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This pre-authorization list includes services and supplies that require pre-authorization or notification for FEP members in Oregon. View pre-authorization requirements for FEP members of other Regence plans:

Important pre-authorization reminders

  1. Failure to pre-authorize services subject to pre-authorization requirements will result in an administrative denial, claim non-payment and provider and facility write-off. Members may not be balance billed.
  2. Before requesting pre-authorization, please verify eligibility and benefits via the Availity Portal as the member contract determines the covered benefits.
  3. Verify that you are an in-network provider for each member to help reduce his or her out-of-pocket expense.
  4. If services are to be rendered in a facility, the pre-authorization request submitted should designate the facility where the treatment will occur to ensure proper reconciliation with related inpatient claims.
  5. Contract exclusions will not be pre-authorized. Denials may be appealed through FEP Provider Customer Service.
  6. Pre-authorizations obtained within 30 business days prior to service are valid except in the case of misrepresentation.
  7. Urgent/Emergent services do not require pre-authorization but are subject to hospital admission notification requirements (see below).
  8. Pre-authorization decisions will be communicated.

Pre-authorization review timeframes

Type of review Timeframe Additional time allowed for review if additional information is needed:
Urgent 72 hours None
Standard initial and concurrent 15 calendar days None
Urgent concurrent 24 hours 72 hours

Note that additional timeframes are after receipt of the documentation or the timeframe for submission of the requested information has expired - whichever comes first.

Payment implications for failure to pre-authorize services

Failure to secure approval for services subject to pre-authorization will result in claim non-payment and provider liability. Our members must be held harmless and cannot be balance billed.

Please note the following:

  • Hospital claims for elective services that require pre-authorization will be reimbursed based upon the member's contract only when the physician or other health care professional has completed and received approval of the pre-authorization for the services. We therefore strongly suggest that facilities develop a method to ensure that required pre-authorization requests have been submitted by the physician or other health care professional and approved prior to admission of the patient.
  • If the physician or other health care professional follows the pre-authorization requirements outlined on our pre-authorization lists, they will not be subject to any penalties for failure of the facility to provide the required inpatient admission and discharge notification. We will review for medical necessity.
  • The following continue to be a facility pre-authorization requirement prior to patient admission:
    • Inpatient rehabilitation
    • Long-term acute care facility (LTAC) care
    • Residential treatment for mental health and chemical dependency
  • A pre-authorization does not guarantee payment for requested services. Health Plan reimbursement policies may affect how claims are reimbursed and payment of benefits is subject to all plan provisions, including eligibility for benefits. Services must always be medically necessary.

Pre-authorization exception

There may be exceptions to obtaining pre-authorization. The six situations listed below may apply as part of our Extenuating Circumstances Policy Criteria (PDF):

  1. Member presented with an incorrect member ID card or member number or indicated they were self-pay, and that no coverage was in place at the time of treatment, or the participating provider or facility is unable to identify from which carrier or its designated or contracted representative to request a pre-authorization.
  2. Natural disaster prevented the provider or facility from securing a pre-authorization or providing hospital admission notification.
  3. Member is unable to communicate (e.g., unconscious) medical insurance coverage. Neither family nor collateral support present can provide coverage information.
  4. Compelling evidence the provider attempted to obtain pre-authorization. The evidence shall support the provider followed our policy and that the required information was entered correctly by the provider office into the appropriate system.
  5. A surgery which requires pre-authorization occurs in an urgent/emergent situation. Services are subject to review post-service for medical necessity
  6. A participating provider or facility is unable to anticipate the need for a pre-authorization before or while performing a service or surgery.

Learn how to notify us about an extenuating circumstance (PDF).

Use PreManage for notification

We receive admissions and discharge information through PreManage.

How to submit a pre-authorization request or notification

Expedited requests

Use this process only when the member or his/her physician believes that waiting for a decision under the standard time frame could place the member's life, health or ability to regain maximum function in serious jeopardy.

