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Prior Authorization

What is Prior Authorization?
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 authorization?
IHN-CCO reviews and updates its Prior Approval List annually. For 2019, IHN-CCO requires prior authorization for the following:

Medical services & surgical procedures

  • Acupuncture
  • 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/Planned procedures in the Hospital or Ambulatory Surgery Center. Exception: Colonoscopies and Endoscopies
  • Genetic Testing. Exception: standard prenatal testing 
  • Hyperbaric Oxygen Therapy
  • Infused/Injected Medications See 2019 Prior Approval List
  • Inpatient Hospital Care*. Exception: Labor & delivery; Exception: Newborn less than 5 days; Exception: Respiratory/Pulmonary therapies
  • Inpatient Rehabilitation Care
  • Mental Health Services: Day Treatment; Inpatient* and Residential
  • Neck and back surgery (including in-office procedures) 
  • Outpatient Rehabilitation services in excess of 30 visits (120 units) per calendar year, including: Occupational Therapy, Physical Therapy, Speech Language Therapy, Cardiac/Pulmonary Rehabilitation
  • 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)
  • Skin Substitute – tissue engineered
  • Transplants: Corneal and Kidney transplants only require approval if performed out of state

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

Medically appropriate - Services and medical supplies that are required for prevention, diagnosis or treatment of a health condition which encompasses physical or mental conditions, or injuries, 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; and
  • The most cost 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.

 

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

**Cosmetic, experimental or reconstructive surgery and services, including new and emerging technologies and clinical trials, have the following requirements and considerations:

  • Cosmetic and experimental services, which may include new or 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 or emerging technologies is required to ensure that the service meets current accepted standards of care.  

2019 Prior Approval List

Dental services & surgical procedures

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
http://www.advantagedental.com/

Capitol Dental Care
800-525-6800, TTY 800-735-2900
http://www.capitoldentalcare.com/

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

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

 

Prescription Drugs

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