Regence Prior Authorization Lookup
Latest Regence prior authorization updates16
- Prior AuthClinical/Medical PolicyEff. 2026-11-01Applied Behavior Analysis for the Treatment of Autism Spectrum DisorderThis policy governs medical necessity, authorization, documentation, provider qualifications, and coverage criteria for ABA assessment and treatment of members with autism spectrum disorder. It applies to member contracts subject to ABA preauthorization and applicable state autism or mental health parity benefits.All regence updates
- Prior AuthClinical/Medical PolicyEff. 2026-11-01Balloon Dilation of the Eustachian TubeThis policy governs coverage and medical-necessity review for balloon dilation of the Eustachian tube to treat chronic obstructive Eustachian tube dysfunction for Regence members, subject to applicable contract terms and prior authorization requirements.All regence updates
- Prior AuthClinical/Medical PolicyEff. 2026-11-01Surgical Site of Care - Colonoscopy and SigmoidoscopyThis policy governs prior authorization for performing colonoscopy or sigmoidoscopy in a hospital outpatient department instead of an ambulatory surgery center or physician office. It applies to outpatient hospital site-of-care requests when specified medical-necessity criteria or qualifying individual risk factors are documented.All regence updates
- Prior AuthClinical/Medical PolicyEff. 2026-11-01Surgical Site of Care - Hospital OutpatientThis policy governs prior authorization for performing eligible surgical procedures in a hospital outpatient department rather than an ambulatory surgery center or physician office. It applies to outpatient hospital procedures on the policy's code list and evaluates individual health status, procedure risk, and other site-of-care considerations.All regence updates
- Prior AuthClinical/Medical PolicyEff. 2026-08-15GLP-1 Agonist-Containing Medications for Non-Diabetic IndicationsThis policy governs pharmacy-benefit coverage and prior authorization for GLP-1 agonist-containing medications used for non-diabetic indications, including obesity or overweight, cardiovascular event prevention, obstructive sleep apnea with obesity, and noncirrhotic MASH/NASH. It applies to members whose benefit contracts permit coverage for the relevant indication and excludes GLP-1 products specifically approved for type 2 diabetes.All regence updates
- Prior AuthClinical/Medical PolicyEff. 2026-04-01Immediate-release (IR) Opioid Medication Products for PainCoverage and prior authorization for immediate-release oral, nasal, and topical opioid medications used for pain, generally when opioid use exceeds 14 cumulative days in 30 days.All regence updates
- Prior AuthClinical/Medical PolicyEff. 2026-02-01Postsurgical Home Use of Limb Compression DevicesThis policy governs coverage of limb compression devices used at home after surgery for venous thromboembolism prophylaxis. It applies only to member contracts that require preauthorization for limb compression devices and affects providers requesting coverage for eligible postsurgical patients.All regence updates
- Prior AuthClinical/Medical PolicyEff. 2026-01-01Intensity Modulated Radiotherapy (IMRT) for Breast CancerThis policy governs when IMRT for breast cancer may be considered medically necessary, including definitive post-lumpectomy and adjuvant post-mastectomy treatment. Prior authorization is required.All regence updates
- Prior AuthClinical/Medical PolicyEff. 2026-01-01Intensity Modulated Radiotherapy (IMRT) for Tumors in Close Proximity to Organs at RiskThis policy governs medical necessity and prior authorization for IMRT used to treat primary or metastatic tumors near organs at risk. Coverage depends on comparative 3D versus IMRT dose-volume analysis demonstrating that published organ dose constraints can be met only with IMRT.All regence updates
- Prior AuthClinical/Medical PolicyEff. 2025-12-01Oxygen ConcentratorsThis policy governs when oxygen concentrators may be considered medically necessary for members whose contracts are subject to oxygen preauthorization requirements. Coverage applies to providers prescribing or dispensing oxygen concentrators and is subject to applicable contract terms.All regence updates
- Prior AuthClinical/Medical PolicyDefinitive Lower Limb ProsthesesMedical-necessity review and preauthorization for definitive, permanent lower limb prostheses and specified components for Regence Medicare Advantage members; preparatory and microprocessor-controlled prostheses are outside scope.All regence updates
- Prior AuthClinical/Medical PolicyElectrical Stimulation and Electromagnetic Therapy DevicesThis Medicare Advantage policy governs coverage and medical-necessity review for electrical stimulation, electromagnetic therapy, and related devices used for pain, neurologic conditions, muscle atrophy, ambulation, wound treatment, and other indications. Coverage depends on applicable CMS guidance, Medicare Advantage criteria, the member Evidence of Coverage, and any applicable prior-authorization requirements.All regence updates
- Prior AuthClinical/Medical PolicyIntensity Modulated Radiotherapy (IMRT) for Breast CancerMedicare Advantage coverage and prior authorization review for breast cancer IMRT when medical necessity and applicable documentation requirements are met.All regence updates
- Prior AuthClinical/Medical PolicyIntensity Modulated Radiotherapy (IMRT) for Tumors in Close Proximity to Organs at RiskMedicare Advantage coverage and prior authorization for medically necessary IMRT when tumors are near organs at risk, with required clinical documentation and comparative dose/volume histogram analysis when applicable.All regence updates
- Prior AuthClinical/Medical PolicyIntensity Modulated Radiotherapy (IMRT) of the Thorax, Abdomen, Pelvis, and ExtremitiesThis Medicare Advantage policy governs coverage and prior authorization for IMRT of tumors in the thorax, abdomen, pelvis, and extremities. Coverage requires medical necessity, required clinical documentation, and comparative 3D-versus-IMRT dose/volume analysis when indicated.All regence updates
- Prior AuthClinical/Medical PolicyNegative Pressure Wound Therapy in the Outpatient SettingMedicare Advantage coverage, prior authorization, documentation, and coding requirements for negative pressure wound therapy in outpatient, home-health, physician-office, and home settings.All regence updates
1–16 of 16
1 / 1
Tool Description
Search Regenceprior 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.
Prior Authorization by Payer
Go deeper
Explore OpenPayer Data
Prior auth requirements change all the time. Keep up with every payer policy update in the live policy feed, or browse payers with prior authorization policies.
Toolbox
More OpenPayer Tools
- Billing Code LookupSearch CPT, HCPCS, J-codes, DRG, and dental codes by number or procedure name.
- Billing Code Reimbursement RatesBuild a reimbursement rate report across any mix of billing codes and states, comparing commercial payers against Medicare.
- Payer Comparison DashboardPick 2-5 payers to compare market share, premium, and membership by region, all at once.
- Facility Comparison DashboardPick 2-6 hospital facility types (or add a specific hospital) to compare facility count, revenue, net income, and Medicare/Medicaid payer mix by region, all at once.
- Healthcare Provider & Facility LookupFind hospitals and healthcare facilities by name, taxonomy, facility type, ownership, or state.
- Health Insurance Payer LookupSearch national health insurance payers and health plans by name and state presence.
- Provider Taxonomy Code LookupSearch NUCC taxonomy codes by code, specialty, grouping, or classification.
- CPT Modifier LookupSearch CPT modifiers by code or name — descriptions, when to use them, and payer policy context.
- Timely Filing LookupFind payer timely filing policies: claim deadlines, corrected claim windows, and appeal timeframes.
- Coverage Criteria LookupSearch payer coverage criteria and medical necessity requirements by drug, procedure, or payer.
- Payer Contact DirectoryClaims, prior authorization, provider services, and appeals contacts for health insurance payers.
Published by
Trek Health powers OpenPayer with a leading commercial payer intelligence platform, seamlessly converting fragmented payer data into actionable insights for provider organizations.