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Prior Authorization and Referrals

Prior Authorization/Prior Approval

Some medical services need approval from Trillium Community Health Plan. This is called a prior authorization. Your healthcare provider can tell you if a medical service or prescription needs prior approval. Please keep in mind that services and benefits change from time to time. This list is for your general information only. Please call Member Services for the most up to date information

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).