Blue Plans obtaining pre-authorization information for Regence members: Members of some group health plans may have terms of coverage or benefits that differ from the information presented here. The following information describes the general policies of Regence and is provided for reference only. This information is NOT to be relied upon as pre-authorization or pre-certification for health care services and is NOT a guarantee of payment. To verify coverage or benefits or determine pre-certification or pre-authorization requirements for a particular member, call 1-800-676-BLUE or send an electronic inquiry through your established connection with your local Blue Plan.

Regence providers obtaining pre-authorization information for out-of-area (BlueCard®) members: Use our online tool to be automatically routed to the home plan's pre-authorization / pre-certification requirements. Launch the tool.

This list does not pertain to Medicare products, Uniform Medical Plan or Federal Employee Program (FEP) members. Please contact your provider relations representative for copies of previous lists.

Upcoming lists

• Effective May 1, 2012 indicated in red text
• Effective July 1, 2012 indicated in green text

Important pre-authorization reminders

1. Before requesting pre-authorization, please verify eligibility and benefits via the Provider Center.
2. Verify that you are an in-network provider for each member to help reduce his or her out-of-pocket expense.
3. Verification of member eligibility is valid if obtained within five business days of service except in the case of misrepresentation.
4. Pre-authorizations obtained within 30 business days prior to service are valid except in the case of misrepresentation.
5. Medical policies related to specific pre-authorization requirements are available at http://blue.regence.com/trgmedpol/index.html.
6. Potentially investigational services may also be considered medically necessary for select diagnoses. Please refer to the Regence Clinical Edits by Code list for additional information. Unlisted codes may be used for potentially investigational services and are subject to review.
7. Some member contracts have specific pre-authorization requirements. The member's contract language will apply.
8. Urgent/Emergent services do not require pre-authorization.
9. Pharmacy prior authorization information and forms can be found at the RegenceRx Physician Web site.
10. Please note that a pre-authorization does not guarantee payment for requested services. Regence reimbursement policies may affect how claims are reimbursed and payment of benefits is subject to all plan provisions, including eligibility for benefits.
11. Pre-authorization approval will be communicated by phone and a pre-authorization approval number will be provided.
12. Pre-authorization denials will be communicated both in writing and by phone.

Pre-authorization for investigational services and supplies is not required as such charges are typically contract exclusions and ineligible for payment.  Charges for investigational services and supplies are denied with financial responsibility assigned to the member.

Potentially investigational services are services that are considered investigational, but for select diagnoses, may also be considered medically necessary, please refer to the Regence Clinical Edits by Code list for additional information. Unlisted codes may be used for potentially investigational services and are subject to review. 

• View investigational and potentially investigational procedures on the current Regence Clinical Edits by Code list. Note: This list does not apply to Medicare products.
• View a sample non-covered member consent form (PDF).

Regence uses Milliman Care Guideline as the basis for determining medical necessity for Mental Health and Substance Abuse services. Visit Milliman’s website for information on purchasing their criteria, or contact Regence at the phone number(s) above and we will be happy to provide you with a copy of guidelines for specific services. 

• Detox/Inpatient/Partial admissions: Notification upon admission required. Concurrent review will occur after 2 days.
• Chemical dependency intensive outpatient: Notification upon admission required. Concurrent review will occur after 8 weeks.
• Outpatient mental health, outpatient chemical dependency, and intensive outpatient mental health: Concurrent review will occur after 20 visits.
• Residential Treatment Center (RTC): Pre-authorization is required prior to patient admission.

Regence uses Milliman Care Guideline as the basis for determining medical necessity on the following procedures. Visit Milliman’s website for information on purchasing their criteria, or contact Regence at the phone number(s) above and we will be happy to provide you with a copy of the specific guideline.   

E0760, 20979- Milliman Care Guideline ACG: A-414

E0983-4, E0986, E1002 - E1008, E1009 - E1010, E1220, E2230, E2295, E2300, E2301, E2310 - E2311, E2331, E2340 - E2343, E2609, E2610, E2617, K0005, K0009 - K0014, K0669, K0813 - K0816, K0820 - K0843, K0848 - K0864, K0868 - K0886, K0890 - K0891, K0898

Please refer to the Regence Clinical Edits by Code list for additional DME code information.

