All Participating, Preferred and Access members (except FEP)
Phone: 1 (800) 547-9718 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 or after eight visits for PEBB preferred providers only.

FEP Members
Phone: 1 (866) 873-9743 Fax: 1 (800) 331-3505

• Inpatient/residential/partial hospitalization/intensive outpatient services within 48 hours of admission
• Outpatient - Basic option at first visit; Standard option at ninth visit.

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).

Hospice (including level of care charges)

S0255, S9125, S9126
Q5001, Q5002, Q5003, Q5004, Q5005, Q5006, Q5007, Q5008, and Q5009

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

All hospital admissions require notification

Concurrent review will occur after 7 days.

Long Term Acute Care Facility (LTAC)

Rehabilitation

Skilled Nursing Facility (SNF)

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

Transplants
G0267, G0341, G0342, G0343, S2053, S2054, S2055, S2060, S2061, S2065, S2150, S2152, 32850, 32851, 32852, 32853, 32854, 33930, 33935, 33940, 33945, 38205, 38206, 38207, 38208, 38209, 38210, 38211, 38230, 38240, 38241, 38242, 44132, 44133, 44135, 44136, 47133, 47135, 47136, 47140, 47141, 47142, 48160, 48550, 48554, 48556, 50300, 50320, 50340, 50360, 50365, 50370, 50380, 0141T, 0142T, 0143T

Ventricular assist devices and total artificial hearts
33975, 33976, 33977, 33978, 33979, 33980, 0048T, 0049T, 0050T, 0051T, 0052T,0053T

Cosmetic or potentially cosmetic procedures

Pre-authorization not required for initial breast reconstruction one or two stages and nipple/areola reconstruction following mastectomy, 19340, 19342, 19350, 19357, 19361, 19364, 19366, 19367, 19368 or 19369

The following codes should be pre-authorized as potentially cosmetic:
11950, 11951, 11952, 11954, 11960, 11970, 11971, 15780, 15781, 15782, 15783, 15786, 15787, 15788, 15789, 15792, 15793, 15820, 15821, 15822, 15823, 15830, 17360, 19316, 19318, 19324, 19325, 19355, 19370, 19371, 19380, 19396, 21210, 21230, 21235, 21740, 21742, 21743, 30400, 30410, 30420, 30430, 30435, 30450, 30460, 30462, 30465, 36470, 36471, 36475, 36476, 36478, 36479, 37500, 37501, 67900, 67901, 67902, 67903, 67904, 67906, 67908, 67909, 69300

Obesity surgery

43644, 43770, 43771, 43772, 43773, 43774, 43843, 43846, 43848, S2083

Orthognathic surgery

21120, 21121, 21123, 21125, 21127, 21137, 21141, 21142, 21143, 21145, 21146, 21147, 21150, 21151,21154, 21155, 21159, 21160, 21193, 21198, 21199, 21206, 21208, 21209, 21210, 21230, 21235, 

Sleep apnea surgery

21685, 42120, 42140, 42145, 42160, 42299

Investigational or potentially investigational services

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 services waiver form (PDF).

Physicians are required to notify Special Beginnings^® of pregnancies within two weeks of the member's first prenatal visit. Phone: 1 (888) 569-2229 Fax: 1 (503) 391-8696.