REFERRAL/AUTHORIZATION GUIDELINES Commercial Plans
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1 Moda Health Referral/Authorization Guidelines Oregon updated September 2014 Page 1 of 7 REFERRAL/AUTHORIZATION GUIDELINES Commercial Plans Referral & Authorization Information Referral and authorization requests may be phoned in to , toll free , or faxed to OEBB Customer Service phone numbers: , toll free Most referrals are authorized for a one-year time span. Retroactive referral requests will be limited to 90 days. For more information, see our referral requirements, authorization requirements or frequently asked questions at Healthcompanies.com/medical. Northwest Permanente (group # V046) and Public Employees Retirement System (PERS) Medicare supplement plans (group # , 05) no authorization required. Services requiring referral Managed Care (MC) and Point of Service (POS) plans Specialist visits. Neuropsychological evaluations. Effective April 1, 2007 a referral is required for all pain management services. Referrals to specialist for PEBB members Note: It is important to refer patients to specialists and/or facilities that are contracted with the member s provider network. Use of non-contracted providers and/or lack of a referral can result in lower benefits or, in some cases, no benefits at all. SELF-REFERABLE SERVICES A member can self-refer for the following services: Child abuse issues. Contraceptive Management Dentist/Oral Surgeons for treatment of dental accidents, TMJ as defined by the member s plan, and/or oral surgery as long as service is covered under the member s medical plan. Other medical services will require the treating provider to be in-panel for the member s plan and will require that a PCP referral be in place. See focus list for services that require authorization. Diabetic annual retinal exams Diabetes self-management, subject to limits of plan. Prenatal care Sterilization Vision emergency services or any medical eye condition Vision Optometrist and Ophthalmologist Women s annual gynecologic exam Follow-up treatment resulting from women s annual exam. Note: Use of non-contracted providers may result in lower benefits or, in some cases, no benefits at all. Payment for self-referable services is dependent on the member s benefits and may be dependent on whether the member has designated a PCP.
2 Moda Health Referral/Authorization Guidelines Oregon updated September 2014 Page 2 of 7 REFERRAL REQUEST REQUIREMENTS Make sure the referral request is complete and contains: All pertinent patient information (subscriber, ID #, group #, relation to subscriber, and patient s birth date). Date of service. Place of service. ICD-9 code(s). Specialist s full name and address. Return fax number, when applicable. Date you want the referral to start and date you want the referral to end. Reminder a referral is NOT an authorization for surgery. A referral indicates that the PCP would like the specialist to request any necessary authorizations for surgical procedures. AUTHORIZATION REQUEST REQUIREMENTS Make sure the authorization request is complete and contains: All pertinent patient information (subscriber, ID #, group #, relation to subscriber, and patient s birth date). The name of the facility where the procedure is to be performed. The date of the procedure or date of admission. Surgeon s or specialist s full name. CPT & ICD-9 (numeric only) codes. Length of stay (indicate if outpatient). Chart notes, when requested. A referral from the PCP (only when the authorization request is being submitted by the specialist). Authorization Requests are required for arthroscopy, outpatient upper endoscopy, and sleep study*. Some employer groups are not subject to this prior authorization requirement. Please contact Medical Intake Department at or toll free for additional information. SERVICES THAT DO NOT REQUIRE AUTHORIZATION Aspiration Infertility treatment (may be a plan exclusion/referrals are required) Biopsies Intravenous/intramuscular pain management Bone mineral density studies, diagnostic Kidney dialysis Brachytherapy for breast cancer Most lab tests Cardiovascular Stress Test Needle biopsy Chemotherapy, standard treatments (outpatient Occupational therapy* only) Physical therapy* Colonoscopy with medical diagnosis (not virtual) Punch biopsy Colonoscopy with routine diagnosis, including Speech therapy** family history diagnosis (not virtual) plan must Trigger point injections have routine benefits (contact customer service Ultrasound for benefits) X-rays Diabetic Shoes (unless >$500 and/or more than 1 pair per year) ECG, EKG Echocardiography EEG EMG CPT: Hydration therapy *Ordering physician must be PCP or referred-to specialist. If the plan has a benefit for therapy visits exceeding 30, medical necessity review will be required for the 31 st visit. Some groups may require a treatment plan for the 13 th visit for medical necessity review. Preauthorization is not required but recommended.
3 Moda Health Referral/Authorization Guidelines Oregon updated September 2014 Page 3 of 7 Note: For Preferred Provider (PPO), Managed Care (MC) and Point of Service (POS) plans, it is important to refer patients to specialists and/or facilities that are contracted with the patient s provider network. Use of noncontracted providers and/or lack of a referral can result in lower benefits or, in some cases, no benefits at all. The scope of the referral needs to include diagnostics and/or office treatment if applicable. Even if a service is listed above, coverage may be limited by benefit limitations and exclusions of the member s plan. Please contact Customer Service for clarification.
