1. Before requesting pre-authorization and providing services, please verify eligibility and benefits.
2. Member contracts determine benefits. Contract exclusions will not be pre-authorized. Denials may be appealed through Customer Service. The member's contract language will apply.
3. Pre-authorizations obtained within 30 business days prior to service are valid except in the case of misrepresentation.
4. Urgent/Emergent services do not require pre-authorization.
5. All acute hospital admissions require notification. Concurrent review will occur after seven days.
6. Pre-authorization for non-participating or out-of-plan providers is not required but is strongly recommended.

• View a list of Medicare potentially investigational procedures (PDF).
• View a list of commonly-questioned codes that do not require pre-authorization (PDF).
• View a list of Medicare non-covered services (PDF).

Criteria used to determine if pre-authorization is needed:

1. Service is specifically listed as requiring pre-authorization on the Regence Medicare Products Pre-authorization List.
2. There are specific criteria for review in Centers for Medicare & Medicaid Services (CMS) policy (e.g., NDC, LCD, Newsletters etc.).
3. CMS clearly states the service is covered when medically necessary; (Medicare non-covered codes will not be accepted for pre-authorization review).
4. Codes that may be listed as a Medicare Pass Through Code and are not accepted for payment therefore, the codes will not be reviewed.
5. The service is not set up on the Physician’s Relative Value Fee Schedule databasetherefore, the codes will not be reviewed.
6. Experimental, investigational, or potentially cosmetic procedures using related approved codes may be pre-authorized if Medicare medical necessity guidelines or policy statements are available to be used for the review. 

Note: For “Procedure Unlisted” or unlisted codes we are unable to determine the actual procedure that will be preformed. They cannot be reviewed as pre-authorization and are subject to post-service review with operative report and medical necessity documentation.

Verification of eligibility and benefits
Please use Regence Online Services for Providers or contact Provider Customer Service:
Phone: 1 (877) 508-7362

Behavioral Health inquires (includes chemical dependency and all mental health inquires) or facility admission notification
Phone: 1 (800)780-7881; Fax: 1(800) 331-3505

Exceptions (pre-authorization is not required regardless of line item charges) Apnea monitors, bilirubin lights, cardiac monitors, CPAP/BiPAP, CPM (knee only), dynamic splints, home dialysis equipment, infusion pumps, insulin pumps, ocular prostheses, orthotics, oxygen and oxygen equipment, psoriasis lights, SIDS monitors, suction pumps, ventilators (including maintenance) and vacuum assisted would closure.

See NCD 280.1 for coverage guidelines/code status.

All hospital admissions require notification

Concurrent review will occur after 7 days.
Phone calls are preferred over faxes for clinical updates. Milliman criteria are used for the clinical reviews.

Long Term Acute Care Facility (LTAC)

Pre-authorization is required prior to patient admission.
Part A Medicare covers admission for special intensive rehabilitation services only.

Acute Rehabilitation

Pre-authorization is required prior to patient admission. Criteria = LCD for Inpatient Rehabilitation Services (L19890) and Medicare Benefit Policy Manual, Chapter 1 - Inpatient Hospital Services Covered Under Part A, Section 110 - Inpatient Stays for Rehabilitation Care.

Skilled Nursing Facility (SNF) - sometimes referred to as "sub-acute rehabilitation"

Pre-authorization is required prior to patient admission. Refer to the Medicare Benefit Policy Manual, Chapter 8 - SNF for Medicare guidelines.

Call from the hospital with clinical details and functional mobility status for pre-authorization prior to transfer to the SNF. Call from the SNF within 1st business day of member arrival to confirm, and concurrent updates with clinical details and functional mobility for ongoing authorization within 1 business day of last authorized day. Faxed information strongly discouraged for any concurrent review authorization.

Transplants
(Pre-authorization not required for corneal and kidney transplants)

Transplants:  G0341, G0342, Lung +: 32850, 32851, 32852, 32854; Heart/Lung: 33930, 33935, 33940, 33945; Bone Marrow/Stem Cell: 38205, 38206, 38207, 38208, 38209, 38210, 38211, 38230, 38240,38241, 38242; Intestinal: 44132, 44133, 44135, 44136; Liver: 47133, 47135, 47136, 47140, 47141, 47142; Pancreas: 48160, 48550, 48554, 48556; Kidney transplant codes do not require pre-authorization. Related testing: 0140T, 0141T, 0142T.

For Medicare guidelines see the following NCDs: Adult Liver, 260.1; Heart Transplants, 260.9; Intestinal and Multi-Visceral Transplant, 260.5; Pancreas Transplant, 260.3; Kidney Transplants - no specific NCD or LCD.

