Medical Policy, Pharmacy Policy, & Provider Information
Providence Health Plan, Providence Health Assurance, and Providence Health Plan Partners
**Please Note**
Temporary Operational Changes During COVID-19
Providence Health Plan (PHP) is committed to assisting our members and provider partners during this uncertain time. Due to cancellation/rescheduling of non-emergent procedures and other services and the need to conserve personal protective equipment (PPE), PHP is implementing the following medical management adjustments:
Prior-authorization and Referral Request Extensions
- Approved prior-authorizations (including medical procedures/services, AIM imaging services, Evicore rehab services) and referral requests received between 2/1/2020-6/15/2020 will be extended until 9/30/2020.
- A referral may not be required for Providence Medicare Advantage Plan members to receive out-of-network care during a disaster.
- Approved Medicaid prior-authorizations will be extended until the end of the year.
- Please note, extensions only apply to the date span of the original request and will not alter the frequency or units or any additional services not otherwise originally approved. If additional procedures/services are necessary, please submit a new prior authorization for review.
- Extensions only apply to approved authorizations for services not yet rendered.
- No further action by you or your staff is necessary — PHP will process extension updates to referrals and prior authorizations.
- Please note, extension dates may change based evolving circumstances related to COVID-19.
- Extension dates noted above are general guidelines which should not supersede extension dates individually communicated to members and providers.
Out-of-network Requests
- This change will be in addition to current UM practices and procedures for OON requests, such as network availability, capacity, and medical necessity of services. >
- Providence Medicare Advantage Plans may cover services rendered by out-of-network providers during a disaster at in-network costs. This coverage is available regardless of the type of plan you are enrolled in.
Providence Health Plan remains open and is operating under normal business hours.
Select a topic below to access policies or more information:
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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
- General PA Requirements Medicare HMO
- General PA Requirements PEBB Statewide and PEBB Choice
- General PA Requirements PPO
- General PA Requirements Standard
- General PA Requirements PHS Swedish, Kadlec, PacMed
- General PA Requirements OHP
Prior-authorization Medical Fax Form
Prior-authorization Behavioral Health Fax Forms
For new members, authorizations will be held until member eligibility can be verified.
- Prior Authorization BH Inpatient Fax Form
- Prior Authorization BH Outpatient Fax Form
- Prior Authorization BH TMS Fax Form
- Prior Authorization BH ABA Fax Form
Clinical Edit Inquiry Form
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.
- Completely fill out the ‘Sender information’ box at the top of the form.
- 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
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Medical, Pharmacy, Billing, Payment, and Coding Policy Alerts
Medical and Pharmacy Policy Alerts
- April 2021
- March 2021
- February 2021
- January 2021
- December 2020
- November 2020
- October 2020
- September 2020
- August 2020
- July 2020
- June 2020
- May 2020
- April 2020
- March 2020
- February 2020
- January 2020
- December 2019
- November 2019
- October 2019
- September 2019
- August 2019
- July 2019
- June 2019
- May 2019
- April 2019
- March 2019
- February 2019
- January 2019
- December 2018
Billing, Payment, and Coding Policy Alerts
- Telehealth Services DURING COVID-19 CRISIS
- Payment and Coding Policy Alerts – COVID-19 UPDATE
- Coding Policy Alert March/April 2020
- Coding Policy Alert March 26, 2020
- Coding Policy Alert April 2, 2020
- Coding Policy Alert June 26, 2020
- Coding Policy Alert July/August 2020
- Coding Policy Alert September/October 2020
- Coding Policy Alert October 2, 2020
- Coding Policy Alert November/December 2020
- Coding Policy Alert January/February 2021
- Coding Policy Alert March/April 2021
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Medical Policy
**Special Notice**
New Laboratory Management Medical Policies (effective 6/1/2021)
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Providence Health Plan (PHP), Providence Health Assurance (PHA), and Providence Health Plan Partners (PPP) Medical Policies serve as guidance for the administration of plan benefits. Medical policies do not constitute medical advice nor a guarantee of coverage. PHP, PHA, and PPP Medical Policies are reviewed annually and are based upon published, peer-reviewed scientific evidence and evidence-based clinical practice guidelines that are available as of the last policy update. PHP, PHA, and PPP reserve the right to determine the application of Medical Policies and make revisions to its Medical Policies at any time. Providers will be given 60-days’ notice of policy changes that are restrictive in nature.