4 Moda Health Referral/Authorization Guidelines Oregon updated September 2014 Page 4 of 7 FOCUS LIST Services that require authorization for all Commercial Plans Do not use this list for City of Portland groups (See Referral and Authorization Information) The following is a list of services that require authorization to determine medical necessity or plan benefit limitations. Even though a service is not listed below, coverage may be limited. Contact Customer Service for benefit limitations and exclusions. To receive the higher level of benefit, services must be performed by participating providers/facilities on Preferred Provider (PPO), Managed Care (MC) and Point of Service (POS) plans. Note: If services are not authorized prior to being rendered, certain plans may apply a cost containment penalty even when services are authorized retroactively. For certain groups, prior authorization for some services is not required. Please contact customer service or medical intake for clarification. COSMETIC PROCEDURES Potentially cosmetic procedures may be a plan exclusion unless medical necessity has been established. The following is a partial list. Abdominoplasty Lipectomy Blepharoplasty and/or brow lift Otoplasty Botox injections Panniculectomy Breast surgery - augmentation or reduction Port wine stain treatment Dermabrasion Rhinoplasty Intralesional Injections (i.e. Kenalog) Scar revisions (includes Kenalog injections) Laser treatment (except for retinopathy ) Silicone breast implant removal Varicose vein surgery/sclerotherapy DENTAL SERVICES TMJ surgical splints Treatment of dental accidents Orthognathic services (excluded from most medical plans) TMJ surgeries DIAGNOSTIC PROCEDURES Genetic Testing RAST allergy testing Routine Colonoscopy: in the absence of colonoscopy Plan wording, Moda Health will allow one colonoscopy over the age of 50 every 10 years. Exception: Routine colonoscopy is not covered under any plan that does not have routine benefits or benefits for routine sigmoidoscopy call Customer Service for benefits PET scans SPECT scans CT scans (including CTA) MRI (including MRA, MRS, MRM) Nuclear cardiology imaging studies fmri Upper Endoscopies Sleep Studies Virtual Colonoscopy DURABLE MEDICAL EQUIPMENT/APPLIANCES/SUPPLIES Airway clearance devices (i.e. chest percussors, Low air loss products vests, etc) Augmentative communication device and system Lymphedema pump Bone growth stimulator Muscle stimulator Braces/Orthotics >$3,000 (except custom made Nebulizer,portable >$300
5 Moda Health Referral/Authorization Guidelines Oregon updated September 2014 Page 5 of 7 foot orthotics) Continuous glucose monitor Oxygen (initial certification only) Custom compression stockings >$500 Patient lift Custom/special seating system Phototherapy lights (for dermatologic diagnosis) Custom wheelchair (also repairs over $500) Power wheelchair/scooter (also repairs > $500) Dynasplint/JAS (or other mechanical stretching Prosthetics (except breast prosthetics) device) Sonic Accelerated Fracture Healing System Enteral feedings/nutritional formulas Spinal cord stimulator External wearable cardiac defibrillator Trapeze Gradient pressure aid Wound vac (including wound warming cover) Hearing aid (Multnomah County) Hospital bed Insulin pump Intrapulmonary percussive ventilation INR Monitor, for home use Light box EAR/NOSE/THROAT PROCEDURES Cochlear implantation/removal Septo-rhinoplasty Otoplasty Rhinoplasty Uvulopalatopharyngoplasty (UPPP)/Uvulectomy EXCLUDED SERVICES/PROCEDURES Contact Customer Service for member s benefit limitations and exclusions. EXPERIMENTAL/INVESTIGATIONAL Services determined by Moda Health to be experimental/investigational are excluded. Listed procedures are not all inclusive contact Customer Service for exclusions Active Cooling Devices (i.e. Game Ready) Micronutrient Testing Anodyne Therapy System Mobile Outpatient Cardiac Telemetry (MOCT) Automated, noninvasive nerve conduction study Nucleoplasty (e.g. NC-Stat) Ossatron/Orthotripsy/ESWT (extracorporeal Balloon Sinuplasty (as standalone procedure) shock wave therapy) Bronchial Thermoplasty (Alair) Platelet Rich Plasma Injections Carotid Sinus Baroreflex Stimulation System Prolotherapy (Rheos) Percutaneous Lumbar Discectomy and Laserassisted Computer Assisted Navigation for musculoskeletal Disc Decompression procedures (effective 10/1/12) Quantitative Sensory Testing Cryoablation of Breast Fibroadenomas Saliva Hormone Testing Dynamic spine stabilization (Dynesys) Sublingual Immunotherapy (SLIT) ExMI (Extracorporeal Magnetic Innervation) Somnoplasty /Coblation Intradiscal Electrothermal Therapy (IDET) Tissue Grafts/Mesh (Biologic engineered from High Density Lipid Profile human or xenograft source many are E/I Home Interferential Muscle Stimulator check prior to use) Microcurrent Stimulators (MENS) (e.g. Alpha Stim Thermal Imaging/Thermography unit) Transcranial Magnetic Stimulation Vertebral Axial Decompression HOME SERVICES Home health services Hospice care Home infusion services Palliative care HOSPITAL EMERGENCY ADMITS Notification is required within 48 hours of hospital admission.
