Prior Authorization and Referrals
Prior Authorization/Prior Approval
|Services that require a Prior Authorization||Some or all of the Services
|Ambulatory Surgery Center. Also known as outpatient surgery centers||Some Services
|Bariatric Surgery or weight loss surgery||All
|Durable Medical Equipment (DME) .Such as wheelchairs and braces.
||Some Services. If the cost to buy is $2000 or more. Or if rental is $250 or more
|Genetic Testing. A test that looks for changes in your genes.
|Radiology/Diagnostic Services. A test that looks at images of the inside of your body.||All
|Home Health Care Services||All
|Hospice Care. A special kind of care that focuses on the quality of life for people and their caregivers who are have an advanced, life-limiting illness
|Inpatient hospital stay. Is when you are in admitted to the hospital.||All
|Emergency Room/Urgent Care||No|
|Hospital Outpatient Services||Some Services|
|Laboratory Services. Tests on items like blood, urine or other parts of the body. Used to diagnose or treat new or ongoing conditions.
|Maternity Services. Services provided to women and babies during pregnancy. Also during labor and birth and up to 6 weeks after birth.||Some Services|
|Non-Participating/Out of Network Providers||All
|Orthotics & Prosthetics: Braces (non-dental). Any man made part that is used to correct a defect or missing body part.||Some Services|
|Oxygen or Respiratory Services||All
|Pain Management||Some Services|
|Scheduled Surgery at the Hospital||Some Services|
|Skilled Nursing Stay or Inpatient Rehabilitation||All|
|Specialists Visits||No- if your condition is covered by Oregon Health Plan|
|Therapy (OT, PT, ST) services (Outpatient)||Evaluation (First visit) - No Continued visits - Yes|
Below is a list of services you can receive without a referral from your primary care provider (PCP):
- Medication Assisted Treatment for Opioid addiction
- Traditional Health Worker support
- Emergency room care;
- Drug and alcohol treatment;
- Routine women’s annual exams and preventive women’s health care services. These include but are not limited to prenatal care, breast exams, mammograms and Pap tests;
- Pregnancy care;
- Family planning and birth control services. You can get these services from any provider who is contracted with Oregon Health Authority and is licensed to perform these services.
- Mental Health;
- Help to stop smoking;
- Kidney dialysis services; and
- Immunizations (shots).