The scope and availability of all plan benefits are determined in accordance with the applicable coverage agreement. Any conflict or variance between the terms of the coverage agreement and PHP, PHA, and PPP Medical Policy will be resolved in favor of the coverage agreement.
- Advanced Diabetes Management Technology (All Lines of Business Except Medicare)
- Advanced Diabetes Management Technology (Medicare Only)
- Allergy Testing (All Lines of Business Except Medicare)
- Allergy Testing (Medicare Only)
- Ambulance Transport
- Anesthesia Care with Diagnostic Endoscopy
- Applied Behavior Analysis
- Athletic Pubalgia/Sports Hernia Surgery
- Auricular Electrostimulation (All Lines of Business Except Medicare)
- Auricular Electrostimulation (Medicare Only)
- Autologous Fat Transfer
- Automatic External Defibrillators (AED)
- Back: Ablative Procedures to Treat Back and Neck Pain (All Lines of Business Except Medicare)
- Back: Artificial Intervertebral Discs (All Lines of Business Except Medicare)
- Back: Artificial Intervertebral Discs (Medicare Only)
- Back: Discography
- Back: Epidural Steroid Injections (All Lines of Business Except Medicare)
- Back: Epidural Steroid Injections (Medicare Only)
- Back: Facet Joint Injections, Medial Branch Blocks, and Facet Joint Radiofrequency Neurotomy (Medicare Only)
- Back: Fusion and Decompression Procedures
- Back: Implantable Spinal Cord and Dorsal Root Ganglion Stimulation (All Lines of Business Except Medicare)
- Back: Implantable Spinal Cord and Dorsal Root Ganglion Stimulation (Medicare Only)
- Back: Intradiscal Procedures for Low Back Pain (All Lines of Business Except Medicare)
- Back: Intradiscal Procedures for Low Back Pain (Medicare Only)
- Back: Lysis of Epidural Adhesions
- Back: Percutaneous Vertebral Augmentation
- Back: Sacroiliac Joint Fusion or Stabilization (All Lines of Business Except Medicare)
- Back: Sacroiliac Joint Fusion or Stabilization (Medicare Only)
- Back: Stabilization Devices and Interspinous Spacers
- Balloon Dilation of the Sinuses or Eustachian Tubes
- Bariatric Surgery (All Lines of Business Except Medicare)
- Bariatric Surgery (Medicare Only)
- Biofeedback and Neurofeedback
- Blood Brain Barrier Disruption and Bypass
- Blood Counts (Medicare Only)
- Bone Growth Stimulators (All Lines of Business Except Medicare)
- Bone Growth Stimulators (Medicare Only)
- Botulinum Toxin (All Lines of Business Except Medicare)
- Botulinum Toxin (Medicare Only)
- Breast Cancer: Focused Microwave Phased Array Thermotherapy
- Breast Cancer: Radiofrequency Ablation of Breast Tumors
- Breast Implant Removal (All Lines of Business Except Medicare)
- Breast Implant Remove (Medicare Only)
- Breast Reconstruction
- Breast Surgery: Reduction Mammoplasty (All Lines of Business Except Medicare)
- Breast Surgery: Reduction Mammoplasty (Medicare Only)
- Bronchial Thermoplasty
- Cardiac: Disease Risk Screening (All Lines of Business Except Medicare)
- Cardiac: Disease Risk Screening (Medicare Only)
- Cardiac: External Ambulatory Electrocardiography (All Lines of Business Except Medicare)
- Cardiac: External Ambulatory Electrocardiography (Medicare Only)
- Cardiac: Implantable Loop Recorder
- Cardiac: Left Atrial Appendage Devices (All Lines of Business Except Medicare)
- Cardiac: Left Atrial Appendage Devices (Medicare Only)
- Cardiac: Transcatheter Aortic Valve Replacement (TAVR) (All Lines of Business Except Medicare)
- Cardiac: Transcatheter Aortic Valve Replacement (TAVR) (Medicare Only)
- Cardiac: Ventricular Assist (VAD.LVAD) and Artificial Heart Devices (BIVAD)
- Cefaly Device for Treatment of Migraine Headaches
- Celiac Disease Serologic Testing
- Chelation Therapy for Non Overload Conditions
- Chemoresistance and Chemosensitivity Assays
- Chiropractic Care (All Lines of Business Except Medicare)
- Chiropractic Care (Medicare Only)
- Circulating Tumor Cell and DNA Assays For Cancer Management
- Clinical Trials and Devices (All Lines of Business Except Medicare)
