Oregon Health Plan referral and authorization FAQs

What is the difference between a referral request and an authorization request?

A referral request is a request by a primary care physician (PCP) for Moda Health approval for a patient to see a specialist. An authorization request is a request for approval of a service for a member based on review of the member's plan benefits or review of the service for medical necessity.

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Does Moda Health guarantee eligibility on authorizations approved for an Oregon Health Plan member?

All services are subject to eligibility and plan provisions in effect at the time services are rendered. Moda Health does not cover services or supplies not covered by the Oregon Health Plan.

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What is the direct line for authorizations and referrals?

Moda Health has dedicated telephone lines for healthcare professionals who would like to process requests for referrals or service authorizations. Please contact us at 503-265-2940 or toll-free at 888-474-8540.

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Do members need a referral for routine vision services, annual womenís exams or maternity care?

No, they can self refer to a participating optometrist for vision services or to a participating OB/GYN for routine annual womenís exams and maternity care. Benefits may be limited for these services. Contact Moda Health Customer Service for benefit limitations and exclusions.

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If an OB/GYN finds something during a routine exam that requires additional testing or treatment, can he or she request an authorization without going through the primary care physician?

Yes, if an OB/GYN determines that further medical investigation is needed relating to an obstetric or gynecologic condition, he or she can contact Moda Health without going through the PCP for an authorization. Nevertheless, the PCP should be informed of the gynecologic condition discovered during the exam. If the medical condition is not related to obstetrics or gynecology, then the PCP will have to initiate any follow-up referrals or authorizations. Some groups have exceptions. Please refer to the OHP Referral & Authorization Guidelines.

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Do diagnostic procedures, including CAT scans, MRIs or special X-rays need a referral?

Normally, diagnostic procedures do not need a separate referral authorization as long as the PCP, or a specialist to whom we have an authorized referral, orders the diagnostic tests. Some diagnostic tests do require an authorization. For a list of diagnostic procedures requiring authorization, refer to the OHP Referral & Authorization Guidelines.

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How do I extend a referral?

If you are the patientís PCP and would like to extend the dates or increase the number of visits on an expired referral, please submit the referral extension request to the Moda Health medical intake unit.

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Does a referral become invalid if the member changes PCPs during the timeframe of the referral?

No. Referrals remain valid until the expiration date of the referral or the number of visits has been exhausted, whichever comes first.

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If a procedure or service is excluded from a member's plan benefits, can we obtain authorization if we are able to establish medical necessity?

If a procedure or service is excluded from a member's plan, benefits will not be available even if medical necessity is established. Please refer to the member's plan benefits for limitations and exclusions.

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Are referrals or authorizations required for mental health and chemical dependency treatment?

Referrals are not required for mental health and chemical dependency treatment. Mental health services for OHP members are not managed by ODS; members may check with their local mental health authority for assistance locating a provider.

OHP providers must seek preauthorization for chemical dependency treatment after the initial evaluation. Providers should contact Moda Health Behavioral Health at 888-474-8538 for authorization.

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