As a provider, it is your responsibility to have an approved prior-authorization (if required) prior to providing the service to the member.
Dowload current list of services that require referral/pre-authorization (PDF) »
For a member’s referral or pre-authorization to be valid, he/she needs to have been evaluated by his/her THA-network PCP within the previous 12 months.
Referral or pre-authorization is not required for visits to a Full/Associate or Preferred THA Specialist, for office or outpatient procedures that are above-the-line on Oregon’s prioritized list with matched ICD and CPT codes, or for covered formulary medications.
Routine Referrals and Prior Authorizations
THA is allowed 14 calendar days to make a pre-determination regarding referral and pre-authorization requests. THA strives to complete requests within the first 7 days. Please do not call to check status within the first 7 days.
Urgent/Expedited Referrals and Prior Authorizations
THA considers URGENT to mean:
- Serious jeopardy to the life or health of the member as based on a prudent layperson’s judgment; or
- In the opinion of a practitioner with knowledge of the member’s medical condition, severe pain or injury that cannot be adequately managed without the care or treatment that is the subject of the request.
Providers may submit requests for “urgent” or “expedited” referrals or pre-authorizations by checking the “Expedite” box on any THA referral or prior authorization form and submitting the form to THA via fax or phone. THA Medical Management staff will make an expedited referral determination within 72 hours of receipt.
Referrals and Pre-Authorizations for After-Hours and Weekend Services
- If a provider renders relevant services to a member without pre-authorization in the event of an emergency, that provider may request a retroactive preauthorization review, notifying THA on the next business day.
- In the event of an emergency, THA will authorize one follow-up visit to the provider who cared for the member in the Emergency Department, or to the provider to whom the member was directed.
- THA reserves the right to deny coverage of any after-hours service that was done out-of-plan and was not emergent.