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

General Prior-authorization Requirements
“Due to recent scheduling issues associated with the COVID19 pandemic, providers and members may call the prior authorization team at 503-574-6400 and request for an extension of approved prior authorization if services have not been rendered. Eligibility and benefits at time of service still apply. Thank you.”

Prior-authorization Medical Fax Form
- PA Fax Form
- Transplant PA Fax Form
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.
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
Coding Policies and Alerts
Billing, Payment, and Coding Policy Alerts
Billing, Payment, and Coding Policies
Medical, Reimbursement, and Pharmacy Policy Alerts
Medical and Pharmacy Policy Alerts
Medical Policies
**SPECIAL NOTICES**

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.

MEDICAL POLICIES (Specialty/Category)

Allergy/Immunology
Audiology
Bariatric
- Bariatric Surgery (All Lines of Business Except Medicare)
- Bariatric Surgery (Medicare Only)
Behavioral Health/ Psychiatrics
Cardiology
Complementary and Alternative Medicine
Definitions and Manuals
Dental/Oral Surgery
Durable Medical Equipment
Emergency Services
- Ambulance Transport
Endocrinology
ENT
Environmental
- Chelation Therapy for Non Overload Conditions (All Lines of Business Except Medicare)
- Chelation Therapy for Non Overload Conditions (Medicare Only)
Gastroenterology
General Surgery
Genetics
Infections Disease
Investigational Technologies
- Investigational and Non-covered Medical Technologies (All Lines of Business Except Medicare)
- Investigational and Non-covered Medical Technologies (Medicare Only)
Lab Tests
Nephrology
- Apheresis (Therapeutic Pheresis) (All Lines of Business Except Medicare)
- Apheresis (Therapeutic Pheresis) (Medicare Only)
Neurology/Neurosurgery
Obstetrics and Gynecology
Oncology/Hematology
Opthalmology
- Eye: Corneal Collagen Cross-Linking (All Lines of Business Except Medicare)
- Eye: Retinopathy Telescreening
Orthopedics
Pain Management
Physical Medicine
Plastic Surgery
Pulmonology
- Bronchial Thermoplasty
Research
- Clinical Trials (All Lines of Business Except Medicare)
- Clinical Trials and IDE Studies (Medicare Only)
Sleep Physicians
Solid Organ Transplants
- Organ Transplantation (All Lines of Business Except Medicare)
- Organ Transplantation (Medicare Only)
Spine Surgery (Neurosurgery/Orthopedic Surgery)
Urology
Vascular Surgery
- Varicose Veins (All Lines of Business Except Medicare)
- Varicose Veins (Medicare Only)
Wound Care
MEDICAL POLICIES (Alphabetical)
Medical Policy Inquiries

Medical Policy Development Process

Providence Health Plan (PHP) medical policies are developed to provide guidelines for determining coverage criteria of medical services based on an evaluation of current evidence and utilization management activities for all applicable ministries. Medical policies are utilized to define medical necessity criteria and establish parameters and guidelines for approving selected medical services that support safe and effective healthcare.

Medical policies are objective and based on current, peer- reviewed clinical evidence and are utilized in making medical service coverage determinations after applicable benefit, contract, and other regulatory restrictions have been applied. Prior to implementation, medical policies are vetted and approved by the PHP Medical Policy Committee. The Medical Policy Committee consists of medical directors, nurse reviewers, and various other internal stakeholders and subject matter experts. Policies are reviewed on an annual basis or as new, relevant evidence is published by peer-reviewed, scientific journals. The timing of annual review is posted in the section below.

Medical Policy Inquiries

All inquiries concerning PHP medical policies or new medical devices and technologies may be sent by filling out our online form.

