Investigational services and supplies

Pre-authorization for investigational services and supplies is required. Charges for investigational services and supplies are denied as provider write-offs unless the patient agrees in writing prior to receiving services to be financially responsible for the charges.

• View investigational and potentially investigational procedures on the current Regence Clinical Edits by Code list. Note: This list does not apply to Medicare products.
• View a sample non-covered services waiver form (PDF).

1. Before requesting pre-authorization, please verify eligibility and benefits via Regence Online Services for Providers.
2. Verification of member eligibility is valid if obtained within five business days of service except in the case of misrepresentation.
3. Pre-authorizations obtained within 30 business days prior to service are valid except in the case of misrepresentation.
4. Medical policies related to specific pre-authorization requirements are available.
5. Potentially investigational services may also be considered medically necessary for select diagnoses. Please refer to the Regence Clinical Edits by Code list for additional information. Unlisted codes may be used for potentially investigational services and are subject to review. 
6. Some member contracts have specific pre-authorization requirements. The member's contract language will apply.
7. Urgent/Emergent services do not require pre-authorization.
8. Pharmacy prior authorization information and forms can be found at the RegenceRx Physician Web site.

• Inpatient/partial/residential admissions require notification. Concurrent review will occur after eight days.
• Outpatient - Concurrent review will occur after 30 visits.

Please refer to the Regence Clinical Edits by Code list for additional DME code information.

Transplants, ventricular assist devices and total artificial hearts (pre-authorization not required for corneal and kidney transplants)

Transplants
G0341, G0342, G0343, S2053, S2054, S2055, S2060, S2065, S2150, S2152, 32851, 32852, 32853, 32854, 33935, 33945, 38205, 38206, 38230, 38240, 38241, 44135, 47135, 47136, 48160, 48554, 0141T, 0142T, 0143T

Ventricular assist devices and total artificial hearts
33975, 33976, 33979, 0048T, 0050T, 0051T

Inpatient Admissions:
Phone: 1 (208) 750-2787 or Toll free: 1 (800) 351-2370, Fax: 1 (800) 453-4341

All hospital admissions require notification

Concurrent review will occur after 7 days.

Long Term Acute Care Facility (LTAC)

Pre-authorization is required prior to patient admission.

Rehabilitation

Pre-authorization is required prior to patient admission.

Skilled Nursing Facility (SNF)

Pre-authorization is required prior to patient admission.

Obesity surgery

43644, 43770, 43771, 43772, 43773, 43774, 43846, 43848, 43886, 43887, 43888

Orthognathic surgery

21120, 21121, 21123, 21125, 21127, 21141, 21142, 21143, 21145, 21146, 21147, 21150, 21151, 21154, 21155, 21159, 21160, 21193, 21194, 21195, 21196, 21198, 21199, 21206, 21230 

Sleep apnea surgery

Please refer to the Regence Clinical Edits by Code list for potentially investigational procedures.

Please refer to the Regence Clinical Edits by Code list for medical necessity review codes and potentially investigational procedures.

Potentially cosmetic procedures to restore or improve appearance that may also correct a functional impairment

Pre-authorization not required for initial breast reconstruction one or two stages and nipple/areola reconstruction following mastectomy.

Please refer to the Regence Clinical Edits by Code list for cosmetic and potentially cosmetic procedures.

Potentially investigational services are services that are considered investigational, but for select diagnoses, may also be considered medically necessary.

May not be covered under the member's contract. However, pre-authorization is recommended for any policy that has specific medical necessity criteria in addition to the experimental and investigational language.

Unlisted codes may be used for potentially investigational services and are subject to review. 

Please refer to the Regence Clinical Edits by Code list for additional information.

Physicians are required to notify Special Beginnings^® of pregnancies within two weeks of the member's first prenatal visit. Phone: 1 (888) 569-2229 Fax: 1 (503) 391-8696.