- Clinical Trials and IDE Studies (Medicare Only)
- Cochlear Implants and Auditory Brainstem Implants (All Lines of Business Except Medicare)
- Cochlear Implants and Auditory Brainstem Implants (Medicare Only)
- Cold Therapy and Cooling Devices in the Home Setting
- Colorectal Cancer Screening
- Complementary and Alternative Medicine
- 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)
- Continuous Passive Motion Device in the Home Setting (All Lines of Business Except Medicare)
- Continuous Passive Motion Devices in the Home Setting (Medicare Only)
- Cosmetic and Reconstructive Surgery (All Lines of Business Except Medicare)
- Cosmetic and Reconstructive Surgery (Medicare Only)
- Cranial Electrical Stimulation
- Deep Brain and Responsive Cortical Stimulation (All Lines of Business Except Medicare)
- Deep Brain and Responsive Cortical Stimulation (Medicare Only)
- Definition: Confined to the Home
- Definition: Experimental and Investigational
- Definition: Medical Necessity
- Definition: Mobility Assistive Equipment (MAE)
- Definition: Urgent Care (Out of Area)
- Dental Anesthesia Services
- Dental Services: Administrative Guideline (All Lines of Business Except Medicare)
- Dental Services: Administrative Guideline (Medicare Only)
- Dermal Injections for the treatment of Facial Lipodystrophy Syndrome (Medicare Only)
- Diabetes: Blood Glucose Monitors and Supplies (All Lines of Business Except Medicare)
- Diabetes: Blood Glucose Monitors and Supplies (Medicare Only)
- Direct-to-Consumer Testing
- Drug Testing for Therapeutic or Substance Use Monitoring (All Lines of Business Except Medicare)
- Drug Testing for Therapeutic or Substance Use Monitoring (Medicare Only)
- Durable Medical Equipment
- Electrothermal Capsular Shrinkage
- Exhaled Breath Tests (All LOB Except Medicare)
- Exhaled Breath Tests (Medicare Only)
- Extended Outpatient Psychotherapy (All Lines of Business Except Medicare)
- Extended Outpatient Psychotherapy (Medicare Only)
- Eye: Automated Evacuation of Meibomian Gland
- Eye: Blepharoplasty, Blepharoptosis Repair, and Brow Lift (All Lines of Business Except Medicare)
- Eye: Blepharoplasty, Blepharoptosis Repair, and Brow Lift (Medicare Only)
- Eye: Corneal Collagen Cross-Linking (All Lines of Business Except Medicare)
- Eye: Retinopathy Telescreening
- Fecal Analysis of Gastrointestinal Microbiome
- Fecal Incontinence: Treatments (All Lines of Business Except Medicare)
- Fecal Incontinence: Treatments (Medicare Only)
- Fecal Microbiota Transplantation
- Ganglion Impar Blocks
- Gastric Electrical Stimulation
- Gastroesophageal Reflux Disease: Endoscopic Treatments (All Lines of Business Except Medicare)
- Gastroesophageal Reflux Disease: Endoscopic Treatments (Medicare Only)
- Gastroesophageal Reflux: Magnetic Esophageal Ring
- Gender Affirming Surgical Interventions
- Genetic Studies and Counseling
- Genetic Testing: Breast Cancer Prognostic Assays (All Lines of Business Except Medicare)
- Genetic Testing: Breast Cancer Prognostic Assays (Medicare Only)
- Genetic Testing: CADASIL Disease
- Genetic Testing: Diagnostic Evaluation of Interstitial Lung Disease (All Lines of Business Except Medicare)
- Genetic Testing: Diagnostic Evaluation of Interstitial Lung Disease (Medicare Only)
- Genetic Testing: Gene Expression Profile Testing for Melanoma (All Lines of Business Except Medicare)
- Genetic Testing: Gene Expression Profile Testing for Melanoma (Medicare Only)
- Genetic Testing: Hereditary Breast and Ovarian Cancer (All Lines of Business Except Medicare)
- Genetic Testing: Hereditary Breast and Ovarian Cancer (Medicare Only)
- 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)
- 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 Lines of Business Except Medicare)
- Genetic Testing: Pharmacogenetic Testing (Medicare Only)
- Genetic Testing: Reproductive Planning and Prenatal Testing (All Lines of Business Except Medicare)