Get in touch
Medical Policy Annual Updates
January
- Advanced Diabetes Management Technology (All LOB Except CMS)
- Advanced Diabetes Management Technology (Medicare Only)
- Exhaled Breath Tests (All LOB Except CMS)
- Exhaled Breath Tests (Medicare Only)
- Fecal Analysis of Gastrointestinal Microbiome
- Gastroesophageal Reflux Disease: Endoscopic Treatments (All Lines of Business Except Medicare)
- Gastroesophageal Reflux Disease: Endoscopic Treatments (Medicare Only)
- Gender Affirming Surgical Interventions
- Lower Limb Prosthesis (All Lines of Business Except Medicare)
- Lower Limb Prosthesis (Medicare Only)
- Myoelectric Upper Limb Prosthesis
- Occipital Nerve Stimulation (All Lines of Business Except Medicare)
- Organ Transplantation (All Lines of Business Except Medicare)
- Organ Transplantation (Medicare Only)
- Stem Cell Therapy for Orthopedic Applications
- Stem Cell Transplantation (All Lines of Business Except Medicare)
- Stem Cell Transplantation (Medicare Only)
February
- Autologous Fat Transfer
- Back: Ablative Procedures to Treat Back and Neck Pain (All Lines of Business Except Medicare)
- Back: Facet Joint Injections, Medial Branch Blocks, and Facet Joint Radiofrequency Neurotomy (Medicare Only)
- Back: Sacroiliac Joint Fusion or Stabilization (All LOB except CMS)
- Back: Sacroiliac Joint Fusion or Stabilization (Medicare Only)
- Breast Cancer: Focused Microwave Phased Array Thermotherapy for Breast Cancer
- Breast Cancer: Radiofrequency Ablation of Breast Tumors
- Cardiac: Ventricular Assist (VAD/pVAD/LVAD) and Artificial Heart (Biventricular) Devices
- Chelation Therapy for Non-Overload Conditions
- Continuous Passive Motion (CPM) Device in the Home Setting (All Lines of Business Except Medicare)
- Continuous Passive Motion (CPM) Device in the Home Setting (Medicare Only)
- Dental Anesthesia Services
- Direct-to-Consumer Testing
- Electrothermal Capsular Shrinkage
- Ganglion Impar Blocks
- Genetic Testing: Reproductive Planning and Prenatal Testing (All Lines of Business Except Medicare)
- Genetic Testing: Reproductive Planning and Prenatal Testing (Medicare Only)
- Hemangioma and Vascular Malformation Treatment
- Interferential Stimulation (IFS)
- Knee Braces (Functional)(All Lines of Business Except Medicare)
- Orthotic Foot Devices and Orthopedic Shoes (All Lines of Business Except Medicare)
- Percutaneous Neuromodulation Therapy (Medicare Only)
- Percutaneous Neuromodulation Therapy (PNT) (All Lines of Business Except Medicare)
- Premature Rupture of Membranes (PROM) Testing
- Radiofrequency Ablation and Cryoablation for Plantar Fasciitis
- Rehabilitation: Acute Inpatient
- Speech Generating Devices
- Transcutaneous Electrical Nerve Stimulators (TENS) and Related Supplies (All Lines of Business Except Medicare)
- Vitamin D Assay Testing
- Wireless Capsule for Gastrointestinal Motility Monitoring
March
- Ambulance Transport
- Anesthesia Care with Diagnostic Endoscopy
- Athletic Pubalgia/Sports Hernia Surgery
- Auricular Electrostimulation (All Lines of Business Except Medicare)
- Auricular Electrostimulation (Medicare Only)
- Bariatric: Surgery (All LOB Except Medicare)
- Bariatric: Surgery (Medicare Only)
- Breast Reconstruction
- Chemoresistance and Chemosensitivity Assays
- Circulating Tumor Cell and DNA Assays for Cancer Management (All Lines of Business Except Medicare)
- Colorectal Cancer Screening
- Eye: Blepharoplasty, Blepharoptosis Repair, and Brow Lift (Medicare Only)
- Fecal Microbiota Transplantation
- Genetic Testing: Inherited Susceptibility to Colorectal Cancer (All Lines of Business Except Medicare)
- Genetic Testing: Inherited Susceptibility to Colorectal Cancer (Medicare Only)
- Genetic Testing: Inherited Thrombophilias (All Lines of Business except Medicare)
- Genetic Testing: Inherited Thrombophilias (Medicare only)
- Genetic Testing: JAK2, CALR, and MPL (All Lines of Business Except Medicare)
- Genetic Testing: JAK2, CALR, and MPL (Medicare Only)
- Hip: Total Joint Arthroplasty (All Lines of Business Except Medicare)
- Hip: Total Joint Arthroplasty (Medicare Only)
- Home Oxygen Therapy and Equipment for Cluster Headaches (All Lines of Business Except Medicare)
- Home Oxygen Therapy and Equipment for Lung Disease or Hypoxia (All Lines of Business Except Medicare)
- Home Oxygen Therapy and Equipment for Cluster Headaches (Medicare Only)
- Home Oxygen Therapy and Equipment for Lung Disease or Hypoxia (Medicare Only)
