Medical Policy, Reimbursement 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.
Please see the “Pharmacy Policies” section below for information regarding drugs that require authorization.

General Prior-authorization Requirements
“Due to recent scheduling issues associated with the COVID19 pandemic, providers and members may call the prior authorization team at 503-574-6400 and request for an extension of approved prior authorization if services have not been rendered. Eligibility and benefits at time of service still apply. Thank you.”

Effective March 1, 2023, American Imaging Management/AIM Specialty Health and Beacon Health Options changed their names to Carelon. AIM transitioned to Carelon Medical Benefits Management, and Beacon Health Options transitioned to Carelon Behavioral Health. If you have questions about this change, please call 800-878-4445 or click here to learn more.

Prior-authorization Medical Fax Form
Prior-authorization Pharmacy Fax Form
- Drug Prior Authorization Request 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

eviCore High Tech Imaging Prior Authorization Code List
Coding Policies and Alerts
Billing, Payment, and Coding Policy Alerts
Billing, Payment, and Coding Policies
Medical, Reimbursement, and Pharmacy Policy Alerts
Medical and Pharmacy Policy Alerts
Company 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.

COMPANY MEDICAL POLICIES

Specialty/Category

Allergy/Immunology
- Allergy Testing
Audiology
- Hearing Aids
- Vestibular Function Testing
Bariatric
- Bariatric Surgery
Behavioral Health/ Psychiatrics
Cardiology
Complementary and Alternative Medicine
- Complementary and Alternative Medicine
Definitions and Manuals
- Definition of Investigational
- Definition of Medical Necessity
Dental/Oral Surgery
Durable Medical Equipment
Emergency Services
- Ambulance Transport
Endocrinology
- Advanced Diabetes Management Technology
EENT
- Balloon Dilation of the Sinuses or Eustachian Tubes
- Eye: Automated Evacuation of Meibomian Gland
Gastroenterology
General Surgery
Genetics
Infectious Disease
- Covid 19 Testing
- Respiratory Viral Panels
Investigational Technologies
- New and Emerging Technologies and Other Non-Covered Services
Lab Tests
Nephrology
- Apheresis (Therapeutic Pheresis)
Neurology/Neurosurgery
Obstetrics and Gynecology
Oncology/Hematology
Opthalmology
- Eye: Corneal Collagen Cross-Linking
Orthopedics
Pain Management
Physical Medicine
- Chiropractic Care
- Outpatient Physical Therapy
Plastic Surgery
Podiatry
- Foot Care Guidelines
Pulmonology
- Bronchial Thermoplasty
Research
- Clinical Trials
Sleep Physicians
Solid Organ Transplants
- Organ Transplantation
Spine Surgery (Neurosurgery/Orthopedic Surgery)
Urology
- Prostate: Benign Prostatic Hyperplasia Treatments
- Urinary Incontinence Treatments
Vascular Surgery
- Varicose Veins
Wound Care
Alphabetical
Medicare Medical Policies
MEDICARE MEDICAL POLICIES

Specialty/Category

Allergy/Immunology
- Allergy Testing
Audiology
- Vestibular Function Testing
Bariatric
- Bariatric Surgery
Behavioral Health/ Psychiatrics
Cardiology
Complementary and Alternative Medicine
- Complementary and Alternative Medicine
Definitions and Manuals
- Definition of Medically Reasonable and Necessary
- PHA Medicare Medical Policy Manual
Dental/Oral Surgery
Durable Medical Equipment
Emergency Services
- Ambulance Transport
Endocrinology
- Advanced Diabetes Management Technology
EENT
- Balloon Dilation of the Sinuses or Eustachian Tubes
- Eye: Automated Evacuation of the Meibomian Gland
Gastroenterology
General Surgery
Genetics
Infectious Disease
- Covid 19 Testing
- Respiratory Viral Panels
New and Emerging Technologies
- New and Emerging Technologies and Other Non-Covered Services
Lab Tests
Nephrology
- Apheresis (Therapeutic Pheresis)
Neurology/Neurosurgery
Obstetrics and Gynecology
- Pelvic Congestion Syndrome Treatment
- Premature Rupture of Membranes (PROM) Testing
Oncology/Hematology
Orthopedics
Pain Management
Physical Medicine
Plastic Surgery
Podiatry
- Foot Care Guidelines
Pulmonology
- Bronchial Thermoplasty
Research
- Clinical Trials, Studies and Registries
Sleep Physicians
Solid Organ Transplants
- Organ Transplantation
Spine Surgery (Neurosurgery/Orthopedic Surgery)
Urology
- Urinary Incontinence Treatments
Vascular Surgery
- Varicose Veins
Wound Care
Alphabetical
Provider Satisfaction Survey

Provider Satisfaction Survey

Providence cares about the experience of our providers. Please click the link below to provide feedback on your experience as a provider working with Providence Health Plan. We look forward to hearing from you.