Transplants, ventricular assist devices and total artificial hearts (pre-authorization not required for corneal and kidney transplants)

Transplants
G0341, G0342, G0343, S2053, S2054, S2055, S2060, S2065, S2140, S2142, S2150, S2152, 32851, 32852, 32853, 32854, 33935, 33945, 38205, 38206, 38230, 38232, 38240, 38241, 38242, 44135, 47135, 47136, 48160, 48554, 0141T, 0142T, 0143T

Ventricular assist devices and total artificial hearts
33975, 33976, 33977, 33978, 33979, 0048T, 0050T, 0051T, 0052T, 0053T

Inpatient Admissions:
Phone: (503) 220-4795, toll-free: 1 (800) 824-8563 or Fax: 1 (800) 453-4341

All hospital admissions require notification

Concurrent review will occur after 7 days.

Long Term Acute Care Facility (LTAC)

Pre-authorization is required prior to patient admission.

Rehabilitation

Pre-authorization is required prior to patient admission.

Skilled Nursing Facility (SNF)

Pre-authorization is required prior to patient admission.

Autologous Fat Grafting to the Breast and Adipose-derived Stem Cells

Endoscopic Radiofrequency Ablation or Cryoablation for Barrett’s Esophagus

Extracranial Carotid Angioplasty / Stenting

77301, 77338, 77418, 0073T

Please reference the following Regence Medical Policies for further information:

• IMRT of the Breast and Lung
• IMRT of the Prostate
• IMRT of the Head and Neck Cancers and Thyroid Cancer
• IMRT of the Abdomen and Pelvis

Obesity surgery

43644, 43770, 43771, 43772, 43773, 43774, 43846, 43848, 43886, 43887, 43888

Orthognathic surgery

21120, 21121, 21123, 21125, 21127, 21141, 21142, 21143, 21145, 21146, 21147, 21150, 21151, 21154, 21155, 21159, 21160, 21193, 21194, 21195, 21196, 21198, 21199, 21206, 21230, S8262

Effective May 1, 2012:
21085, 21110, 21122, 21188, 21208, 21209, 21210, 21215

Sleep apnea surgery

Please refer to the Regence Clinical Edits by Code list for potentially investigational procedures.

Regence uses Milliman Care Guideline as the basis for determining medical necessity on the following procedures. Visit Milliman’s website for information on purchasing their criteria, or contact Regence at the phone number(s) above and we will be happy to provide you with a copy of the specific guideline.   

• 22552 (Effective July 1, 2012), 22554, 22551 - Milliman Care Guideline ORG S-320
• 22600 - Milliman Care Guideline ORG S-330
• 22533 (Effective July 1, 2012), 22558, 22612, 22630, 22633 - Milliman Care Guideline ORG S-820

The following procedures use Regence Medical Policy, Percutaneous Vertebroplasty and Kyphoplasty, as the basis for determining medical necessity:

22520, 22521, 22522, 22523, 22524, 22525, 72291, 72292, S2360, S2361

Regence uses Milliman Care Guideline as the basis for determining medical necessity on the following procedures. Visit Milliman’s website for information on purchasing their criteria, or contact Regence at the phone number(s) above and we will be happy to provide you with a copy of the specific guideline.   

• 21010 - Milliman Care Guideline A‐0522
• 21050 - Milliman Care Guideline A‐0521
• 29800, 29804 - Milliman Care Guideline A‐0492
• 21240, 21242, 21243 - Milliman Care Guideline A‐0523

Please refer to the Regence Clinical Edits by Code list for medical necessity review codes and potentially investigational procedures.

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

Pre-authorization not required for initial breast reconstruction one or two stages and nipple/areola reconstruction following mastectomy.

Please refer to the Regence Clinical Edits by Code list for cosmetic and potentially cosmetic procedures.

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

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.

Unlisted codes may be used for potentially investigational services and are subject to review. 

Please refer to the Regence Clinical Edits by Code list for additional information.