Medical Policy, Pharmacy Policy, & Provider Information

Providence Health Plan, Providence Health Assurance, and Providence Health Plan Partners

Select a topic below to access policies or more information:

Prior-authorization, Non-covered, and DME and Supplies Lists and Fax Forms
The following lists are intended to provide guidance regarding coverage of healthcare services and are not all inclusive. Additional exclusions may apply based on benefit and contract terms.
General Prior-authorization Requirements
Prior-authorization Medical Fax Form
- PA Fax Form
- Transplant PA Fax Form
Prior-authorization Behavioral Health Fax Forms

For new members, authorizations will be held until member eligibility can be verified.
Clinical Edit Inquiry Form
- Clinical Edit Inquiry Form - Fax Version
Clinical Edit Inquiry Form instructions

**Before sending in a Clinical Edit Inquiry form, review all applicable Payment Policies and Medical Director Edits.

This form can be completed by participating providers.
1. Completely fill out the ‘Sender information’ box at the top of the form.
2. Include the following as instructed on the form:
  - Chart notes for date of service that support all procedures.
  - Letter of explanation for the inquiry
  - Check the box to identify which edit is being appealed. If the edit you are appealing is not listed, enter the edit code in the blank box.
  - Pay close attention to which fax number is listed above the edit code that applies to ensure that the form is sent to the correct area.
Non- participating providers that are disputing a clinical edit would need to send information to the claim support team fax # 503-574-8146
Coding Policies and Alerts
Billing, Payment, and Coding Policy Alerts
Billing, Payment, and Coding Policies
Medical and Pharmacy Policy Alerts
Medical and Pharmacy Policy Alerts
Medical Policies
**Special Notice**

Medical Policy Committee: External Provider Review

PHP/PHA Medical Policy Committee is looking to expand our group of external providers who serve as clinical subject matter experts (SMEs) through the policy development and annual review processes. We are seeking provider participation across various clinical specialties who will review and provide feedback on our medical policies. The medical policy specialties include (but are not limited to) pain management, behavioral health, endocrinology, genetics, orthopedics, neurology, urology, cardiology, oncology and general surgery. A complete list of medical policies is below.

Provider SME responsibilities include the following tasks and would occur via email or ad hoc virtual meetings:
- Reviewing medical policies and providing feedback during the annual review and policy development process.
- Working with Medical Policy Analysts and Medical Directors to address any feedback.
- Responding to any questions that may arise throughout the year related to medical policies of their specialty.
If you are interested in becoming an external provider reviewer, please contact the medical policy team at PHPMedicalPolicy@providence.org with the following information:
- Name
- Specialty
- Email
- Phone number
- Any specific medical policies that you are interested in reviewing. By default, we will include you in any policies related to your specialty.
Thank you, and we look forward to hearing from you.

**Lab Management FAQ**

Effective 11/1/2021, Providence Health Plan and Providence Health Assurance will institute additional CMS National Coverage Determinations (NCDs) of selected lab services for Medicare, commercial and individual plans.

Q: What is the CMS NCD coding policy manual?

A: The final rule, published in the Federal Register on November 23, 2001 (66 FR 58788), established the national coverage and administrative policies for clinical diagnostic laboratory services. It promoted Medicare program integrity and national uniformity, and simplified administrative requirements for clinical diagnostic services. A total of 23 lab NCDs for diagnostic lab testing services were established as part of this 2001 final rule.

For each of the 23 NCDs, the CMS NCD coding policy manual outlines ICD-10-CM codes that are medically necessary or do not support medical necessity. The coding policy manual also includes limitations to these lab testing services, such as frequency limits.

Q: What is a NCD for diagnostic laboratory testing?

A: A national coverage policy for diagnostic laboratory test(s) is a document stating CMS’s policy with respect to the clinical circumstances in which the test(s) will be considered reasonable and necessary, and not screening, for Medicare purposes. Such a policy applies nationwide.

Q: How is Providence Health Plan and Providence Health Assurance implementing the NCDs for diagnostic laboratory testing and the CMS NCD coding policy manual?

A: Through medical policy, we will create new policies based on the NCDs for diagnostic laboratory testing and the CMS NCD coding policy manual. The CPT/HCPCS codes for the various lab testing services are configured to pay or deny (not medically necessary) based on the diagnosis codes outlined in the coding policy manual.