Thank you!

Start survey
Credentialing Services

Providence Credentialing Services

Credentialing Services Policies and Procedures
Reimbursement Policies

REIMBURSEMENT POLICIES

+ Ambulatory Surgery Center (ASC) Payment Structure

+ Birthing Center Services

+ Facility Routine Supplies and Services

+ Inpatient Readmission Policy

+ Observation Status

+ Plan-Directed Care

+ Preventable Adverse Events

+ Reimbursement Methodologies and All Inclusive Rates

+ Robotic Surgical Systems

+ Transfers Between Hospitals
Pharmacy Policies
*NEW* NDC Required for Medical Claims Reimbursement effective 11/1/2023

Providence Health Plan (PHP) is now requiring providers to submit National Drug Codes (NDCs) on provider drug claims and hospital outpatient facility claims that are reported for reimbursement. This new PHP requirement will begin November 1st, 2023.
- Brand Drug Definition, Benefit Administration and Payment Policy revised and approved by ORPTC on August 4, 2023.
National Drug Code (NDC) numbers are the industry standard identifier for drugs and provide full transparency to the medication administered. The NDC number identifies the manufacturer, drug name, dosage, strength, package size and quantity.

For purposes of this policy, a valid NDC number, NDC unit of measure and NDC units dispensed for the drug administered will be required for reimbursement of professional drug claims on a1500 Health Insurance Claim Form (a/k/a CMS-1500), the 837-professional transaction, a UB-04 Claim Form or the 837i facility transaction.

Drug Prior Authorization

Below you will find lists of drugs with their associated medical necessity criteria for coverage. Please select the list of drugs based on the medical plan of your patient (e.g., Commercial, Medicaid, Medicare). You may use the drug prior authorization request form below to request authorization for a drug.

Please note that the presence of drugs on these lists does not indicate that the particular drug will be covered under your patient’s medical or prescription drug benefit. You can verify drug coverage by accessing your patient’s formulary on the pharmacy resources page.

Formulary exceptions: There may be times that you prescribe a drug that is not on your patient’s formulary. You may want to consider prescribing a formulary alternative for your patient; however, you may also request a formulary exception for the drug you wish to prescribe by using the drug prior authorization form below.

Drug Prior Authorization Request Form
- Drug Prior Authorization Request Form
- Commercial Maximum Allowable Opioid Dose Request Form
Commercial Plans
- 2023 Commercial Pharmacy Policy Criteria
- 2023 Commercial Medical Benefit Drug Policy Criteria
Medicare Plans
Medicaid Plans
- Medicaid Pharmacy Policy Criteria
Biosimilar Preferred Product Program

Providence Health Plan (PHP) implemented a biosimilar preferred product formulary strategy for medical benefit drugs effective July 1, 2021. The October 2021 Oregon Regional Pharmacy and Therapeutics Committee (ORPTC) approved expansion of the biosimilar preferred product formulary to include infliximab products. This change is effective January 1, 2022.
- PHP Provider Information and Biosimilar Preferred Product Drug List
- PHP Biosimilar Preferred Product Drug List
Refer to the policies below for clinical criteria by line of business:

Commercial and Medicaid:
Medicare Part B:
Infusion Therapy Site of Care (SOC)

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 Commercial Infusion Therapy SOC Policy link below.
- Infusion Therapy SOC Policy - Effective 8/1/2022
- Infusion Therapy SOC Policy - Effective 1/1/2023
- Site of Care Prior Authorization Request Form
Infusion Therapy Site of Care Facility Contracting:
- Approved Site of Care Facility List
- 2023 Outpatient Infusion Services SOC Contract list of Drug Codes
Specialty Drugs Shipped from Pharmacies to Providers and Facilities ("White Bagging")
- Specialty Drugs Shipped from Pharmacies to Providers and Facilities - Operational Policy
Self-Administered Drug Exclusion Policy

Self-Administered Drugs definition - Medications which have been identified as being medically appropriate for administration by a patient or caregiver, safely and effectively, without medical supervision.

Certain medications considered to be usually self-administered by the patient or their caregiver are excluded from coverage under the medical benefit without prior-authorization.
- Self-Administered Drug Exclusion Policy - Commercial and Medicaid
- Medicare Part B – Refer to Noridian Healthcare Solutions’ Self-Administered Drugs (SADs) Policy: https://med.noridianmedicare.com/web/jfb/policies/sads
- Self-Administered Drug Exclusion Drug List - Applies to All Lines of Business
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
Outpatient Rehabilitation
eviCore ASO Expansion

Please be aware that several Self-Funded Administrative Only (ASO) group plans will be adding the use of eviCore medical necessity reviews for outpatient rehabilitation, group and renewal dates provided below. Providers will need to request medical necessity review through eviCore healthcare for dates of service starting on plan renewal dates, as outlined below.

