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Prior Authorization and Referrals

Prior Authorization/Prior Approval

Services that require a Prior Authorization  Prior Authorization Required for Some or All of the Services? 
Ambulatory Surgery Center  Some Services require prior authorization 
Bariatric Surgery  Yes
Durable Medical Equipment (DME)  Yes - required if purchase price is equal to or greater than $2000 or if rental is equal to or greater than $250 
Genetic Testing  Yes
Radiology/Diagnostic Services  Yes
Home Health Care Services  Yes
Hospice Care  Yes
Inpatient hospital stay  Yes
Emergency Room/Urgent Care  No
Hospital Outpatient Services  Some Services require prior authorization 
Laboratory Services: All services necessary for the diagnosis, treatment and prevention of disease, and for the maintenance of health  Some Services require prior authorization 
Maternity Services  Some Services require prior authorization 
Non-Participating/Out of Network Providers  Yes
Orthotics & Prosthetics: Braces (non-dental) and other mechanical or molded devices to support or correct any defect of form or function of the human body.  Some Services require prior authorization 
Oxygen or Respiratory Services  Yes
Pain Management  Some Services require prior authorization 
Scheduled Surgery at the Hospital  Some Services require prior authorization 
Skilled Nursing Stay or Inpatient Rehabilitation  Yes
Second Opinions  No
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 
Transplant Services  Yes
Transportation  Some Services require prior authorization 

Below is a list of services you can receive without a referral from your PCP:

  • 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).