Preauthorization
The following are lists of services that require preauthorization for many plans. To see if a member's plan is subject to these lists, please check the member's ID card, refer to member benefits using InTouch, or call our Customer Service Department. If you have questions about preauthorization other than eligibilty, please call our Health Services Department at (800) 624-6052, ext. 2584. These lists do not imply that a plan provides benefits for these items, and they are subject to revision as new technologies and standards of medical practice are reviewed.
Healthy KidsConnect plans:
View the preauthorization requirements for Oregon Healthy KidsConnect plans by selecting from the links below:
All other plans (excluding PacificSource Medicare and PacificSource Community Solutions):
Please note: This list was updated, effective November 1, 2011.
View printable list.
- Advanced diagnostic imaging (through AIM®) for services on or after November 1, 2010. Please note that AIM is not utilized by PacificSource Administrators, Inc. at this time.
- Ambulance transports (air or ground) between medical facilities, except in emergencies (air or ground) between medical facilities, except in emergencies
- Artificial intervertebral disc replacement
- Back surgeries - instrumented for services on or after January 1, 2011
- Breast Brachytherapy (Accelerated Partial Breast Irradiation (PBI)
- Breast reconstruction, including reduction and implants
- Chelation therapy
- Chondrocyte implants
- Cochlear implants
- Cosmetic and reconstructive procedures including skin peels, scar revisions, facial plastic procedures or reconstruction, and procedures to remove superficial varicosities or other superficial vascular lesions
- CT Scans – see “Advanced diagnostic imaging”
- Durable medical equipment expense over $800, including purchase, rental, repair, lease, or replacement, or rental for longer than three months. Preauthorization is not required for hospital beds, manual wheelchairs, or initial purchase of CPAP/BiPAP equipment.
- Dynamic elbow/knee/shoulder flexion devices
- Elective medical admissions, such as preadmission, or admission to a hospital for diagnostic testing or procedures normally done in an outpatient setting, and transfers to nonparticipating facilities
- Enteral nutrition and supplies
- Excimer laser for psoriasis
- Experimental or investigational procedures or surgeries
- Genetic (DNA) testing
- Home health nursing and social worker – preauthorization required for all visits
- Home heath rehabilitation (physical, occupational or speech therapy) – preauthorization required after initial 10 visits
- Home Infusion and freestanding infusion centers
- Hospice – Inpatient only
- Hospitalization for dental procedures when covered under this plan, including pediatric dental procedures
- Hyperbaric oxygen
- Ingestible telemetric gastrointestinal capsule imaging system (wireless capsule enteroscopy)
- Intradiscal electrothermal therapy (IDET)
- Kidney dialysis
- Laparoscopies of the female reproductive system, and hysterosalpingograms, hysteroscopies, and chromotubations. Preauthorization not required for females age 45 and older.
- Mental health and chemical dependency inpatient or residential treatment, including intensive outpatient mental health treatment
- Mobile Cardiac Outpatient Telemetry (MCOT) e.g., CardioNet Ambulatory ECG or HEARTlink Telemetry
- MRIs - see "Advanced diagnostic imaging"
- Neurostimulators – implantable
- Out-of-country medical services, except in emergencies
- Parenteral nutrition
- PET scans - see "Advanced diagnostic imaging"
- Prescription drugs - some require preauthorization; view list
- Proton beam treatment delivery
- Radiofrequency procedures including radiofrequency neurotomy
- Rehabilitation or skilled nursing facility admissions
- Skin Substitutes (e.g., Apligraf, Dermagraft, or other)
- Surgical procedures and tongue retaining orthodontic appliances for sleep apnea and other sleeping disorders
- Stereotactic radiosurgery
- Surgeries or procedures in a hospital or ambulatory center during any exclusion period
- Transplantation of organ, bone marrow, and stem cells, including evaluations, related donor services, and HLA tissue typing. Preauthorization is not required for corneal transplants.
- Varicose vein procedures
This list was updated, effective November 1, 2011.