- Genetic Testing: Reproductive Planning and Prenatal Testing.(Medicare Only)
- Genetic Testing: Thyroid Nodules (All Lines of Business Except Medicare)
- Genetic Testing: Thyroid Nodules (Medicare Only)
- Genetic Testing: Whole Exome, Whole Genome, and Proteogenomic Testing
- Glycated Hemoglobin and Protein Diagnostic Testing (Medicare Only)
- Hearing Aids (All Lines of Business Except Medicare)
- Hemangioma and Vascular Malformation Treatment
- Hip Arthroscopy
- 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 Cluster Headaches (Medicare Only)
- Home Oxygen Therapy and Equipment for Lung Disease and Hypoxia (All Lines of Business Except Medicare)
- Home Oxygen Therapy and Equipment for Lung Disease and Hypoxia (Medicare Only)
- Hyperbaric Oxygen Therapy (All Lines of Business Except Medicare)
- Hyperbaric Oxygen Therapy (Medicare Only)
- Inflammatory Bowel Disease (IBD) Serologic Testing and Therapeutic Monitoring
- Inflammatory Bowel Disease Measurement of Antibodies to Immunosuppressive Therapies
- Interferential Stimulation (IFS)
- Investigational and Non-covered Medical Technologies (All Lines of Business Except Medicare)
- Investigational and Non-covered Medical Technologies (Medicare Only)
- Joint Resurfacing
- Knee Braces (Functional)
- Knee: Ablative Procedures of Peripheral Nerves to Treat Knee Pain
- Knee: Autologous Chondrocyte Implantation (ACI) for Cartilaginous Defects
- Knee: Meniscal Allograft Transplantation
- Knee: Osteochondral Allografts and Autografts for Cartilaginous Defects
- Lipid Testing (Medicare Only)
- Liver Tumor Treatment (All Lines of Business Except Medicare)
- Liver Tumor Treatment (Medicare Only)
- Low-Level and High-Power Laser Therapy
- Lower Limb Prosthesis (All Lines of Business Except Medicare)
- Lower Limb Prosthesis (Medicare Only)
- Lyme Disease
- Mechanical Stretching Devices for Joints of the Extremities
- Microcurrent Electrical Nerve Stimulation (MENS)
- Minimal Residual Disease Detection in Lymphoid Malignancies (All Lines of Business Except Medicare)
- Minimal Residual Disease Detection in Lymphoid Malignancies (Medicare Only)
- Multi-spectral Digital Skin Lesion Analysis
- Myoelectric Upper Limb Prosthesis
- NanoKnife System.Irreversible Electroporation (IRE)
- Negative Pressure Wound Therapy (NPWT) (All Lines of Business Except Medicare)
- Negative Pressure Wound Therapy (NPWT) (Medicare Only)
- Nerve Conduction Studies (All Lines of Business Except Medicare)
- Nerve Conduction Studies (Medicare Only)
- Non-Contact Wound Therapy (All Lines of Business Except Medicare)
- Non-Contact Wound Therapy (Medicare Only)
- 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)
- Occipital Nerve Stimulation and Ablation (All Lines of Business Except Medicare)
- Organ Transplantation (All Lines of Business Except Medicare)
- Organ Transplantation (Medicare Only)
- Organic Acid Testing and Nutritional Panels
- Orthognathic Surgery
- Orthotic Foot Devices and Therapeutic Shoes
- Outpatient Physical Therapy (All Lines of Business Except Medicare)
- Ovarian Cancer: Multimarker Serum Testing (All Lines of Business Except Medicare)
- Oxygen Therapy and Home Equipment
- Pelvic Congestion Syndrome Treatment
- Percutaneous Neuromodulation Therapy (PNT) (All Lines of Business Except Medicare)
- Percutaneous Neuromodulation Therapy (PNT) (Medicare Only)
- Percutaneous Ultrasonic Ablation for Tendinopathy
- Peripheral Nerve Stimulation for Chronic Pain (Medicare Only)
- Peroral Endoscopic Myotomy (POEM)
- PHA Medical Policy Medicare Manual
- Platelet-Rich Plasma (PRP) for Orthopedic Indications, Wound Care, Other Misc Conditions (All Lines of Business Except Medicare)
- Platelet-Rich Plasma (PRP) for Orthopedic Indications, Wound Care, Other Misc Conditions (Medicare Only)
- Port Wine Stain Laser Treatment
- Premature Rupture of Membranes (PROM) Testing
- Prolotherapy
- Prostate: High Intensity Focused Ultrasound (All Lines of Business Except Medicare)
- Prostate: MRI-Transrectal Ultrasound Fusion Biopsy
