Skip to Main Content

What Is Prior Approval?

Some medical services, surgical procedures, and medications require IHN-CCO’s written approval before you can get them. This process is called prior authorization, also called prior approval. It basically means that your provider has to ask permission to prescribe you a drug or have you undergo a treatment, service, or surgery that isn’t covered by your health plan.

How Does It Work?

Your provider fills out a form requesting permission to give you a certain drug, treatment, service, or surgery. If approved, it will be covered to some extent by IHN-CCO. If not, IHN-CCO may recommend an alternative that is covered, or you may opt to get the drug, treatment, service, or surgery anyway and cover the costs yourself. 

What Requires Approval?

IHN-CCO reviews and updates its Prior Approval List annually. For 2020, IHN-CCO requires prior authorization for the following:

Some medical services, procedures, supplies and equipment require IHN-CCO written approval before being performed or supplied. All coverage is limited by Oregon Administrative Rules and the Oregon Health Evidence Review Commission (HERC) Prioritized list may review and deny services that are not medically appropriate****.

  • Acupuncture in excess of 30 visits per calendar year.
  • All non-contracted services. Exceptions: labs, x-rays and dialysis.
  • Capsule/wireless endoscopies and motility monitoring studies.
  • Chemical dependency: Inpatient and residential; medical/chemical detoxification.
  • Contact lenses.
  • Durable Medical Equipment (DME) and supplies, prosthetics and orthotics with billed amount greater than $300 for purchase. Rental items with rental fee greater than $300 per month or rental length greater than 3 months.
  • Elective coronary angioplasty.
  • Elective/planned surgeries/procedures in outpatient hospital or Ambulatory Surgery Center*. Exception: colonoscopies, gastrointestinal and ear, nose, and throat endoscopies.
  • Genetic Testing. Exception: standard prenatal testing.
  • Hyaluronic acid or viscosupplementation, intra-articular injection (i.e. Orthovisc, Synvisc, etc.).
  • Hyperbaric oxygen therapy.
  • Infused/injected medications See 2020 Prior Approval List
  • Inpatient Hospital Care**. Exception: labor and delivery stays less than 96 hours; Exception: newborn stays less than 5 days.
  • Inpatient rehabilitation care.
  • Mental health services: Day treatment; inpatient** and residential.
  • Outpatient rehabilitation services in excess of 30 visits (120 units) per calendar year, including: Occupational therapy, physical therapy, speech language therapy, cardiac/pulmonary rehabilitation.
  • Parenteral nutrition.
  • Potentially cosmetic, experimental, or reconstructive surgery and services, including new and emerging technologies and clinical trials***.
  • Radiological services (for the following): Magnetic Resonance Imaging (MRI); Nuclear Medicine – PET and CTA coronary.
  • Skilled Nursing Facility (SNF) stays greater than 7 days.
  • Skin substitute – tissue engineered.
  • Spinal surgeries and spinal injections (including in-office procedures).
  • Transplants: Corneal and kidney transplants only require approval if performed out of state.
  • Urine drug tests (prior approval required after 12 units per year).

IHN-CCO may review and deny services that are not medically appropriate.

*Infused/injected drugs given in an outpatient hospital or ASC will not require prior authorization unless they are on the list below. 

**Emergency services do not require prior approval. Please tell IHN-CCO of all emergency admissions and post-emergency observation stays that exceed 48 hours (2 days) to ensure that all the member’s care is appropriately coordinated.

***Potentially cosmetic, experimental, or reconstructive surgery and services, including new and emerging technologies and infused/injected drugs, and clinical trials have the following requirements and considerations:

  • Cosmetic and experimental services, which may include new and emerging technologies, often do not meet medical necessity and are generally not covered.
  • Services which may be considered reconstructive will require prior approval to show medical necessity regardless of dollar amounts or codes billed.
  • Prior approval for new and emerging technologies is required to ensure that the service meets current accepted standard of care.
  • Potentially experimental, new and emerging infused/injected drugs include those which are not approved by the Food and Drug Administration (FDA), or have been FDA approved within the last 3 years.

****Medically appropriate: Services and medical supplies that are required for prevention, diagnosis or treatment of a medical or mental health condition or injury, and which are:

  • Consistent with the symptoms of a health condition or treatment of a health condition.
  • Meet standards of good health practice, are generally accepted by the medical community, use evidence-based medicine and are considered effective.
  • Not only for the convenience of the member or a provider of the service or medical supplies.
  • The most effective of the medical services or medical supplies that can be safely provided to the member.
  • In IHN-CCO’s determination as based on available information and documentation, according to the terms of the Plan.

2020 Prior Approval List

For a complete list of services that require approval, please contact your dental plan directly.

Advantage Dental Services
866-268-9631, TTY 866-268-9617
advantagedental.com

Capitol Dental Care
800-525-6800, TTY 800-735-2900
capitoldentalcare.com

Oregon Dental Services
800-342-0526, TTY 800-342-0526 x711
modahealth.com/ohp

Willamette Dental Group
855-433-6825 option 3, TTY 800-735-1232
willamettedental.com

Some of your prescription drugs may require prior authorization. To find out if your medication requires prior authorization, please search our drug list.