Q: What laboratory services will be affected by this change?

A: For Medicare, commercial, and individual lines of business, we will implement medical policies and coding configuration based on the CMS NCD coding policy manual for the following NCDs:
- Prostate Specific Antigen (NCD 190.31)
- Serum Iron Studies (NCD 190.18)
- Partial Thromboplastin Time (NCD 190.16)
- Hepatitis Panel/Acute Hepatitis Panel (NCD 190.33)
  
  Q: When will the new policies and coding configuration take effect?
  
  A: 11/1/2021 for Medicare, commercial, and individual plans. On this date, the medical policies will be accessible here:
  
  https://www.providencehealthplan.com/providers/medical-policy--rx-pharmacy-and-provider-information
  
  Q: Where can I access the NCDs for diagnostic laboratory testing and the CMS NCD coding policy manual?
  
  A: The NCDs are linked below. Within every NCD there is a section titled “Covered Code Lists”. Under this section, you may download the most recent version of the CMS NCD coding policy manual.
- Prostate Specific Antigen (NCD 190.31)
- Serum Iron Studies (NCD 190.18)
- Partial Thromboplastin Time (NCD 190.16)
- Hepatitis Panel/Acute Hepatitis Panel (NCD 190.33)
MEDICAL POLICIES:
Medical Policy Inquiries
Medical Policy Development Process

Providence Health Plan (PHP) medical policies are developed to provide guidelines for determining coverage criteria of medical services based on an evaluation of current evidence and utilization management activities for all applicable ministries. Medical policies are utilized to define medical necessity criteria and establish parameters and guidelines for approving selected medical services that support safe and effective healthcare.

Medical policies are objective and based on current, peer- reviewed clinical evidence and are utilized in making medical service coverage determinations after applicable benefit, contract, and other regulatory restrictions have been applied. Prior to implementation, medical policies are vetted and approved by the PHP Medical Policy Committee. The Medical Policy Committee consists of medical directors, nurse reviewers, and various other internal stakeholders and subject matter experts. Policies are reviewed on an annual basis or as new, relevant evidence is published by peer-reviewed, scientific journals. The timing of annual review is posted in the section below.

Medical Policy Inquiries

All inquiries concerning PHP medical policies or new medical devices and technologies may be sent to: PHPMedicalPolicyInquiry@providence.org

Please do not contact PHP medical directors or medical policy analysts directly.