* Please note that Providence will continue to require a request to eviCore on all Commercial and Individual members.

For additional information, including eviCore’s clinical guidelines and a complete list of services requiring medical necessity review, please visit: https://www.eviCore.com/healthplan/PHP or call the eviCore Client Provider Operations department at (800) 646-0418 (Option #4).

The following ASO plans become effective with the process outlined above on the following dates:

Effective 1/1/2023:
- Providence St. Joseph Health Groups (including Providence Health & Services, Swedish Health Services, Kadlec, Pacific Medical Centers, St. Joseph Health, and Covenant Health)
- Clackamas County
- COLLEGENET Inc
- Covenant Health
- Umpqua Health LLC
- Riverpoint Medical
- Oregon Episcopal School
- SAIF Corporation
  Effective 2/1/2023:
- Combined Transport, Inc.
  Effective 4/1/2023:
- School District Trust
  Effective 6/1/2023:
- Orthopedic and Fracture Clinic PC
  Effective 8/1/2023:
- Jet Industries
  Effective 9/1/2023:
- Nosler
- Hydra Power
  Effective 10/1/2023:
- Valley View Health
  Effective 1/1/2024:
- PEBB
  
  The following ASO plans do not require eviCore:
- Intel
- Marathon Coach
Outpatient Rehabilitation Resources
- PHP Outpatient Rehabilitation Information
- PHP Outpatient Rehabilitation CPT Code List
No Surprises Act

Reimbursement to providers and facilities for services subject to the No Surprises Act are paid according to the qualifying payment amount (QPA) as defined by the No Surprises Act. The methodology for calculating the QPA was determined by the Plan to be consistent with the requirements of the No Surprises Act. If the out-of-network provider or facility wishes to initiate a 30 business day negotiation period, they may contact ClearHealth via https://clearhs.com, claimsinquiry@clearhs.com, or by calling (866) 722-3773. Independent Dispute Resolution may be initiated within 4 days after the end of the 30 day negotiation period.
Contact Us

The PHP Medical Policy Team only deals with evidence-based reviews around published medical policies. All inquiries concerning PHP medical policies or new medical devices and technologies may be sent by filling out our online form

Do not submit the Medical Policy Inquiry Feedback form for questions regarding pricing, benefits, claims, EOB statements, or contract issues. Medical policy staff cannot answer or forward these issues. Please contact Customer Service or Provider Relations for assistance with the above.

If you are a member please do not use this form. Please call customer service.

Medical Policy Inquiry Form

Provider Relations can be contacted here: https://healthplans.providence.org/providers/provider-support/provider-relations-representatives/

Customer Service can be reached at: 503-574-7500 or 800-878-4445 (TTY: 711); or at https://healthplans.providence.org/about-us/contact-us/

For questions related to pharmaceuticals please contact our PHP Pharmacy Policy Team at PHPRX@providence.org.

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Medical Policy, Reimbursement 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 Pharmacy Fax Form

Prior-authorization Behavioral Health Fax Forms

Clinical Edit Inquiry Form

eviCore High Tech Imaging Prior Authorization Code List

Coding Policies and Alerts

Billing, Payment, and Coding Policy Alerts

Billing, Payment, and Coding Policies

Medical, Reimbursement, and Pharmacy Policy Alerts

Medical and Pharmacy Policy Alerts

Company Medical Policies

COMPANY MEDICAL POLICIES

Specialty/Category

Alphabetical

Medicare Medical Policies

MEDICARE MEDICAL POLICIES

Specialty/Category

Alphabetical

Provider Satisfaction Survey

Provider Satisfaction Survey

Credentialing Services

Reimbursement Policies

Pharmacy Policies

*NEW* NDC Required for Medical Claims Reimbursement effective 11/1/2023

Drug Prior Authorization

Biosimilar Preferred Product Program

Refer to the policies below for clinical criteria by line of business:

Infusion Therapy Site of Care (SOC)

Specialty Drugs Shipped from Pharmacies to Providers and Facilities ("White Bagging")

Self-Administered Drug Exclusion Policy

Opioid Resources and Guidelines

Outpatient Rehabilitation

eviCore ASO Expansion

No Surprises Act

Contact Us

Hey!

NEW NDC Required for Medical Claims Reimbursement effective 11/1/2023