6 Moda Health Referral/Authorization Guidelines Oregon updated September 2014 Page 6 of 7 IMMUNOTHERAPY/ALLERGY INJECTIONS Pre-authorization is required for more than 56 units of CPT (56 units = 2 treatment sets at 28 doses per treatment set) IMMUNIZATIONS: Zostavax for under age 60 Rabies Vaccine INFUSION SERVICES (OUTPATIENT) Abatacept (Orencia Ado-trastuzumab (Kadcyla) Agalsidase beta (Fabrazyme) Alglucosidase Alfa (Lumizyme) Alpha 1 Proteinase Inhibitor (GLASSIA) Amevive Infusion Belimumab (Benlysta) Bendamustine (Treanda) Bevacizumanb (Avastin for cancer diagnosis) Bortezomib (Velcade) Brentuximab (Adcetris) Cabazitaxel (Jevtana) Carfilzomib (Kyprolis) Cetuximab (Erbitux) Eribulin Mesylate (Halaven) Denosumab (Xgeva and Prolia) Golimumab (Simponi Aria) Ipilimumab (Yervoy) Iron Intravenous Intravenous Immune Globulin (IVIG)) Natalizumab (Tysabri) Octreotide Acetate (Sandostatin) Omacetaxine mepesuccinate (Synribo) Paclitaxel Protein Bound (Abraxane) Palonosetron (Aloxi) Pamidronate (Aredia) Panitumumab (Vectibix) Pegloticase (Krystexxa) Pemetrexed (Alimta) Pertuzumab (Perjeta) Provenge (Sipuleucel-T) Reclast and Zometa (Zoledronic acid) Remicade (Infliximab) Infusion Rituximab (for rheumatoid arthritis) Soliris (Eculizumab) Trastuzumab (Herceptin) Tocilizumab (Actemra) Ziv-Aflibercept (Zaltrap) INJECTABLES Aflibercept (Eylea) Humira Aranesp Infergen Arixtra Intron A Avonex Kineret Betaseron Leukine Botox Neulasta/Neupogen
7 Moda Health Referral/Authorization Guidelines Oregon updated September 2014 Page 7 of 7 Cimzia Pegasys Copaxone Peg-Intron Enbrel Rebetron Epogen/Procrit Rebig Eylea/Lucentis/Macugen Remodulin Forteo Somavert Stelara (ustekinumab) Growth Hormone Synagis Hepsara Xolair Hydroxyprogesterone Caproate (Makena) INPATIENT REHABILITATION INPATIENT SURGERIES AND PROCEDURES- ALL ELECTIVE CASES OUT-OF-NETWORK REQUESTS PAID AT THE IN-NETWORK LEVEL Managed Care (MC) and Point of Service (POS) plans only. Services at out-of-network facilities Visits to out-of-network providers or facilities PAIN MANAGEMENT Epidural pain pump insertion Spinal Cord Stimulator (trial and permanent placement) Multidisciplinary pain team evaluation at Progressive Rehab Synvisc, Supartz, Hyalgan, Orthovisc, Euflexxa Injections (all viscosupplementation) Spine Injections for chronic back pain PHARMACEUTICAL Obesity/Weight loss drugs REHABILITATIVE AND RECUPERATIVE SERVICES Cardiac rehabilitation Multidisciplinary pain team evaluation at progressive Rehab Pulmonary rehabilitation REPRODUCTIVE SERVICES DNA testing Genetic testing SKILLED NURSING FACILITY SURGERY ALL INPATIENT ELECTIVE SURGERIES AND PROCEDURES SURGERY/TREATMENT OUTPATIENT All outpatient surgeries on this focus list Prophylactic surgery (e.g. mastectomy) Cartilage Transplants of the knee Thoracic Sympathectomy (for hyperhidrosis) Capsule Endoscopy Kyphoplasty/Vertebroplasty Circumcision after 3 months of age Stereotactic Radiosurgery (ie Gamma Knife Eye surgery for cataracts with implant of Outpatient Arthroscopies intraocular telescopic lens Hip, knee, shoulder surgeries Hyperbaric Oxygen Therapy Neck/back/spine surgeries TRANSPLANTS All transplants except cornea Donor services
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