Referral and prior authorization guidelines
To help you understand what services need prior authorization, Moda Health provides these prior authorization lists.
Submit your prior authorization request electronically
SERVICE AUTHORIZATION REQUEST REQUIREMENTS
Make sure the prior authorization request is complete and contains:
- All pertinent member information (name, ID #, group #, and member's birth date)
- PCP information (name, TIN, phone, fax and contact name)
- The name and TIN of the facility where the procedure is to be performed
- The date of the procedure or date of admission
- Surgeon's or specialist's full name and TIN
- CPT & diagnosis codes must be included
- Length of stay (indicate if inpatient)
- Chart notes
Please refer to these documents to help you determine if your patient needs a prior authorization:
Medicare
- Procedures and services requiring prior authorization
- Procedures and services requiring prior authorization (excel)
- Referral/Authorization - Medicare only
- Step Therapy requirements for Medicare outpatient (Part B) medications
Group/Individual
- electronic Rx Prior Authorization Portal
- Commercial Prior Authorization List
- Group/Individual always not covered list
- Referral/Authorization - Commercial only
- Behavioral Health Authorization Request Form
- OHSU Employee Massage Therapy Request Form
eviCore
Prime Therapeutics Management
| Prior authorization contact information | |||
|---|---|---|---|
| Type of Service | Phone Number | OEBB Phone Number | PEBB Phone Number |
| Inpatient Elective Procedures Outpatient Selected Elective Procedures Skilled Nursing Facility Long-Term Acute Care Inpatient Rehabilitation Home Health/Home Infusion Hospice – Initial Evaluation and Service Durable Medical Equipment (DME) Transplants |
Local: 503-243-4496 Toll-free: 800-258-2037 Fax: 503-243-5105 |
Local: 503-243-4496 Toll-free: 800-258-2037 |
PEBB Customer Service: Toll-free: 844-776-1593 |
| Chemical Dependency and Mental Health | Toll-free: 855-294-1665 Fax: 503-670-8349 |
OEBB Authorization Number: Toll-free: 855-294-1665 Fax: 503-670-8349 |
PEBB Customer Service: Toll-free: 800-799-9391 |
| Expedited Requests | Local: 503-243-4496 Toll-free: 800-258-2037 Fax: 503-243-5105 |
OEBB Authorization Number: Local: 503-243-4496 Toll-free: 800-258-2037 |
PEBB Customer Service: Toll-free: 844-776-1593 |
| Referrals for Managed Care/Point of Service Groups | Local: 503-243-4496 Toll-free: 800-258-2037 Fax: 503-243-5105 |
Not applicable | Not applicable |
| Advanced Imaging and Musculoskeletal Services |
Authorizations for advanced imaging studies and musculoskeletal services are obtained through eviCore healthcare Log in to eviCore's Provider Portal at Phone: 844-303-8451 For more information and codes requiring authorization go to www.evicore.com |
||
| Specialty Infusion/Injectable Drugs | Authorizations for selected Intravenous infusion or injectable drugs are obtained through Prime Therapeutics Management. Login to Prime Therapeutics Management Provider Portal at Prime Therapeutics Management. |
||
| Instructions for requesting prior authorization | |
|---|---|
| Urgent/Emergent Hospital Admissions | Contact Moda Health within 48 hours of all urgent/emergent admission. |
| Elective inpatient procedures |
|
Questions?
We're here to help! If you have questions, please call our Customer Service team at 503-243-3962 or toll-free at 877-605-3229. Or, email us at
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