This Medicare Pre-authorization List includes services and supplies that require pre-authorization or notification for Medicare Advantage products in Oregon. View Medicare pre-authorization requirements for other Regence plans:
- Regence BlueShield of Idaho
- Regence BlueCross BlueShield of Utah
- Regence BlueShield serves select counties in the state of Washington
How to submit a pre-authorization request or notification
Please use the online form or pre-authorization request form below to ensure the most current version is utilized as forms are subject to change. If your Medicare patient requests a service or item that you know or expect is non-covered, please follow our Medicare pre-authorization process to request a pre-service organization determination.
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
If your Medicare Advantage patient requests a service or item you expect to be non-covered (including those that are statutorily excluded by Medicare, or non-covered by the member's Medicare Advantage plan), you can request a pre-service determination by submitting our pre-authorization request form by phone or fax. Note: Do not submit them via the Availity electronic authorization tool. You must follow our Medicare pre-authorization process for a pre-service organization determination in order for services to be considered for approval and for you to be able to bill the member for services that are not covered. This process replaces the former Advanced Beneficiary Notification (ABN) process for Medicare Advantage.
Within 14 calendar days, we will approve or deny the request, and provide notification to you and the member. A denial notice will include the reason and explain the appeal process. If you wish to appeal a denial on behalf of the member, you must also have a completed Appointment of Representative form (Form CMS-1696).
Submit an electronic pre-authorization request, and supporting clinical documentation through the Availity Portal Login>Patient Registration>Authorizations & Referrals>Authorizations
- Learn more about submitting requests through Availity
- Submit a pre-authorization request form
- Radiology and sleep medicine: Sign into the AIM Specialty HealthSM Provider Portal
- Physical medicine: Sign in to the eviCore portal
Phone or fax
Submit the appropriate pre-authorization request form only if unable to submit online or if submitting an expedited request:
- Medical services (PDF)
- Behavioral health services (PDF)
- Medicare home health services (PDF)
- Durable medical equipment (DME) (PDF)
- Skilled nursing facility (SNF), long term acute care (LTAC) and inpatient rehabilitation (PDF)
|Type of service||Online||Phone||Fax (only if unable to submit online)|
|Skilled nursing facility only||Submit an electronic pre-authorization request through the Availity Portal||1 (844) 600-4376||1 (855) 848-8220|
Long term acute care
|1 (800) 423-6884||1 (855) 848-8220|
|1 (800) 780-7881||1 (888) 496-1540|
|Transplants||1 (800) 423-6884||1 (800) 584-0689|
|Professional services and DME||1 (800) 423-6884||1 (855) 232-0085|
|Expedited requests||1 (800) 423-6884||1 (855) 240-6498|
Codes requiring authorization are listed in the Radiology section below. View a list of groups and products that participate in this program (PDF).
Obtain an order number with AIM Specialty HealthSM:
Codes requiring authorization are listed in the Physical Medicine section below. View a list of groups and products that participate in this program (PDF).
Obtain or verify an authorization with eviCore healthcare (eviCore):
Codes requiring authorization are listed in the Sleep Medicine section below. View a list of groups and products that participate in this program (PDF).
Obtain an order number with AIM:
Inpatient concurrent review
|1 (800) 423-6884||1 (800) 453-4341|
Clinical Records for:
|1 (800) 423-6884||1 (844) 629-4404|
Important pre-authorization reminders
- 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.
- Before requesting pre-authorization and providing services, please verify member eligibility and benefits via the Availity Portal as the member contract determines the covered benefits.
- Verify that you are an in-network provider for each member to help reduce his or her out-of-pocket expense.
- 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.
- Emergency services do not require pre-authorization, but notification should be provided for all hospital admissions or discharges within 24 hours of admission or discharge (or one business day, if the admission occurs on a weekend or a federal holiday).
- Our Medicare Medical Policy, MCG and CMS criteria may be used as the basis for medical necessity determinations, including length of stay and level of care.
- Experimental and cosmetic services and supplies are typically contract exclusions and are ineligible for payment. Unlisted codes may be used for potentially experimental services and are subject to review. Experimental procedures and items are those items and procedures determined by our plan and Original Medicare to not be generally accepted by the medical community. Please refer to the Always Not Medically Necessary Denials list for additional information.
- Please note that a notification or pre-authorization does not guarantee payment for requested services. Payment of benefits is subject to pre-payment and/or post-payment review, and all plan provisions, including, but not limited to, eligibility for benefits and our Coding Toolkit clinical edits.
- Pre-authorization requirements are not dependent upon site of service. All CPT and HCPCS codes listed on our pre-authorization lists require pre-authorization. View list below for complete information.
Pre-authorization review timeframes
|Type of review||Timeframe||Additional time allowed for review if additional information is needed:|
|Standard initial||14 calendar days||
Regence provider: None
Non-Regence provider: 14 calendar days
|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 write-off. Our members must be held harmless and cannot be balance billed.
Notification of inpatient admission should be provided to the health plan. Urgent/emergent services are subject to review post-service for medical necessity; please submit proper clinical documentation with claim.
Please note the following:
- Hospital claims for elective services 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. Additionally, the pre-authorization should designate the facility where the treatment will occur to ensure proper reconciliation with related inpatient claims.
- 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.
- If an elective service that requires pre-authorization needs to occur during the course of an inpatient admission, and that need could not be foreseen prior to admission, the facility/provider can request pre-authorization for the service while the member is inpatient (before the service occurs). If pre-authorization does not occur during the stay, services are subject to review post-service for medical necessity.
There may be exceptions to obtaining pre-authorization. The six situations listed below may apply as part of our Extenuating Circumstances Policy Criteria (PDF):
- 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.
- Natural disaster prevented the provider or facility from securing a pre-authorization or providing hospital admission notification.
- Member is unable to communicate (e.g., unconscious) medical insurance coverage. Neither family nor collateral support present can provide coverage information.
- 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.
- A surgery which requires pre-authorization occurs in an urgent/emergent situation. Services are subject to review post-service for medical necessity
- 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) prior to claim submission.
- Learn now to appeal a claim that has been administratively denied (PDF).
Use PreManage for notification
We receive admissions and discharge information through PreManage.
See below for chemical dependency and mental health admissions.
Pre-authorization is required for elective inpatient admissions occurring on or after May 1, 2019. For more information, read our Frequently Asked Questions (PDF).
Notification of a hospital admissions or discharge is necessary within 24 hours of admission or discharge (or one business day, if the admission or discharge occurs on a weekend or a federal holiday).Notification should be provided via electronic medical record, if available. If electronic medical records are not available, notifications should be provided 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.
Notification of admission or discharge is necessary within 24 hours of admission or discharge (or one business day, if the admission or discharge occurs on a weekend or a federal holiday).
Notification should be provided via electronic medical record, if available. If electronic medical records are not available, notifications should be provided 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 required prior to patient admission.
Pre-authorization required prior to patient admission.
Skilled Nursing Facility (SNF) (PDF) - sometimes referred to as "sub-acute rehabilitation
Pre-authorization required prior to patient admission.
SNF is required to fax the Notice of Medicare Non-Coverage (NOMNC) on discharge from services.
|Extracorporeal Circulation Membrane Oxygenation (ECMO) for the Treatment of Respiratory Failure in Adults (PDF)||Regence requires the facility to specifically notify Regence when ECMO is initiated on a Regence Member. We will initiate concurrent review upon this notification.|