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. |
All |
| 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 |
All |
| 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).