Prior authorization

Certain services require a prior authorization before you receive care, meaning that before you receive care, the service must be pre-approved by Providence Health Plan. Here’s what you should know about prior authorization:

Certain services need to be approved before you receive them from a health care provider.

Sometimes you need to get the prior authorization; sometimes your provider will get the approval. 

Make sure to discuss prior authorization with your provider when you are considering one of the following procedures:

  • Inpatient hospital admissions, including maternity
  • High tech diagnostic imaging, such as MRI, MRA, SPECT, CT, CTA, PET, Nuclear Cardiology (American Imaging Management authorizes these services; contact AIM at 800-920-1250)
  • Mental Health and/or Chemical Dependency services (PBH, a team of experts in mental health – sometimes called "behavioral health," is the authorizing agent: 800-711-4577)
  • Select outpatient procedures, included but not limited to these categories:
    • Miscellaneous cosmetic, reconstructive, nasal, oral/dental/orthognathic procedures
    • Cervical, thoracic and lumbar spinal surgeries
    • All bariatric services
    • Organ/tissue and bone marrow transplants (including pre-transplant evaluations and HLA typing)
    • Uvulectomy, uvulopalatophyaryngoplasty (UPPP), laser-assisted uvulopalatoplasty (LAUP)
    • Select hip, knee and shoulder procedures
    • Sleep studies and/or treatment of sleep disorders
  • Skilled nursing facility admissions
  • Inpatient rehabilitation facility admissions
  • Inpatient hospice
  • Pulmonary rehabilitation
  • Cardiac rehabilitation
  • General anesthesia for dental services
  • Procedures/surgeries/treatment that may be considered experimental or investigational
  • Genetic testing (Cytogenetic Studies) and counseling
  • Neuropsychological testing
  • Prosthetics
  • Select Durable Medical Equipment including but not limited to the following categories:
    • Power-wheel chairs & supplies
    • Seat Lift Mechanisms,
    • Select nerve stimulators,
    • Skin substitutes
    • Oral appliances
    • Flexion/Extension devices
    • Wound Therapy pumps
    • Speech Generating devices
    • Purchase of CPAP post trial rental period
  • Select injectable medications also require prior authorization. See your pharmacy medical services prior-authorization list (PDF) for details.

The list of services needing prior authorization is not exhaustive. For a complete list of services that require prior authorization, please refer to your summary plan description.

Important information about how prior authorization works

Talk with your provider about getting prior authorization. Many times a provider will obtain the prior authorization on your behalf. You can call Providence Health Plan customer service at 800-878-4445 to verify if prior authorization has been obtained. If you do not obtain prior authorization for services received from an out-of-network provider, a financial penalty may apply.