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Regence Group and Individual Products
This list does not pertain to Medicare products
Important pre-authorization reminders
- Some member contracts have specific pre-authorization
requirements. The member's contract language will apply.
- Urgent/Emergent services do not require pre-authorization.
- Before requesting pre-authorization, please verify eligibility and benefits via Regence Online Services for Providers.
- Verification of member eligibility is valid if
obtained within five business days of service except
in the case of misrepresentation.
- Contract exclusions will not be pre-authorized.
Denials may be appealed through Customer Service.
- Pre-authorizations obtained within 30 business
days prior to service are valid except in the case
of misrepresentation.
- Medical policies related to specific pre-authorization
requirements are available online.
Boeing ONLY: Out-of-area PPO and Selections Plus authorizations are offered when requested.
Effective November 1, 2008
Regence Group and Individual Products
| Chemical Dependency and Mental Health |
All providers (except FEP)
Phone: 1 (800) 780-7881 Fax: 1 (800) 331-3505
- Inpatient/partial/residential admissions require notification. Concurrent review will occur after eight days.
- Outpatient - Concurrent review will occur after 30 visits.
FEP Members
Phone: 1 (800) 780-7881 Fax: 1 (800) 331-3505
- Inpatient/residential/partial hospitalization/intensive outpatient services within 48 hours of admission
- Outpatient - Basic option prior to first visit; Standard option at ninth visit.
Boeing Helpline Phone: 1 (800) 892-1411 |
Durable Medical Equipment
Phone: (206) 464-3748
Toll free: 1 (800) 367-2766 (in state) or 1 (800) 423-6884 (out of state)
Fax: (800) 453-4341
Pre-authorization not required for FEP members |
Equipment purchase or repair with billed charges over $1,500 for any single line item or component unless listed as an exception below. |
Equipment rental with billed charges over $500/month for any single line item or component unless listed as an exception below. |
Extremity prosthetics with billed charges over $5,000 for any single line item or component. |
Exceptions (the following items do not require pre-authorization, regardless of line item charges)
Apnea monitors, bilirubin lights, cardiac monitors, CPAP/BiPAP, CPM (knee only), dynamic splints, home dialysis equipment, infusion pumps, insulin pumps, ocular prostheses, orthotics, oxygen and oxygen equipment, psoriasis lights, SIDs monitors, suction pumps, ventilators (including maintenance), vacuum assisted wound closure. |
Please refer to the Regence Clinical Edits by Code list for additional DME code information. |
Hospice Services: (Pre-authorization required for FEP or or as indicated by member contract)
Phone: (206) 464-3748
Toll free: 1 (800) 367-2766 (in state) or 1 (800) 423-6884 (out of state)
Fax: (800) 453-4341 |
S0255, S9125, S9126,
Q5001, Q5002, Q5003, Q5004, Q5005, Q5006, Q5007, Q5008, and Q5009 |
Inpatient Admissions:
Phone: (206) 464-3748
Toll free: 1 (800) 367-2766 (in state) or 1 (800) 423-6884 (out of
state)
Fax: (800) 453-4341 |
All hospital admissions require notification |
Concurrent review will occur after 7 days. |
Long Term Acute Care Facility (LTAC) |
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Rehabilitation |
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Skilled Nursing Facility (SNF) |
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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, S2150, S2152, , 32851,
32852, 32853, 32854, 33935, 33945, 38205, 38206,
38230, 38240, 38241, 44135, 47135, 47136, 48160,
48554, 0141T, 0142T, 0143T
Ventricular assist devices and total artificial hearts
33975, 33976, 33977, 33978, 33979, 33980, 0048T, 0049T, 0050T, 0051T, 0052T,0053T |
Other Services:
Phone: (206) 464-3748
Toll free: 1 (800) 367-2766 (in state) or 1 (800) 423-6884 (out of state)
Fax: (800) 453-4341 |
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. |
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, 21210, 21230 |
Sleep apnea surgery |
21685, 42120, 42140, 42145, 42160, 42299 |
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. |
| Pregnancy |
Physicians are asked to notify Special
Beginnings® of pregnancies within two weeks of
the member's first prenatal visit. Phone: 1 (888) 569-2229 Fax: (503)
391-8696. |
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