Ventricular Assistive Devices: 0048T, 0050T, 0051T, 0052T, 0053T, 33975, 33976, 33977, 33978, 33979, 33980. For Medicare guidelines see NCD 20.9

Home health agencies

Are required to fax the Notice of Medicare Non-Coverage (NOMNC) on discharge from services. No pre-authorization required.

• Idaho NOMNC Form (PDF)
• Asotin County, Washington NOMNC (PDF)

• NOMNC Fact Sheet (PDF)

Obesity surgery

21120, 21121, 21122, 21123, 21125, 21127, 21137, 21141, 21142, 21143, 21145, 21146, 21147, 21150, 21151, 21154, 21155, 21159, 21160, 21188, 21193, 21194, 21195, 21196, 21198, 21199, 21206, 21208, 21209, 21210, 21230.

Sleep apnea surgery

21199, 21685, 42120, 42140, 42145, 42160.
Refer to Medicare guidelines for the Treatment of Obstructive Sleep Apnea: L19078.

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

Skin: 11950, 11951, 11952, 11954, 11960, 11970, 11971, 15780, 15781, 15782, 15783, 15786, 15787, 15788, 15789, 15792, 15793, 15830, 15832, 15833, 15834, 15835, 15836, 15837, 15838, 15839, 15847, 15876, 15877, 15878, 15879, 17360, 17380

Breast: 19300, 19318 (reduction mammoplasty), 19324, 19325, 19328, 19330, 19340*, 19342, 19350, 19355, 19357*, 19361*, 19364*, 19366*,19367*, 19368*, 19369*, 19370, 19371, 19396*  *No pre-authorization is required: for broken/failed/extruded implants, painful/infected breasts, or initial breast reconstruction for diagnosis of CA* (198.81, 173.5, 174, 175) for one or two stages and nipple/areola reconstruction following mastectomy.

Eyelid/Brow: 67902, 67906, 67908, 67909

Ear: 69300

Face/Neck (incl nose): 21235, 21740-21743, 30400, 30410, 30420, 30430, 30435, 30450, 30460*, 30462*

*Rhinoplasty (30460, 30462) required for pre-authorization review if not related to trauma/injury reconstruction.

Venous: 36468**, 36469**, 36470**, 36471**, 36475**, 36476**, 36478**, 36479**, 37500, 37501.

**Venous procedures:   **36468, 36469, 36470, 36471, 36475, 36476, 36478, 36479 require chart notes with documentation of 3 months use conservative tx/no significant improvement, clinical indications, vascular studies, specific vessels to be treated, maximum diameter of vessels to be ablated); If no pre-authorization on file: Requires initial consultation, chart notes with clinical indications for the procedure, operative report.

Vaginal: 57295, 57296;

Fax pre-authorization requests to 1 (800) 453-4341. Requires consultation with chart note clinical indications to support the requested procedure.                                                             

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

Not considered reasonable and necessary for the diagnosis or treatment of illness or injury, or to improve functioning of a malformed body member. Program payment, therefore, may not be made for medical procedures and services performed using devices that have not been approved for marketing by the Food and Drug Administration (FDA) or for those not included in an FDA approved investigational (IDE) trial.

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.
 
View a list of Medicare potentially investigational procedures (PDF).

This category includes medical devices not approved for marketing by the FDA or or still medical devices considered investigational by Medicare. Examples: 0075T, 0076T, 23929, 44238, 50590 (lithotripsy for gallbladder) 50593, 64553, 64573, 95974, 95975, 97026, 97033, 97139, 97545, 97546, E0770 (NCD 160.12) J2010; PreGen-Plus (screening DNA stool test)* Unlisted codes would require operative report and would not be preauthorized with very rare exceptions. See L27449, L24773; MLN Matters Number: MM6145 (4/28/08); For post op cold compression requests (Game Ready, Cryo Cuff, etc.) see Noridian bulletin on Continuous Passive Motion Machines Claim Submission, LCD for Cold Therapy (L11567), and LCD for Pneumatic Compression Devices (L11492) for related guidelines.

Stereotactic Radiotherapy/Radiosurgery Procedures (including navigational procedures):, 61796, 61797, 61798, 61799, 61800, 63620, 63621,  77371, 77372, 77373, 77399, 77432, 77435, G0339, G0340, G0173, G0251, G0173. See LCD for Radiation Oncology: L23754; Radiotherapy: L23760 (body); Stereotactic Body radiation: L26109; Medicare Claims Processing Manual, Chapter 4 – Part B Hospital – 200.3.4 – Billing for Linear Accelerator.

Wireless Capsule Enteroscopy, CT Colonography: 067T (virtual colonoscopy); 91110 (wireless capsule endoscopy). Virtual Colonoscopy: L18717, L24203; Wireless Capsule Endoscopy: L12210.