When inquiries are submitted through the e-mail address above, the following information is required in order to adequately address questions or policy change recommendations:
- Type of technology/procedure and the condition being treated
- A detailed description of the ask of medical policy and desired outcome
- Any relevant, published, peer-reviewed studies
- Any relevant, evidence-based clinical practice guidelines
- Regulatory or FDA approved information
Medical Policy Annual Updates
January
- Advanced Diabetes Management Technology (All LOB Except CMS)
- Advanced Diabetes Management Technology (Medicare Only)
- Exhaled Breath Tests (All LOB Except CMS)
- Exhaled Breath Tests (Medicare Only)
- Fecal Analysis of Gastrointestinal Microbiome
- Gastroesophageal Reflux Disease: Endoscopic Treatments (All Lines of Business Except Medicare)
- Gastroesophageal Reflux Disease: Endoscopic Treatments (Medicare Only)
- Gender Affirming Surgical Interventions
- Lower Limb Prosthesis (All Lines of Business Except Medicare)
- Lower Limb Prosthesis (Medicare Only)
- Myoelectric Upper Limb Prosthesis
- Occipital Nerve Stimulation (All Lines of Business Except Medicare)
- Organ Transplantation (All Lines of Business Except Medicare)
- Organ Transplantation (Medicare Only)
- Stem Cell Therapy for Orthopedic Applications
- Stem Cell Transplantation (All Lines of Business Except Medicare)
- Stem Cell Transplantation (Medicare Only)
February
- Autologous Fat Transfer
- Back: Ablative Procedures to Treat Back and Neck Pain (All Lines of Business Except Medicare)
- Back: Facet Joint Injections, Medial Branch Blocks, and Facet Joint Radiofrequency Neurotomy (Medicare Only)
- Back: Sacroiliac Joint Fusion or Stabilization (All LOB except CMS)
- Back: Sacroiliac Joint Fusion or Stabilization (Medicare Only)
- Breast Cancer: Focused Microwave Phased Array Thermotherapy for Breast Cancer
- Breast Cancer: Radiofrequency Ablation of Breast Tumors
- Cardiac: Ventricular Assist (VAD/pVAD/LVAD) and Artificial Heart (Biventricular) Devices
- Chelation Therapy for Non-Overload Conditions
- Continuous Passive Motion (CPM) Device in the Home Setting (All Lines of Business Except Medicare)
- Continuous Passive Motion (CPM) Device in the Home Setting (Medicare Only)
- Dental Anesthesia Services
- Direct-to-Consumer Testing
- Electrothermal Capsular Shrinkage
- Ganglion Impar Blocks
- Genetic Testing: Reproductive Planning and Prenatal Testing (All Lines of Business Except Medicare)
- Genetic Testing: Reproductive Planning and Prenatal Testing (Medicare Only)
- Hemangioma and Vascular Malformation Treatment
- Interferential Stimulation (IFS)
- Knee Braces (Functional)(All Lines of Business Except Medicare)
- Orthotic Foot Devices and Orthopedic Shoes (All Lines of Business Except Medicare)
- Percutaneous Neuromodulation Therapy (Medicare Only)
- Percutaneous Neuromodulation Therapy (PNT) (All Lines of Business Except Medicare)
- Premature Rupture of Membranes (PROM) Testing
- Radiofrequency Ablation and Cryoablation for Plantar Fasciitis
- Rehabilitation: Acute Inpatient
- Speech Generating Devices
- Transcutaneous Electrical Nerve Stimulators (TENS) and Related Supplies (All Lines of Business Except Medicare)
- Vitamin D Assay Testing
- Wireless Capsule for Gastrointestinal Motility Monitoring
March
- Ambulance Transport
- Anesthesia Care with Diagnostic Endoscopy
- Athletic Pubalgia/Sports Hernia Surgery
- Auricular Electrostimulation (All Lines of Business Except Medicare)
- Auricular Electrostimulation (Medicare Only)
- Bariatric: Surgery (All LOB Except Medicare)
- Bariatric: Surgery (Medicare Only)
- Breast Reconstruction
- Chemoresistance and Chemosensitivity Assays
- Circulating Tumor Cell and DNA Assays for Cancer Management (All Lines of Business Except Medicare)
- Colorectal Cancer Screening
- Eye: Blepharoplasty, Blepharoptosis Repair, and Brow Lift (Medicare Only)
- Fecal Microbiota Transplantation
- Genetic Testing: Inherited Susceptibility to Colorectal Cancer (All Lines of Business Except Medicare)
- Genetic Testing: Inherited Susceptibility to Colorectal Cancer (Medicare Only)
- Genetic Testing: Inherited Thrombophilias (All Lines of Business except Medicare)
- Genetic Testing: Inherited Thrombophilias (Medicare only)
- Genetic Testing: JAK2, CALR, and MPL (All Lines of Business Except Medicare)
- Genetic Testing: JAK2, CALR, and MPL (Medicare Only)
- Hip: Total Joint Arthroplasty (All Lines of Business Except Medicare)
- Hip: Total Joint Arthroplasty (Medicare Only)
- Home Oxygen Therapy and Equipment for Cluster Headaches (All Lines of Business Except Medicare)