- Lyme Disease
- Mechanical Stretching Devices for Joints of the Extremities
- Microcurrent Electrical Neuromuscular Stimulation (MENS)
- Next Generation Sequencing for Minimal Residual Disease Detection (All Lines of Business Except Medicare)
- Next Generation Sequencing for Minimal Residual Disease Detection (Medicare Only)
- Ovarian Cancer: Multimarker Serum Testing (All Lines of Business Except Medicare)
- Prostate Protein Biomarkers and Genetic Testing (All Lines of Business Except Medicare)
- Prostate Protein Biomarkers and Genetic Testing (Medicare Only)
- Prostate: MRI-Transrectal Ultrasound (MRI-TRUS) Fusion Biopsy
- Subcutaneous Hormone Pellet Implant
- Surgical Treatment for Skin Redundancy (All Lines of Business Except Medicare)
- Surgical Treatment for Skin Redundancy (Medicare Only)
- Vectra DA Test for Rheumatoid Arthritis (All Lines of Business Except Medicare)
- Vectra DA Test for Rheumatoid Arthritis (Medicare Only)
- Wilderness Therapy
April
- Ankle-Foot/Knee-Ankle-Foot Orthoses (All Lines of Business Except Medicare)
- Ankle-Foot/Knee-Ankle-Foot Orthoses (Medicare Only)
- Back: Stabilization Devices and Interspinous Spacers
- Blood Brain Barrier Disruption and Bypass
- Cardiac: Disease Risk Screening (All Lines of Business Except Medicare)
- Cardiac: Disease Risk Screening (Medicare Only)
- Compression Bandages, Stockings, and Wraps (All Lines of Business Except Medicare)
- Compression Bandages, Stockings, and Wraps (Medicare Only)
- Compression: Outpatient Pneumatic Devices (All Lines of Business Except Medicare)
- Compression: Outpatient Pneumatic Devices (Medicare Only)
- Durable Medical Equipment (All Lines of Business Except Medicare)
- Durable Medical Equipment (Medicare Only)
- Genetic Testing: Hereditary Breast and Ovarian Cancer (All Lines of Business Except Medicare)
- Genetic Testing: Hereditary Breast and Ovarian Cancer (Medicare Only)
- Helicobacter Pylori Serologic Testing
- Intraoperative Neurophysiological Testing and Monitoring (All Lines of Business Except Medicare)
- Intraoperative Neurophysiological Testing and Monitoring (Medicare Only)
- Knee Braces (Functional)(Medicare Only)
- NanoKnife System: Irreversible Electroporation (IRE)
- Nerve Conduction Studies (ALL LOB Except Medicare)
- Nerve Conduction Studies (Medicare Only)
- Orthotic Foot Devices and Therapeutic Shoe (Medicare only)
- Pelvic Congestion Syndrome Treatment
- Prostate: High Intensity Focused Ultrasound (All Lines of Business Except Medicare)
- Prostate: Prostatic Urethral Lift
- Seat Lift Chair Mechanism (All Lines of Business Except Medicare)
- Seat Lift Chair Mechanism (Medicare only)
- Sleep Disorder Testing (All Lines of Business Except Medicare)
- Sleep Disorder Testing (Medicare Only)
- Sleep Disorder Treatment: Oral Appliances (All Lines of Business Except Medicare)
- Sleep Disorder Treatment: Oral Appliances (Medicare Only)
- Sleep Disorder Treatment: Positive Airway Pressure (All Lines of Business Except Medicare)
- Sleep Disorder Treatment: Positive Airway Pressure (Medicare Only)
- Surface Electromyography (sEMG) Testing
- Surgical Site of Service
- Transcutaneous Electrical Nerve Stimulators (Medicare only)
- Wheelchair and Power Vehicles (All Lines of Business Except Medicare)
- Wheelchair and Power Vehicles (Medicare only)
- Wireless Capsule Endoscopy (All Lines of Business Except Medicare)
- Wireless Capsule Endoscopy (Medicare Only)
May
- Allergy Testing (All LOB Except Medicare)
- Allergy Testing (Medicare Only)
- Back: Artificial Intervertebral Disc (All Lines of Business Except Medicare)
- Back: Artificial Intervertebral Disc (Medicare Only)
- Back: Discography
- Back: Intradiscal Procedures for Low Back Pain (All Lines Of Business Except Medicare)
- Back: Intradiscal Procedures for Low Back Pain (Medicare Only)
- Blood Counts (All Lines of Business Except Medicare)
- Breast Implant Removal (All Lines of Business Except Medicare)
- Breast Implant Removal (Medicare Only)
- Breast Surgery: Reduction Mammoplasty (All Lines of Business Except Medicare)
- Breast Surgery: Reduction Mammoplasty (Medicare Only)
- Bronchial Thermoplasty
- Cardiac Left Atrial Appendage Devices (All Lines of Business Except Medicare)
- Cardiac Left Atrial Appendage Devices (Medicare Only)
- Cardiac: External Ambulatory Electrocardiography (All Lines of Business Except Medicare)
- Cardiac: External Ambulatory Electrocardiography (Medicare Only)
