICIES

Specialty/Category

Alphabetical

Medicare Medical Policies

MEDICARE MEDICAL POLICIES

Specialty/Category

Alphabetical

Provider Satisfaction Survey

Provider Satisfaction Survey

Credentialing Services

Reimbursement Policies

Pharmacy Policies

Medical Benefit Drug Search Tool - Click[HERE] -for all lines of business

NDC Required for Medical Claims Reimbursement effective 11/1/2023

More Members Eligible for Copay Maximizer Program

Medical Benefit Drug Prior Authorization

Medical Benefit Drug Search Tool - Click[HERE] -for all lines of business

Biosimilar Preferred Product Program

Infusion Therapy Site of Care (SOC)

Specialty Drugs Shipped from Pharmacies to Providers and Facilities ("White Bagging")

Self-Administered Drug Exclusion Policy

Opioid Resources and Guidelines

Outpatient Rehabilitation

Health Related Social Needs (HRSN)

Health Related Social Needs (HRSN)

No Surprises Act

Contact Us

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