Medical Policy, Pharmacy Policy, and Provider Information

Providence Health Plans, 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

    • Requests to undergo a procedure at an Out-of-Network facility, and/or see an Out-of-Network provider will be reviewed in terms of whether the procedure is considered elective/semi-elective or urgent/emergent. 
    • 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.

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

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

Medical, Pharmacy, Billing, Payment, and Coding Policy Alerts

Medical Policy

**Special Notice**

New Laboratory Management Medical Policies (effective 1/1/2021)


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.

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:

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

Pharmacy Policy

Drug Prior Authorization Request Form:

Commercial Plans:

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:

Medicaid Plans:

Opioid Resources & 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. 

Outpatient Rehabilitation