- Home Oxygen Therapy and Equipment for Lung Disease or Hypoxia (All Lines of Business Except Medicare)
- Home Oxygen Therapy and Equipment for Cluster Headaches (Medicare Only)
- Home Oxygen Therapy and Equipment for Lung Disease or Hypoxia (Medicare Only)
- Lyme Disease
- Mechanical Stretching Devices for Joints of the Extremities
- Microcurrent Electrical Neuromuscular Stimulation (MENS)
- Next Generation Sequencing for Minimal Residual Disease Detection (All Lines of Business Except Medicare)
- Next Generation Sequencing for Minimal Residual Disease Detection (Medicare Only)
- Ovarian Cancer: Multimarker Serum Testing (All Lines of Business Except Medicare)
- Prostate Protein Biomarkers and Genetic Testing (All Lines of Business Except Medicare)
- Prostate Protein Biomarkers and Genetic Testing (Medicare Only)
- Prostate: MRI-Transrectal Ultrasound (MRI-TRUS) Fusion Biopsy
- Subcutaneous Hormone Pellet Implant
- Surgical Treatment for Skin Redundancy (All Lines of Business Except Medicare)
- Surgical Treatment for Skin Redundancy (Medicare Only)
- Vectra DA Test for Rheumatoid Arthritis (All Lines of Business Except Medicare)
- Vectra DA Test for Rheumatoid Arthritis (Medicare Only)
- Wilderness Therapy
April
- Ankle-Foot/Knee-Ankle-Foot Orthoses (All Lines of Business Except Medicare)
- Ankle-Foot/Knee-Ankle-Foot Orthoses (Medicare Only)
- Back: Stabilization Devices and Interspinous Spacers
- Blood Brain Barrier Disruption and Bypass
- Cardiac: Disease Risk Screening (All Lines of Business Except Medicare)
- Cardiac: Disease Risk Screening (Medicare Only)
- Compression Bandages, Stockings, and Wraps (All Lines of Business Except Medicare)
- Compression Bandages, Stockings, and Wraps (Medicare Only)
- Compression: Outpatient Pneumatic Devices (All Lines of Business Except Medicare)
- Compression: Outpatient Pneumatic Devices (Medicare Only)
- Durable Medical Equipment (All Lines of Business Except Medicare)
- Durable Medical Equipment (Medicare Only)
- Genetic Testing: Hereditary Breast and Ovarian Cancer (All Lines of Business Except Medicare)
- Genetic Testing: Hereditary Breast and Ovarian Cancer (Medicare Only)
- Helicobacter Pylori Serologic Testing
- Intraoperative Neurophysiological Testing and Monitoring (All Lines of Business Except Medicare)
- Intraoperative Neurophysiological Testing and Monitoring (Medicare Only)
- Knee Braces (Functional)(Medicare Only)
- NanoKnife System: Irreversible Electroporation (IRE)
- Nerve Conduction Studies (ALL LOB Except Medicare)
- Nerve Conduction Studies (Medicare Only)
- Orthotic Foot Devices and Therapeutic Shoe (Medicare only)
- Pelvic Congestion Syndrome Treatment
- Prostate: High Intensity Focused Ultrasound (All Lines of Business Except Medicare)
- Prostate: Prostatic Urethral Lift
- Seat Lift Chair Mechanism (All Lines of Business Except Medicare)
- Seat Lift Chair Mechanism (Medicare only)
- Sleep Disorder Testing (All Lines of Business Except Medicare)
- Sleep Disorder Testing (Medicare Only)
- Sleep Disorder Treatment: Oral Appliances (All Lines of Business Except Medicare)
- Sleep Disorder Treatment: Oral Appliances (Medicare Only)
- Sleep Disorder Treatment: Positive Airway Pressure (All Lines of Business Except Medicare)
- Sleep Disorder Treatment: Positive Airway Pressure (Medicare Only)
- Surface Electromyography (sEMG) Testing
- Surgical Site of Service
- Transcutaneous Electrical Nerve Stimulators (Medicare only)
- Wheelchair and Power Vehicles (All Lines of Business Except Medicare)
- Wheelchair and Power Vehicles (Medicare only)
- Wireless Capsule Endoscopy (All Lines of Business Except Medicare)
- Wireless Capsule Endoscopy (Medicare Only)
May
- Allergy Testing (All LOB Except Medicare)
- Allergy Testing (Medicare Only)
- Back: Artificial Intervertebral Disc (All Lines of Business Except Medicare)
- Back: Artificial Intervertebral Disc (Medicare Only)
- Back: Discography
- Back: Intradiscal Procedures for Low Back Pain (All Lines Of Business Except Medicare)
- Back: Intradiscal Procedures for Low Back Pain (Medicare Only)
- Blood Counts (All Lines of Business Except Medicare)
- Breast Implant Removal (All Lines of Business Except Medicare)
- Breast Implant Removal (Medicare Only)
- Breast Surgery: Reduction Mammoplasty (All Lines of Business Except Medicare)
- Breast Surgery: Reduction Mammoplasty (Medicare Only)
- Bronchial Thermoplasty
- Cardiac Left Atrial Appendage Devices (All Lines of Business Except Medicare)
- Cardiac Left Atrial Appendage Devices (Medicare Only)
- Cardiac: External Ambulatory Electrocardiography (All Lines of Business Except Medicare)
