Fee-for-Service Physical Health Prior Authorization Requests

Before Submitting Requests:

The Eligibility Verification page lists resources to use.

If the member has current OHP coverage:

For services covered by the patient's coordinated care organization (CCO), refer to the CCO for their procedures.
For services covered fee-for-service by the Oregon Health Authority, the Prior Authorization Handbook provides step-by-step instructions.

For services covered by the patient's coordinated care organization (CCO), refer to the CCO for service coverage.

For services covered by OHA, you can use the HSC List Inquiry to see if a specific service is covered by the patient's OHP benefit package.

If the Prioritized List of Health Services does not show coverage of the service for the condition being treated, ask the member's CCO or OHA to review for medical necessity.

CCOs and OHA may each have different requirements.

For services covered by the member's CCO, refer to the CCO.
For services covered by OHA, refer to the provider guidelines for your program, or use the HSC List Inquiry in the MMIS Provider Portal at https://www.or-medicaid.gov.

The requesting, performing and referring providers for the requested service(s) on the request must all be enrolled Oregon Health Plan (OHP) providers.

Use our enrollment verification tool to verify OHP enrollment using the provider's National Provider Identifier.
For providers not enrolled with OHP, complete and submit the OHP 3113 form to OHP Provider Enrollment.

How to Submit Requests to OHA

Use the Provider Portal or MSC 3971. The portal is best because:

The request and all attachments are submitted to OHA in a single secure transaction.
You can easily update the request as needed rom your Provider Portal account.

Please attach only the clinical documentation required for review. Do not attach unrelated documents.

Sending more than the required documents to determine medical necessity may delay review.
For specific requirements, refer to the provider guidelines for the requested service(s).

To update existing requests:

Use the Provider Portal (search by Prior Authorization Number for the existing request), or
Fax a new MSC 3971 with requested documentation. List the Prior Authorization Number for the existing request on the EDMS Coversheet; otherwise, OHA will process the request as a new request, delaying review.

How to Check Prior Authorization Status

OHA no longer calls providers with prior authorization status. To find out the status of a prior authorization request submitted to OHA:

Use the Provider Portal “PA Inquiry” function. To learn more about checking status on the web, view our self-study guide. Don’t have a Provider Portal account? Learn how to get one on the Provider Portal resources page.
Review the notices OHA sends you. Sample notices are in the Prior Authorization Handbook. If you don’t get notices from OHA, you may need to update your mailing address. To learn how to update your mailing address with OHA, visit the Provider Enrollment page.

Fee-for-Service Prior Authorization Resources

Tools

Forms and quick references

Resources

Prioritized List of Health Services

Questions?

Call 800-336-6016.

For help with existing prior authorization/requests: Choose option 3
To find out if a specific diagnosis/procedure code pair requires authorization: Choose option 4

Fee-for-Service Physical Health Prior Authorization Requests

Before Submitting Requests:

Verify OHP eligibility and CCO enrollment

Check whether OHP covers the service

Check whether the service requires authorization

Make sure the requesting, performing and referring providers are enrolled OHP providers