  • Availity Portal: Read the information carefully to ensure your request meets the qualifications, then check the box on the form to attest that it is an expedited request
  • Via fax using the appropriate pre-authorization request form below

Online

Phone or fax

Submit the appropriate pre-authorization request form only if unable to submit online or if submitting an expedited request:

Direct clinical information reviews (MCG Health)

For select CPT codes, Availity's electronic authorization tool automatically routes you to MCG Health's website where you can document specific clinical criteria for your patient. If all criteria are met, you will see the approval on the Auth/Referral Dashboard soon after you click submit. Once all criteria are documented, you will then be routed back to the Availity Portal to attach supporting documentation and submit the request. Documenting complete and accurate clinical information for your patients helps to reduce the overall time it takes to review a pre-authorization request.

This applies to pre-authorizations for our group and Individual, Uniform Medical Plan (UMP) and Blue Cross and Blue Shield Federal Employee Program® (BCBS FEP®) members. It does not currently include Medicare Advantage pre-authorizations. View the services that may receive automated approval (PDF).

Chemical dependency and mental health

See the "Other services" section below for Applied Behavior Analysis (ABA) requirements.

Pre-authorization is required prior to patient admission for the following services. Emergency services do not require pre-authorization but are subject to admission notification requirements. NOTE: Medically necessary emergency services for detoxification are not subject to admission notification requirements. 

  • Outpatient treatment – Requires pre-authorization for all services billed by a residential facility (PHP, IOP, group therapy, psychological testing, etc.).
  • Partial hospitalization: Psychiatric or ASAM level 2.5 for Substance Use Disorders
    • No pre-authorization required.
  • Intensive outpatient: Psychiatric or ASAM level 2.1 for Substance Use Disorders
    • No pre-authorization required.
  • Inpatient: Psychiatric or ASAM 4.0 Detoxification:
    • Notification of admission must be received within 24 hours of admission or the next business day (whichever comes first). Medical necessity review will be conducted.
  • Detoxification – NOTE: Medically necessary emergency services for detoxification are not subject to admission notification requirements.
    • Sub-Acute Detoxification/ASAM Level 3.7
      • Requires pre-authorization before the member is admitted for services. Under certain circumstances, pre-authorization requests can be made within 24 hours of admission or the next business day.
  • Residential treatment: Psychiatric or ASAM Level 3.5 for Substance Use Disorders
    • Requires pre-authorization before the member is admitted for services. Case Management required. Under certain circumstances, pre-authorization requests can be made within 24 hours of admission or the next business day.

Inpatient medical admissions and discharges

*Elective inpatient admissions

Pre-authorization is required for elective inpatient admissions occurring on or after July 1, 2019. For more information, read our Frequently Asked Questions (PDF).

*Due to contractual requirements, Intermountain Healthcare facilities are still required to obtain pre-authorization for elective inpatient admissions for acute medical admissions, chemical dependency, and mental health admissions.

Hospital admissions (including inpatient hospice, maternity and newborn)

Notification is required for all hospital admissions or discharges within 24 hours of admission or discharge (or one business day, if the admission or discharge occurs on a weekend or a federal holiday). Maternity and newborn admissions require notification for a stay that will exceed 48 hours for a vaginal delivery or 96 hours for a cesarean section. (The stay begins at time of delivery if the delivery occurred in the hospital or at time of the hospital admission for delivery outside of the hospital.) Regence may initiate concurrent review upon notification of admission, or conduct review post-payment.

Notification is required via electronic medical record, when available. If electronic medical records are not available, notifications are required via fax. Learn more about this requirement. If your facility submits electronic admission and discharge data to Collective Medical Technologies, we will receive it through PreManage/EDIE.

Long-Term Acute Care Facility (LTAC)

  • Pre-authorization is required prior to patient admission.

Rehabilitation

  • Pre-authorization is required prior to patient admission.

Skilled Nursing Facility (SNF) Standard Option

  • Pre-authorization is required prior to patient admission.
  • Case Management is required prior to admission.

Hospice services

Regence uses MCG - End of Life Care PO-006 (Home Care) or End of Life Care PO-006 (Inpatient) as the basis for determining medical necessity for hospice services.

Prior approval is required for home hospice, continuous home hospice and inpatient hospice care services.

For listings of Preferred hospice providers, use the National Doctor & Hospital Finder on the FEP website.