- Cardiac: External Ambulatory Electrocardiography (Medicare Only)
- Cardiac: Transcatheter Aortic Valve Replacement (TAVR) (All Lines of Business Except Medicare)
- Cardiac: Transcatheter Aortic Valve Replacement (TAVR) (Medicare Only)
- Cefaly Device for Treatment of Migraine Headaches
- Circulating Tumor Cell and DNA Assays For Cancer Management (Medicare Only)
- Cochlear Implants and Auditory Brainstem Implants (All Lines of Business Except Medicare)
- Cochlear Implants and Auditory Brainstem Implants (Medicare Only)
- Definition: Confined to the Home
- Definition: Mobility Assistive Equipment
- Dental Services: Administrative Guideline (All Lines of Business Except Medicare)
- Dental Services: Administrative Guideline (Medicare Only)
- Eye: Blepharophasty, Blepharoptosis Repair, and Brow Lift (All Lines of Business Except Medicare)
- Eye: Corneal Collagen Cross-Linking (All Lines of Business Except Medicare)
- Eye: Retinopathy Telescreening
- Genetic Testing: Diagnostic Evaluation of Interstitial Lung Disease (All Lines of Business Except Medicare)
- Genetic Testing: Diagnostic Evaluation of Interstitial Lung Disease (Medicare Only)
- Glycated Hemoglobin and Glycated Protein Diagnostic Testing (All Lines of Business Except Medicare)
- Lipid Testing (All Lines of Business Except Medicare)
- Negative Pressure Wound Therapy (All Lines of Business Except Medicare)
- Negative Pressure Wound Therapy (Medicare Only)
- Orthognathic Surgery
- Proton Beam Radiation Therapy
- Residential Mental Health Treatment Facilities
- Standing Systems (All Lines of Business Except Medicare)
- Standing Systems (Medicare Only)
- Surgical Treatment of Lymphedema
- Thyroid Testing (All Lines of Business Except Medicare)
- Tumor Treatment Fields Therapy for Glioblastoma (All Lines of Business Except Medicare)
- Tumor Treatment Fields Therapy for Glioblastoma (Medicare Only)
June
- Blood Counts (Medicare Only)
- Celiac Disease: Serologic Testing
- Gastric Electrical Stimulation
- Gastroesophageal Reflux: Magnetic Esophageal Ring
- Hyperbaric Oxygen Therapy (All LOB Except Medicare)
- Hyperbaric Oxygen Therapy (Medicare Only)
- Low-level and High-power Laser Therapy
- Non-Small Cell Lung Cancer: Molecular Testing for Targeted Therapy (All Lines of Business Except Medicare)
- Non-Small Cell Lung Cancer: Molecular Testing for Targeted Therapy (Medicare Only)
- Peroral Endoscopic Myotomy (POEM)
- Prolotherapy
- Thyroid Testing (Medicare Only)
- Urinary Incontinence Treatments (All Lines of Business Except Medicare)
- Urinary Incontinence Treatments (Medicare Only)
- Viscosupplementation (All Lines of Business Except Medicare)
- Viscosupplementation (Medicare Only)
- Walkers (All Lines of Business Except Medicare)
- Walkers (Medicare Only)
July
- Apheresis (Therapeutic Pheresis) (All Lines of Business Except Medicare)
- Apheresis (Therapeutic Pheresis)(Medicare Only)
- Genetic Testing for Heritable Connective Tissue Disorders
- Genetic Testing: Non-Covered Genetic Panel Tests (All Lines of Business Except Medicare)
- Genetic Testing: Non-Covered Genetic Panel Tests (Medicare Only)
- Genetic Testing: Pharmacogenetic Testing (All LOB Except Medicare)
- Genetic Testing: Pharmacogenetic Testing (Medicare Only)
August
- Back: Percutaneous Vertebral Augmentation
- Bone Growth Stimulators (All LOB except CMS)
- Bone Growth Stimulators (CMS Only)
- Cardiac: Implantable Loop Recorders
- Clinical Trials and IDE Studies (Medicare Only)
- Clinical Trials and Devices (All Lines of Business Except Medicare)
- Cosmetic and Reconstructive Surgery (All Lines of Business Except Medicare)
- Cosmetic and Reconstructive Surgery (Medicare Only)
- Diabetes: Blood Glucose Monitor and Supplies (All Lines of Business Except Medicare)
- Diabetes: Blood Glucose Monitor and Supplies (Medicare Only)
- Fecal Incontinence Treatments (All Lines of Business Except Medicare)
- Fecal Incontinence Treatments (Medicare Only)
- Genetic Counseling
- Genetic Testing: CADASIL Disease
- Genetic Testing: MTHFR (Medicare Only)
- Genetic Testing: Whole Exome and Whole Genome
- Glycated Hemoglobin and Glycated Protein Diagnostic Testing (Medicare Only)
- Inflammatory Bowel Disease: Measurement of Antibodies to Immunosuppressive Therapies
- Inflammatory Bowel Disease: Serologic Testing and Therapeutic Monitoring
- Investigational and Non-Covered Medical Technologies (Medicare Only)
- Knee: Ablative Procedures of Peripheral Nerves to Treat Knee Pain
- Knee: Autologous Chondrocyte Implantation (ACI) for Cartilaginous Defects
