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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.
Some Services
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
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  All
Transportation  Some Services 

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).