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
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.
- 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
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 approval information