- Prostate: Prostatic Urethral Lift
- Prostate: Protein Biomarkers and Genetic Testing (All Lines of Business Except Medicare)
- Prostate: Protein Biomarkers and Genetic Testing (Medicare Only)
- Prostate: Water Vapor Thermotherapy for Benign Prostatic Hyperplasia (All Lines of Business Except Medicare)
- Proton Beam Radiation Therapy
- Psychological and Neuropsychological Testing (All Lines of Business Except Medicare)
- Psychological and Neuropsychological Testing (Medicare Only)
- Radiofrequency Ablation or Cryoablation for Plantar Fasciitis (All Lines of Business Except Medicare)
- Rehabilitation: Mechanical Stretching Devices for Joints of the Extremities
- Rehabilitation: Acute Inpatient
- Respiratory Viral Panels (All Lines of Business Except Medicare)
- Respiratory Viral Panels (Medicare Only)
- Rhinoplasty (All Lines of Business Except Medicare)
- Rhinoplasty (Medicare Only)
- Salivary Hormone Testing (All Lines of Business Except Medicare)
- Salivary Hormone Testing (Medicare Only)
- Seat Lift Chair Mechanism
- Skin and Tissue Substitutes
- 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)
- Sleep Disorder Treatment: Surgical (All Lines of Business Except Medicare)
- Sleep Disorder Treatment: Surgical (Medicare Only)
- Speech Generating Devices
- Standing Systems (All Lines of Business Except Medicare)
- Standing Systems (Medicare Only)
- Stem Cell Therapy for Orthopedic Applications
- Stem Cell Transplantation (All Lines of Business Except Medicare)
- Stem Cell Transplantation (Medicare Only)
- Stereotactic Body Radiation Therapy and Stereotactic Radiosurgery (All Lines of Business Except Medicare)
- Stereotactic Body Radiation Therapy and Stereotactic Radiosurgery (Medicare Only)
- Subcutaneous Hormone Pellet Implant
- Surface Electromyography (sEMG) Testing
- Surgical Site of Service
- Surgical Treatment for Skin Redundancy (All Lines of Business Except Medicare)
- Surgical Treatment for Skin Redundancy (Medicare Only)
- Surgical Treatments for Lymphedema
- Thyroid Testing (Medicare Only)
- Transcranial Magnetic Stimulation (All Lines of Business Except Medicare)
- Transcranial Magnetic Stimulation (Medicare Only)
- Transcutaneous Electrical Nerve Stimulators (TENS) and Related Supplies
- Tumor Treatment Fields Therapy for Glioblastoma (All Lines of Business Except Medicare)
- Tumor Treatment Fields Therapy for Glioblastoma (Medicare Only)
- Ultrarapid Detoxification
- Urinary Incontinence Treatments (All Lines of Business Except Medicare)
- Urinary Incontinence Treatments (Medicare Only)
- Urinary Dysfunction: Vesicoureteral Reflux Treatments
- Vagus Nerve Stimulation (All Lines of Business Except Medicare)
- Vagus Nerve Stimulation (Medicare Only)
- Varicose Veins (All Lines of Business Except Medicare)
- Varicose Veins (Medicare Only)
- Vectra DA Test for Rheumatoid Arthritis (All Lines of Business Except Medicare)
- Vectra DA Test for Rheumatoid Arthritis (Medicare Only)
- Vestibular Function Testing
- Viscosupplementation (All Lines of Business Except Medicare)
- Viscosupplementation (Medicare Only)
- Vitamin D Assay Testing
- Walkers (All Lines of Business Except Medicare)
- Walkers (Medicare Only)
- Wheelchairs and Power Vehicles
- Wilderness Therapy
- Wireless Capsule Endoscopy (Medicare Only)
- Wireless Capsule for Gastrointestinal Motility Monitoring
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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.
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
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Pharmacy Policy
Drug Prior Authorization Request Form
Commercial Plans
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.
- Infusion Therapy SOC Policy
- Site of Care Prior Authorization Request Form
- Approved Site of Care List
Medicare Plans
Medicaid Plans
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.
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Outpatient Rehabilitation