- Cardiac: Transcatheter Aortic Valve Replacement (TAVR) (All Lines of Business Except Medicare)
- Cardiac: Transcatheter Aortic Valve Replacement (TAVR) (Medicare Only)
- Cefaly Device for Treatment of Migraine Headaches
- Circulating Tumor Cell and DNA Assays For Cancer Management (Medicare Only)
- Cochlear Implants and Auditory Brainstem Implants (All Lines of Business Except Medicare)
- Cochlear Implants and Auditory Brainstem Implants (Medicare Only)
- Definition: Confined to the Home
- Definition: Mobility Assistive Equipment
- Dental Services: Administrative Guideline (All Lines of Business Except Medicare)
- Dental Services: Administrative Guideline (Medicare Only)
- Eye: Blepharophasty, Blepharoptosis Repair, and Brow Lift (All Lines of Business Except Medicare)
- Eye: Corneal Collagen Cross-Linking (All Lines of Business Except Medicare)
- Eye: Retinopathy Telescreening
- Genetic Testing: Diagnostic Evaluation of Interstitial Lung Disease (All Lines of Business Except Medicare)
- Genetic Testing: Diagnostic Evaluation of Interstitial Lung Disease (Medicare Only)
- Glycated Hemoglobin and Glycated Protein Diagnostic Testing (All Lines of Business Except Medicare)
- Lipid Testing (All Lines of Business Except Medicare)
- Negative Pressure Wound Therapy (All Lines of Business Except Medicare)
- Negative Pressure Wound Therapy (Medicare Only)
- Orthognathic Surgery
- Proton Beam Radiation Therapy
- Residential Mental Health Treatment Facilities
- Standing Systems (All Lines of Business Except Medicare)
- Standing Systems (Medicare Only)
- Surgical Treatment of Lymphedema
- Thyroid Testing (All Lines of Business Except Medicare)
- Tumor Treatment Fields Therapy for Glioblastoma (All Lines of Business Except Medicare)
- Tumor Treatment Fields Therapy for Glioblastoma (Medicare Only)
June
- Blood Counts (Medicare Only)
- Celiac Disease: Serologic Testing
- Gastric Electrical Stimulation
- Gastroesophageal Reflux: Magnetic Esophageal Ring
- Hyperbaric Oxygen Therapy (All LOB Except Medicare)
- Hyperbaric Oxygen Therapy (Medicare Only)
- Low-level and High-power Laser Therapy
- Non-Small Cell Lung Cancer: Molecular Testing for Targeted Therapy (All Lines of Business Except Medicare)
- Non-Small Cell Lung Cancer: Molecular Testing for Targeted Therapy (Medicare Only)
- Peroral Endoscopic Myotomy (POEM)
- Prolotherapy
- Thyroid Testing (Medicare Only)
- Urinary Incontinence Treatments (All Lines of Business Except Medicare)
- Urinary Incontinence Treatments (Medicare Only)
- Viscosupplementation (All Lines of Business Except Medicare)
- Viscosupplementation (Medicare Only)
- Walkers (All Lines of Business Except Medicare)
- Walkers (Medicare Only)
July
- Apheresis (Therapeutic Pheresis) (All Lines of Business Except Medicare)
- Apheresis (Therapeutic Pheresis)(Medicare Only)
- Genetic Testing for Heritable Connective Tissue Disorders
- Genetic Testing: Non-Covered Genetic Panel Tests (All Lines of Business Except Medicare)
- Genetic Testing: Non-Covered Genetic Panel Tests (Medicare Only)
- Genetic Testing: Pharmacogenetic Testing (All LOB Except Medicare)
- Genetic Testing: Pharmacogenetic Testing (Medicare Only)
August
- Back: Percutaneous Vertebral Augmentation
- Bone Growth Stimulators (All LOB except CMS)
- Bone Growth Stimulators (CMS Only)
- Cardiac: Implantable Loop Recorders
- Clinical Trials and IDE Studies (Medicare Only)
- Clinical Trials and Devices (All Lines of Business Except Medicare)
- Cosmetic and Reconstructive Surgery (All Lines of Business Except Medicare)
- Cosmetic and Reconstructive Surgery (Medicare Only)
- Diabetes: Blood Glucose Monitor and Supplies (All Lines of Business Except Medicare)
- Diabetes: Blood Glucose Monitor and Supplies (Medicare Only)
- Fecal Incontinence Treatments (All Lines of Business Except Medicare)
- Fecal Incontinence Treatments (Medicare Only)
- Genetic Counseling
- Genetic Testing: CADASIL Disease
- Genetic Testing: MTHFR (Medicare Only)
- Genetic Testing: Whole Exome and Whole Genome
- Glycated Hemoglobin and Glycated Protein Diagnostic Testing (Medicare Only)
- Inflammatory Bowel Disease: Measurement of Antibodies to Immunosuppressive Therapies
- Inflammatory Bowel Disease: Serologic Testing and Therapeutic Monitoring
- Investigational and Non-Covered Medical Technologies (Medicare Only)
- Knee: Ablative Procedures of Peripheral Nerves to Treat Knee Pain