Other services

Applied Behavior Analysis (ABA)
  • Pre-authorization is required prior to the initial treatment.
  • Pre-authorization is required for continued ABA and related services, including assessments, evaluations and treatment.
  • 0362T, 0373T, 97151, 97152, 97153, 97154, 97155, 97156, 97157, 97158

BRCA testing

  • Pre-authorization is required for BRCA testing and testing for large genomic rearrangements in the BRCA1 and BRCA2 genes whether performed for preventive or diagnostic reasons.
  • 81212, 81215, 81216, 81217, 81162, 81163, 81164, 81165, 81166, 81167

Clinical trials for certain organ/tissue transplants - for blood or marrow stem cell transplants

  • S9988, S9990, S9991

Congenital abnormalities (Surgical correction)

  • 0254T, 23400, 27158, 27258, 27259, 27727, 31300, 33813, 33814, 34707, 34708, 35180, 35182, 35184, 40700, 40701, 40702,  40720, 40761, 42200, 42205, 42210, 42215, 42220, 42225, 43313, 43314, 44126, 44127, 44128, 47700, 50070, 50135, 50405, 52400, 61613. 61680, 61682, 61684, 61686, 61690, 61692, 61705, 61708, 61710, 63250, 63251, 63252, 69320. 93580, 93581

Gender reassignment surgery

  • A treatment plan, including all surgeries planned and the estimated date each will be performed, is required.
  • 17380, 19303, 19304, 53410, 53430, 54125, 54400, 54401, 54405, 54520, 54660, 54690, 55175, 55180, 55899, 55970, 55980, 56625, 56805, 57110, 57291, 57292, 57335, 58150, 58180, 58260, 58262, 58275, 58290, 58291, 58541, 58542, 58543, 58544, 58550, 58552, 58553, 58554, 58570, 58571, 58572, 58573, 58661, 58720, 58999, C1813, C2622,

Intensity-modulated radiation therapy (IMRT) 

  • Prior approval is required for all outpatient IMRT services EXCEPT those related to treatment of the head, neck, breast, prostate or anal cancer. NOTE: Brain cancer is not considered a form of head or neck cancer; therefore, prior approval is required for IMRT treatment of brain cancer.
  • 77301, 77338, 77385, 77386
  • G6015, G6016

Obesity surgery (bariatric) 

  • 43644, 43645, 43770,  43773, 43775, 43845, 43846, 43847, 43848

Oral/Maxillofacial surgery 

  • Surgery needed to correct accidental injuries to jaws, cheeks, lips, tongue, roof and floor of mouth.
  • 0150T, 1511T, 21010, 21050, 21060, 21070, 21073, 21193, 21194, 21195, 21196, 21198, 21199, 21206, 21210, 21215, 21240, 21242, 21243, 21244, 21245, 21246, 21247, 21248, 21249, 21440, 21445, 21452, 21454, 21461, 21462, 21465, 21470, 21480, 21485, 21490, 21497, 29804, 40510, 40520, 40525, 40527, 40530, 40650, 40652, 40654, 40800, 40801, 40804, 40805, 40830, 40831, 41000, 41005, 41006, 41007, 41008, 41009, 41015, 41016, 41017, 41018, 41250, 41251, 41252, 42180, 42182

Blood or Marrow Stem Cell Transplants

  • 38240, 38241, S2142, S2150

Artificial Heart Transplants

  • 33927, 33928, 33929

Organ/tissue transplants

  • 32851, 38282, 32853, 32854, 33935, 33945, 44135, 44136, 47135, 47136, 48160, 48554
  • G0341, G0342, G0343, S2053, S2054, S2060, S2152

Transplant Travel

  • S9992, S9994

Gene Therapy and Cellular Immunotherapy

  • Q2041, Q2042, J3398, S2107, 0537T, 0538T, 0539T, 0540T

Air ambulance transport (non-emergent)

  • A0430, A0431, A0435, A0436

Sleep studies

  • Pre-authorization is required for sleep studies performed outside a home setting: 95782, 95783, 95803, 95805,  95807, 95808, 95810, 95811

Prescription drugs

Certain prescription drugs require prior authorization. Contact CVS Caremark at 1 (800) 624-5060 to request prior approval or to obtain a list of the drugs that require prior approval.