- Knee: Meniscal Allograft Transplantation and Other Meniscal Implants
- Knee: Osteochondral Allografts and Autografts for Cartilaginous Defects
- Lipid Testing (Medicare Only)
- Molecular and Genetic Diagnostic Testing (All Lines of Business Except Medicare)
- Platelet-Rich Plasma (PRP) for Orthopedic Indications, Wound Care and Other Miscellaneous Conditions (Medicare Only)
September
- Chiropractic Care (All Lines of Business Except Medicare)
- Chiropractic Care (Medicare Only)
- Cranial Electrical Stimulation
- Genetic Testing: Genetic Expression Profile Testing for Melanoma (All Lines of Business Except Medicare)
- Genetic Testing: Genetic Expression Profile Testing for Melanoma (Medicare Only)
- Joint Resurfacing
- Molecular and Genetic Diagnostic Testing (Medicare Only)
- Organic Acid Testing
- Outpatient Physical Therapy (All Lines of Business Except Medicare)
- Platelet-Rich Plasma (PRP) for Orthopedic Indications, Wound Care and Other Miscellaneous Conditions (All Lines of Business Except Medicare)
- Respiratory Viral Panels (All Lines of Business Except Medicare)
- Respiratory Viral Panels (Medicare Only)
- Sleep Disorder Treatment: Surgical (All Lines of Business Except Medicare)
- Sleep Disorder Treatments: Surgical (Medicare Only)
- Ultrarapid Detoxification
- Varicose Veins (All LOB except Medicare)
- Varicose Veins (Medicare Only)
October
- Back: Fusion and Decompression Procedures
- Complimentary and Alternative Medicine (CAM) Treatments
- Definition: Urgent Care (Out of Area)
- Hearing Aids (All Lines of Business Except Medicare)
- Investigational and Non-Covered Medical Technologies (All Lines of Business Except Medicare)
- Liver Tumor Treatment (All Lines of Business Except Medicare)
- Liver Tumor Treatment (Medicare Only)
- Prostate: Water Vapor Thermotherapy for Benign Prostatic Hyperplasia
November
- Back: Epidural Steroid Injections (Medicare Only)
- Back: Epidural Steroid Injections All LOBs except Medicare)
- Back: Implantable Spinal Cord and Dorsal Root Ganglion Stimulation (All LOB Except CMS)
- Back: Implantable Spinal Cord and Dorsal Root Ganglion Stimulation (CMS Only)
- Cold Therapy and Cooling Devices in the Home Setting
- Definition: Experimental/Investigational
- Definition: Medical Necessity
- Eye: Automated Evacuation of the Meibomian Glands
- Genetic Testing: Thyroid Nodules (All Lines of Business Except Medicare)
- Genetic Testing: Thyroid Nodules (Medicare Only)
- Percutaneous Ultrasonic Ablation for Tendinopathy
- Peripheral Nerve Stimulation for Chronic Pain (Medicare Only)
- Rhinoplasty (All Lines of Business Except Medicare)
- Rhinoplasty (Medicare Only)
- Stereotactic Body Radiation Therapy and Stereotactic Radiosurgery (All LOB Except Medicare)
- Stereotactic Body Radiation Therapy and Stereotactic Radiosurgery (Medicare Only)
- Transcranial Magnetic Stimulation (All LOB Except CMS)
- Transcranial Magnetic Stimulation (CMS Only)
December
- Applied Behavior Analysis
- Balloon Dilation of the Sinuses or Eustachian Tubes
- Biofeedback and Neurofeedback
- Centers for Medicare & Medicaid Services (CMS) Medical Policy Manual
- Deep Brain and Responsive Cortical Stimulation (All LOB Except CMS)
- Deep Brain and Responsive Cortical Stimulation (CMS Only)
- Drug Testing for Therapeutic or Substance Use Monitoring (All LOB Except Medicare)
- Drug Testing for Therapeutic or Substance Use Monitoring (Medicare Only)
- Extended Outpatient Psychotherapy (All LOB Except Medicare)
- Extended Outpatient Psychotherapy (Medicare Only)
- General Prior Authorization Requirements Pages
- Genetic Testing: Gene Expression Profile Testing for Breast Cancer (All Lines of Business Except Medicare)
- Genetic Testing: Gene Expression Profile Testing for Breast Cancer (Medicare Only)
- Medical Policy Development and Application
- Prior Authorization Application Procedure
- Providence Healthcare Services Medical Policy Alert
- Psychological and Neuropsychological Testing (All LOB Except Medicare)
- Psychological and Neuropsychological Testing (Medicare Only)
- Salivary Hormone Testing (All Lines of Business Except Medicare)
- Salivary Hormone Testing (Medicare Only)
- Skin and Tissue Substitutes
- Vagus Nerve Stimulation (All Lines of Business Except Medicare)
- Vagus Nerve Stimulation (Medicare Only)
- Vendor and Delegate Medical Policy Adoption
Pharmacy Policies
Drug Prior Authorization Request Form
- Drug Prior Authorization Request Form
- Commercial Maximum Allowable Opioid Dose Request Form
Commercial Plans
- Commercial Pharmacy Policy Criteria
- Commercial Medical Benefit Drug Policy Criteria
Infusion Therapy Site of Care