- Knee: Autologous Chondrocyte Implantation (ACI) for Cartilaginous Defects
- Knee: Meniscal Allograft Transplantation and Other Meniscal Implants
- Knee: Osteochondral Allografts and Autografts for Cartilaginous Defects
- Lipid Testing (Medicare Only)
- Molecular and Genetic Diagnostic Testing (All Lines of Business Except Medicare)
- Platelet-Rich Plasma (PRP) for Orthopedic Indications, Wound Care and Other Miscellaneous Conditions (Medicare Only)
September
- Chiropractic Care (All Lines of Business Except Medicare)
- Chiropractic Care (Medicare Only)
- Cranial Electrical Stimulation
- Genetic Testing: Genetic Expression Profile Testing for Melanoma (All Lines of Business Except Medicare)
- Genetic Testing: Genetic Expression Profile Testing for Melanoma (Medicare Only)
- Joint Resurfacing
- Molecular and Genetic Diagnostic Testing (Medicare Only)
- Organic Acid Testing
- Outpatient Physical Therapy (All Lines of Business Except Medicare)
- Platelet-Rich Plasma (PRP) for Orthopedic Indications, Wound Care and Other Miscellaneous Conditions (All Lines of Business Except Medicare)
- Respiratory Viral Panels (All Lines of Business Except Medicare)
- Respiratory Viral Panels (Medicare Only)
- Sleep Disorder Treatment: Surgical (All Lines of Business Except Medicare)
- Sleep Disorder Treatments: Surgical (Medicare Only)
- Ultrarapid Detoxification
- Varicose Veins (All LOB except Medicare)
- Varicose Veins (Medicare Only)
October
- Back: Fusion and Decompression Procedures
- Complimentary and Alternative Medicine (CAM) Treatments
- Definition: Urgent Care (Out of Area)
- Hearing Aids (All Lines of Business Except Medicare)
- Investigational and Non-Covered Medical Technologies (All Lines of Business Except Medicare)
- Liver Tumor Treatment (All Lines of Business Except Medicare)
- Liver Tumor Treatment (Medicare Only)
- Prostate: Water Vapor Thermotherapy for Benign Prostatic Hyperplasia
November
- Back: Epidural Steroid Injections (Medicare Only)
- Back: Epidural Steroid Injections All LOBs except Medicare)
- Back: Implantable Spinal Cord and Dorsal Root Ganglion Stimulation (All LOB Except CMS)
- Back: Implantable Spinal Cord and Dorsal Root Ganglion Stimulation (CMS Only)
- Cold Therapy and Cooling Devices in the Home Setting
- Definition: Experimental/Investigational
- Definition: Medical Necessity
- Eye: Automated Evacuation of the Meibomian Glands
- Genetic Testing: Thyroid Nodules (All Lines of Business Except Medicare)
- Genetic Testing: Thyroid Nodules (Medicare Only)
- Percutaneous Ultrasonic Ablation for Tendinopathy
- Peripheral Nerve Stimulation for Chronic Pain (Medicare Only)
- Rhinoplasty (All Lines of Business Except Medicare)
- Rhinoplasty (Medicare Only)
- Stereotactic Body Radiation Therapy and Stereotactic Radiosurgery (All LOB Except Medicare)
- Stereotactic Body Radiation Therapy and Stereotactic Radiosurgery (Medicare Only)
- Transcranial Magnetic Stimulation (All LOB Except CMS)
- Transcranial Magnetic Stimulation (CMS Only)
December
- Applied Behavior Analysis
- Balloon Dilation of the Sinuses or Eustachian Tubes
- Biofeedback and Neurofeedback
- Centers for Medicare & Medicaid Services (CMS) Medical Policy Manual
- Deep Brain and Responsive Cortical Stimulation (All LOB Except CMS)
- Deep Brain and Responsive Cortical Stimulation (CMS Only)
- Drug Testing for Therapeutic or Substance Use Monitoring (All LOB Except Medicare)
- Drug Testing for Therapeutic or Substance Use Monitoring (Medicare Only)
- Extended Outpatient Psychotherapy (All LOB Except Medicare)
- Extended Outpatient Psychotherapy (Medicare Only)
- General Prior Authorization Requirements Pages
- Genetic Testing: Gene Expression Profile Testing for Breast Cancer (All Lines of Business Except Medicare)
- Genetic Testing: Gene Expression Profile Testing for Breast Cancer (Medicare Only)
- Medical Policy Development and Application
- Prior Authorization Application Procedure
- Providence Healthcare Services Medical Policy Alert
- Psychological and Neuropsychological Testing (All LOB Except Medicare)
- Psychological and Neuropsychological Testing (Medicare Only)
- Salivary Hormone Testing (All Lines of Business Except Medicare)
- Salivary Hormone Testing (Medicare Only)
- Skin and Tissue Substitutes
- Vagus Nerve Stimulation (All Lines of Business Except Medicare)
- Vagus Nerve Stimulation (Medicare Only)
- Vendor and Delegate Medical Policy Adoption
Reimbursement Policies

