Providence Health Plan Prior Authorization Lookup
- Providence Health Plan coverage criteria
- Providence Health Plan contact directory
- All Providence Health Plan policy updates
Latest Providence Health Plan prior authorization updates25
- Prior AuthClinical/Medical PolicyEff. 2026-07-01Medicare Part B Step Therapy Criteria for Part B DrugsDefines step therapy, prior authorization, and the list of Medicare Part B drugs (by HCPCS/CPT) subject to step therapy protocols for Providence Medicare Advantage Plans; applies to providers prescribing or administering Part B medications for plan members.All Providence Health Plan updates
- Prior AuthClinical/Medical PolicyEff. 2026-07-01Miscellaneous Products Infusion Therapy Site-of-Care Prior AuthorizationPolicy governs prior authorization and site-of-care requirements for administration of specified infusion medications for Providence Health Plan commercial members aged 13 and older, defining approved and unapproved infusion settings and criteria for allowing administration in unapproved hospital outpatient infusion centers.All Providence Health Plan updates
- Prior AuthClinical/Medical PolicyEff. 2026-07-01Non-Covered Genetic Panel TestsDefines genetic panel tests considered not medically necessary by Providence Health Plan and the documentation/prior authorization expectations for providers requesting genetic panel testing for Commercial plan members.All Providence Health Plan updates
- Prior AuthReimbursement/Payment PolicyEff. 2026-07-01Providence Medicare Advantage Plans 2026 Prior Authorization Criteria for Part B DrugsPrior authorization requirements for certain Medicare Part B–covered drugs for Providence Medicare Advantage Plans effective 7/1/2026; applies to members and prescribing providers who seek coverage for listed Part B drugs.All Providence Health Plan updates
- Prior AuthClinical/Medical PolicyEff. 2026-07-01Step therapy criteria for pharmacy-covered drugsDefines step therapy (prior authorization and step requirements) for various pharmacy and specialty drugs covered under Providence Health Plan's pharmacy benefit; applies to providers prescribing these medications for plan members.All Providence Health Plan updates
- Prior AuthClinical/Medical PolicyEff. 2026-06-01Intradiscal Procedures for Low Back PainDefines Providence Health Plan's coverage stance for thermal and non-thermal intradiscal procedures for treatment of low back pain for applicable company commercial products; describes clinical context, evidence review, and coding/regulatory notes. Affects providers submitting claims or prior authorizations to Providence Health Plan and affiliated companies.All Providence Health Plan updates
- Prior AuthClinical/Medical PolicyEff. 2026-06-01Medicare Part B Drug Prior Authorization CriteriaDefines prior authorization requirements for selected Medicare Part B drugs administered by providers under Providence Medicare Advantage Plans; affects providers seeking coverage for listed Part B medications for plan members.All Providence Health Plan updates
- Prior AuthClinical/Medical PolicyEff. 2026-06-01Medicare Part B Step Therapy Criteria for Part B DrugsDefines step therapy requirements, prior authorization expectations, and the list of Part B-administered drugs subject to step therapy for Providence Medicare Advantage Plans members. Affects providers prescribing or administering Medicare Part B drugs to Providence Medicare Advantage enrollees.All Providence Health Plan updates
- Prior AuthClinical/Medical PolicyEff. 2026-06-01Miscellaneous Products — Self‑Administered Drugs (SAD)Policy governing coverage, prior authorization, and medical necessity for miscellaneous self-administered drugs (SAD) for Providence Health Plan commercial and Medicaid members, including transition/monitoring provisions when administration in a provider office is requested.All Providence Health Plan updates
- Prior AuthClinical/Medical PolicyEff. 2026-06-01Shoulder Arthroscopy and Open ProceduresClinical coverage criteria and prior authorization/documentation guidance for selected elective shoulder arthroscopy and open procedures for Providence Health Plan members (commercial and Medicaid/OHP). Applies to non-emergent cases and excludes acute fractures and other emergent conditions.All Providence Health Plan updates
- Prior AuthClinical/Medical PolicyEff. 2026-06-01Spinal Stabilization Devices and Interspinous SpacersMedicare medical policy governing coverage and medical necessity determinations for dynamic spinal stabilization devices and interspinous spacers for Providence Health Plan Medicare members; applies when Medicare coverage criteria are not fully established. Affects providers submitting claims or prior authorization requests for these devices/procedures.All Providence Health Plan updates
- Prior AuthClinical/Medical PolicyEff. 2026-05-11Knee Arthroscopy and Open ProceduresMedical necessity, documentation, and coverage criteria for knee arthroscopy and arthroscopically assisted/open knee surgical procedures for Providence Health Plan members; applies to providers requesting prior authorization and claims review.All Providence Health Plan updates
- Prior AuthClinical/Medical PolicyEff. 2026-05-11Outpatient Surgical Site of Service (Hospital outpatient POS 22) coverage criteriaDefines medical necessity review and site-of-service requirements for hospital outpatient (place of service 22) use for knee and shoulder arthroscopy/open procedures and small joint surgery for Providence Health Plan commercial fully insured groups; affects providers requesting prior authorization. Does not apply to Providence Medicare or Providence OHP members.All Providence Health Plan updates
- Prior AuthClinical/Medical PolicyEff. 2026-05-11Outpatient Surgical Site of Service — Appendix (knee, shoulder, small joint procedures)Defines medical necessity review of hospital outpatient site of service (Place of Service 22) for knee, shoulder, and small joint outpatient procedures for Providence Health Plan commercial fully insured groups; affects providers requesting prior authorization for these procedures and their planned site of service.All Providence Health Plan updates