Providence Health Plan (PHP) requires site of care prior authorization for the medications listed below when given in an unapproved hospital setting. A separate prior authorization may be required for the drug. Refer to the Infusion Therapy SOC Policy link below.
Medicare Plans
- Medicare Part D Pharmacy Policy Criteria
- Medicare Part B Step Therapy Drug List
Medicaid Plans
- Medicaid Pharmacy Policy Criteria
Opioid Resources and Guidelines

PHP has created a list of links designed to empower providers to make evidence based decisions when starting opioid therapy as well provide support when taper is indicated.
- Opioid Resources & Guidelines
Biosimilar Preferred Product Program

Applies to Commercial and Medicaid Only

Effective July 1, 2021, the brand name medications listed below will become non-preferred products and will require a separate prior authorization review for ongoing coverage.
- Provider Information and Biosimilar Preferred Product Drug List
Refer to the policies below for clinical criteria changes effective July 1, 2021:
- Injectable Anti-Cancer Medications
- Rituximab
Outpatient Rehabilitation
- PHP Outpatient Rehabilitation Information
- PHP Outpatient Rehabilitation CPT Code List

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Medical Policy, Pharmacy Policy, & Provider Information

Select a topic below to access policies or more information:

Prior-authorization, Non-covered, and DME and Supplies Lists and Fax Forms

General Prior-authorization Requirements

Prior-authorization Medical Fax Form

Prior-authorization Behavioral Health Fax Forms

Clinical Edit Inquiry Form

Coding Policies and Alerts

Billing, Payment, and Coding Policy Alerts

Billing, Payment, and Coding Policies

Medical and Pharmacy Policy Alerts

Medical and Pharmacy Policy Alerts

Medical Policies

Medical Policy Inquiries

Medical Policy Development Process

Medical Policy Inquiries

Medical Policy Annual Updates

January

February

March

April

May

June

July

August

September

October

November

December

Pharmacy Policies

Drug Prior Authorization Request Form

Commercial Plans

Infusion Therapy Site of Care

Medicare Plans

Medicaid Plans

Opioid Resources and Guidelines

Biosimilar Preferred Product Program

Outpatient Rehabilitation

providers

We've got you covered. If you need information or help, don't hesitate to reach out.

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