REIMBURSEMENT POLICIES

+ Inpatient Readmission Policy
Pharmacy Policies
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 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
Commercial Plans
- Commercial Pharmacy Policy Criteria
- Commercial Medical Benefit Drug Policy Criteria
Medicare Plans
Medicaid Plans
- Medicaid Pharmacy Policy Criteria
Biosimilar Preferred Product Program

Providence Health Plan (PHP) implemented a biosimilar preferred product formulary strategy for medical benefit drugs effective July 1, 2021. The October 2021 Oregon Regional Pharmacy and Therapeutics Committee (ORPTC) approved expansion of the biosimilar preferred product formulary to include infliximab products. This change is effective January 1, 2022.
- PHP Provider Information and Biosimilar Preferred Product Drug List
- PHP Biosimilar Preferred Product Drug List
Refer to the policies below for clinical criteria by line of business:

Commercial and Medicaid:
Medicare Part B:
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 1/1/2022
- Infusion Therapy SOC Policy - Effective 8/1/2022
- Site of Care Prior Authorization Request Form
- Approved Site of Care Drug List
- Approved Site of Care Facility List
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
Self-Administered Drug (SAD) Exclusion Policy

Self-Administered Drugs (SADs) 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 - Applies to All Lines of Business *Coming Soon*
- Self-Administered Drug Exclusion Drug List *Coming Soon*
Outpatient Rehabilitation
- PHP Outpatient Rehabilitation Information
- PHP Outpatient Rehabilitation CPT Code List
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.

Medical Policy Inquiries

We are seeking provider participation across various clinical specialties who will review and provide feedback on our medical policies.

Get in touch

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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

General Prior-authorization Requirements

Prior-authorization Medical Fax Form

Prior-authorization Pharmacy Fax Form

Prior-authorization Behavioral Health Fax Forms

Clinical Edit Inquiry Form

Coding Policies and Alerts

Billing, Payment, and Coding Policy Alerts

Billing, Payment, and Coding Policies

Medical, Reimbursement, and Pharmacy Policy Alerts

Medical and Pharmacy Policy Alerts

Medical Policies

MEDICAL POLICIES (Specialty/Category)

Medical Policy Inquiries

Medical Policy Development Process

Medical Policy Inquiries

Medical Policy Annual Updates

January

February

March

April

May

June

July

August

September

October

November

December

Reimbursement Policies

Pharmacy Policies

Drug Prior Authorization

Biosimilar Preferred Product Program

Refer to the policies below for clinical criteria by line of business:

Infusion Therapy Site of Care (SOC)

Opioid Resources and Guidelines

Self-Administered Drug (SAD) Exclusion Policy

Outpatient Rehabilitation

No Surprises Act

Medical Policy Inquiries

We are seeking provider participation across various clinical specialties who will review and provide feedback on our medical policies.

Hey!