To see if a member’s plan is subject to preauthorization, please check the member’s ID card, refer to member benefits using InTouch, or call our Customer Service Department at (888) 532-5332. For pre-existing waiting period information, please contact our Customer Service Department.
If you have questions about preauthorization other than eligibility, please contact our Health Services Department at (800) 624-6052, ext. 2584. These lists do not imply that a plan provides benefits for these items, and they are subject to revision as new technologies and standards of medical practice are reviewed.
This list is not a complete list of all services requiring preauthorization. Please use the search tool to check for preauthorization requirements for services with specific procedure codes (CPTs or HCPCS).
All plans (excluding PSA, PacificSource Medicare, PacificSource Community Solutions, and Legacy Employee Health Plan):
Please note: This list was updated, effective November 14, 2016. We maintain a separate list for Medical Drugs & Diabetic Supplies: Medical Drug and Diabetic Supplies Formulary.
- Ambulance transports (air or ground) between medical facilities, except in emergencies (air or ground) between medical facilities, except in emergencies
- Anesthesia or Sedation for Dental Procedures - when covered under the members plan, including pediatric dental procedures
- CPAP or BiPAP - While prior authorization is not required, certain criteria must be met for rental, purchase, replacement and repair. Replacement every 5 Years.
- Dental Services & Procedures - billed under the member's medical coverage
- Durable medical equipment (DME) expense over $800, including purchase, rental, repair, lease, or replacement, or rental for longer than three months.
- Elective medical admissions, such as preadmission, or admission to a hospital for diagnostic testing or procedures normally done in an outpatient setting, and transfers to nonparticipating facilities
- Experimental or investigational procedures or surgeries
- Home Infusion and freestanding infusion centers
- Hospice - Inpatient only
- Hospitalization for dental procedures when covered under this plan, including pediatric dental procedures
- Impella 2.5 System with Percutaneous Coronary Intervention
- Mental health and chemical dependency residential detox and residential treatment, partial hospitalization, including intensive outpatient mental health treatment and intensive chemical dependency treatment
- Non-Medically Indicated (Elective) Induction of Labor Before 39 Weeks Gestational Age
- Out-of-country medical services, except in emergencies
- Rehabilitation or skilled nursing facility admissions
Criteria for Preauthorization Decisions
Criteria may be requested by contacting our Health Services team. Criteria can be emailed, faxed, or mailed to you per your request.
Oregon: (541) 684-5584, Toll free (888) 691-8209, ext. 2584
Idaho: (208) 333-1563, Toll free (800) 688-5008
Montana: (406) 442-6595, Toll free (877) 570-1563
TTY: (800) 735-2900
Oregon: (541) 225-3625
Idaho: (208) 333-1597
Montana: (406) 441-3378
PacificSource Health Plans, Attn: Health Services
PO Box 7068
Springfield, OR 97475-0068