Oregon Health Plan (OHP) Referrals and Authorizations FAQs
- What is the difference between a referral request and an authorization request?
- Does ODS guarantee eligibility on authorizations approved for an OHP member?
- What is the direct line for authorizations and referrals?
- Do members need a referral for routine vision services, annual women's exam, or maternity care?
- If the OB/GYN finds something during a routine exam that requires additional testing or treatment, can he/she request an authorization without going through the Primary Care Physician ( PCP )?
- Do diagnostic procedures, including CAT scans, MRIs or special x-rays need a referral?
- How do I extend a referral?
- Does a referral become invalid if the member changes PCP 's during the timeframe of the referral?
- If a procedure or service is excluded from the member's plan benefits, can we obtain authorization if we are able to establish medical necessity?
- Are referrals or authorizations required for mental health / chemical dependency treatment?
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 ODS 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 and/or review of the service for medical necessity.
Does ODS guarantee eligibility on authorizations approved for an OHP member?
All services are subject to eligibility and plan provisions in effect at the time services are rendered. ODS does not cover services or supplies not covered by the Oregon Health Plan.
What is the direct line for authorizations and referrals?
ODS has dedicated telephone lines for healthcare professionals who wish to process requests for referrals and/or service authorizations. Please call 503-265-2940 , locally, or at 1-888-474-8540 if you are calling long distance.
Do members need a referral for routine vision services, annual women's exam, or maternity care?
No, they can self refer to a participating optometrist for vision services or to a participating OB/GYN for routine annual women's exam and/or maternity care. Benefits may be limited for these services. Contact customer service for benefit limitations and exclusions.
If the OB/GYN finds something during a routine exam that requires additional testing or treatment, can he/she request an authorization without going through the Primary Care Physician (PCP)?
Yes, if an OB/GYN determines that further medical investigation is needed relating to an OB/GYN condition, he/she may contact ODS 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 OB/GYN, then the PCP will have to initiate any follow-up referrals or authorizations. Some groups have exceptions, refer to the OHP Referral & Authorization Guidelines.
Do diagnostic procedures, including CAT scans, MRIs or special x-rays need a referral?
Normally, they 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. There are some diagnostic tests that do require an authorization. For a list of diagnostic procedures requiring authorization, refer to the OHP Referral & Authorization Guidelines.
How do I extend a referral?
To extend the dates or increase the number of visits on an expired referral, the patient's current primary care physician submits the referral extension request to the ODS medical intake unit.
Does a referral become invalid if the member changes PCP 's during the timeframe of the referral?
Referrals remain valid until the expiration date of the referral or the number of visits has been exhausted whichever comes first.
If a procedure or service is excluded from the member's plan benefits, can we obtain authorization if we are able to establish medical necessity?
If a procedure or service is excluded from the 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.
Are referrals or authorizations required for mental health / chemical dependency treatment?
Referrals are not required for mental health / chemical dependency treatment, however, OHP Providers must seek preauthorization for further outpatient chemical dependency treatment after nine months or $2,000 (whichever comes first).
Verbal preauthorization for detoxification or synthetic opiate treatment must be obtained from ODS by the provider.