- Prior AuthClinical/Medical PolicyEff. 2026-05-01Breast Reconstructive Surgery, Reduction Mammoplasty, and Implant ManagementMedicare policy governing coverage, coding, and billing for breast reconstruction, reduction mammoplasty, and implant management for Providence Medicare members; clarifies reconstructive vs cosmetic determinations, coding guidance, and prior authorization considerations.All Providence Health Plan updates
- Prior AuthClinical/Medical PolicyEff. 2026-05-01Cosmetic and Reconstructive ProceduresMedicare medical policy governing determination of coverage for cosmetic versus reconstructive plastic and reconstructive surgery procedures for Providence Health Plan Medicare members; guides prior authorization and claims decision-making based on Medicare rules, LCDs/NCDs, member EOCs, and clinical necessity.All Providence Health Plan updates
- Prior AuthClinical/Medical PolicyEff. 2026-05-01Medicare Part B Step Therapy Criteria for Part B DrugsDefines step therapy protocols, prior authorization expectations, and the list of Part B medications (by HCPCS/J-codes and others) subject to step requirements for Providence Medicare Advantage members.All Providence Health Plan updates
- Prior AuthAdministrative/Operational PolicyEff. 2026-05-01Providence Medicare Advantage Plans 2026 Prior Authorization Criteria for Part B DrugsThis document lists Providence Medicare Advantage Plans' prior authorization requirements for selected Medicare Part B drugs (infused or injected) and provides contact information for providers and members about obtaining prior authorization. It affects Providence Medicare Advantage Plan members and their prescribing providers.All Providence Health Plan updates
- Prior AuthClinical/Medical PolicyEff. 2026-03-16Breast Reconstructive Surgery, Implant Management and Reduction Mammoplasty (Special Alert)This policy governs coverage and authorization for breast reconstructive surgery, implant management, and reduction mammoplasty for Providence Health Plan members and providers. It communicates a correction to previously intended updates and instructs providers to resubmit prior authorizations or appeals if negatively affected.All Providence Health Plan updates
- Prior AuthClinical/Medical PolicyEff. 2026-02-01Miscellaneous Products Infusion Therapy — Site of Care Prior AuthorizationDefines site-of-care prior authorization requirements for selected infused medications administered in outpatient settings for Providence Health Plan commercial members aged 13 and older, including permitted exceptions and reauthorization rules.All Providence Health Plan updates
- Prior AuthClinical/Medical PolicyEff. 2026-02-01Miscellaneous Products — Self‑Administered Drugs (SAD) Prior Authorization and Medical Administration CriteriaDefines prior authorization, medical necessity, coding, and monitoring requirements for medications identified as self‑administered drugs (SADs) under Providence Health Plan, affecting Commercial and Medicaid members and providers requesting healthcare professional administration.All Providence Health Plan updates
- Prior AuthClinical/Medical PolicyEff. 2026-01-01Complex Rehab Technology (CRT) Repair — Medicaid (OHP) coverage and billingDefines Providence Health Plan Medicaid (Oregon) coverage, billing, and documentation requirements for repairs to Complex Rehab Technology (CRT) and explains when prior authorization is or is not required under Oregon Senate Bill 549.All Providence Health Plan updates
- Prior AuthClinical/Medical PolicyEff. 2026-01-01Outpatient Surgical Site of ServicePolicy requires prior authorization for hospital outpatient (POS 22) site of service for select outpatient surgical procedures for Commercial Fully Insured members and directs that services not meeting criteria must be performed at an ambulatory surgery center (ASC) unless an attestation of no accessible ASC is on file.All Providence Health Plan updates
- Prior AuthClinical/Medical PolicyEff. 2026-01-01Spinal Fusion and Decompression ProceduresMedical policy governing medical necessity, documentation, and coverage criteria for spinal fusion and decompression procedures for Providence Health Plan commercial products; describes indications, not medically necessary services, and required documentation for prior authorization.All Providence Health Plan updates
- Prior AuthClinical/Medical PolicyEff. 2026-01-01Transcranial Magnetic Stimulation (TMS)Covers clinical background, FDA status, devices, and evidence for use of transcranial magnetic stimulation for behavioral health conditions (primarily major depressive disorder, OCD, and migraine with aura). Affects providers requesting coverage or prior authorization for TMS services under Providence Health Plan.All Providence Health Plan updates
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Tool Description
Search Providence Health Planprior authorization policies by drug name, procedure, or policy title. Results include any policy that mentions prior authorization requirements (drug coverage criteria, imaging guidelines, site-of-service rules) not just documents titled “prior authorization.” Every result links to a full policy page with clinical criteria, covered billing codes, documentation requirements, and effective dates.
Filter by payer, specialty, policy type, or effective year; or search directly for a drug (“Wegovy,” “Ozempic”), a procedure (“MRI,” “knee arthroplasty”), or a policy number.
Coverage spans 110+ payers. Jump straight to the busiest prior-auth publishers: UnitedHealthcare, Cigna, Aetna, Anthem, and Centene. You can also browse the full policy updates feed.
Pair a prior-auth search with the billing code lookup to confirm the CPT or J-code on the claim, the payer lookup for plan footprint, and payer profiles for contacts and coverage context.
FAQ
Type a drug name (“Wegovy,” “Ozempic”), a procedure (“MRI,” “knee”), or a policy title into the search bar. Filter results by payer, specialty, policy type, or effective year. Open any result for the full policy page with clinical criteria, covered billing codes, documentation requirements, and effective dates.
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