What is Prior Authorization?
Some medical services, surgical procedures, and medications require IHN-CCO’s approval before you can get them. This process is called Prior Authorization. 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 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 Authorization lists annually. For 2017, IHN-CCO requires Prior Authorization for the following:
- All non-contracted services. Exception: labs, x-rays, and dialysis
- Chemical Dependency: Inpatient, Outpatient, and Residential; Medical/Chemical Detoxification
- Contact Lenses
- Durable Medical Equipment (DME): Prosthetics, Orthotics, and Hearing Aids; Cochlear implants, replacements and repairs; Continuous Glucose Monitors (CGM) and CGM Supplies. Exception: Incontinence, diabetic and CPAP supplies
- Elective/Planned procedures in the Hospital or Ambulatory Surgery Center includes the following: Genetic testing, except standard prenatal testing and Non-Invasive Prenatal Testing (NIPT); Neck and back surgery (done as inpatient, outpatient and those done as in-office procedures). Exception: Endoscopies
- Inpatient Hospital Care, including Inpatient Rehabilitation: Exception: Labor & delivery. Exception: Newborn less than 5 days. Exception: Respiratory/pulmonary therapies
- Mental Health Services: Day Treatment; Inpatient, Outpatient, and Residential, Skills Training
- Outpatient Rehabilitation services in excess of 30 visits (120 units) per calendar year, including, Occupational Therapy, Physical Therapy, Speech Language Therapy
- Potentially cosmetic, reconstructive and/or experimental surgery and services (including Botox Injections)
- Radiological services (for the following): CT (CAT) scans, Magnetic Resonance Imaging (MRI), Nuclear Medicine – PET and CTA coronary
- Skilled Nursing Facility (SNF)
- Transplants (including evaluation): Corneal and Kidney transplants only require approval if performed out of state
InterCommunity Health Network CCO has the right to review or deny services that are not found to be< medically appropriate.
*Diabetic supplies that DO require approval: Insulin pumps, diabetic shoes/inserts.
*Diabetic supplies that DO NOT require approval: lancets, test strips, meters, syringes, and pump supplies.
Medically appropriate - Services and medical supplies that are needed for prevention, diagnosis or treatment of a physical or mental health condition, or injury, and which are:
- Consistent with the symptoms of a health condition or treatment of a health condition;
- Appropriate with regard to standards of good health practice and generally recognized as effective by the related scientific community, evidence-based medicine and professional standards of care;
- Not only for the convenience of the member or a provider of the service or medical supplies; and
- The most cost effective of the treatment options which are safe for the member.
Emergency services do not require prior approval. We do request notification of all emergency inpatient
For a complete list of services that require approval, please contact your dental plan directly.
Advantage Dental Services
1-866-268-9631, TTY 1-866-268-9617
Capitol Dental Care
1-800-525-6800, TTY 1-800-735-2900
Oregon Dental Services
1-800-342-0526, TTY 1-800-342-0526 x711
Willamette Dental Group
1-855-433-6825 option 3, TTY 1-800-735-1232