THA requires the following forms to be submitted to request a referral to a non-THA specialist, a non-formulary medication, or medical equipment. For help with any of these forms, please call our Referral Coordinators at: 503-844-8104.

THA PCP/Specialist Referral Form 

This form must be used for all THA member referrals and procedure pre-authorizations. The form must be filled out completely and accurately to ensure timely processing. The form should include at a minimum:

  • The member’s name, THA ID number, and birth date;
  • The name and contact information for all involved healthcare providers;
  • A current ICD-10 code diagnosis that accurately reflects the condition for which the member is being referred;
  • The CPT or HCPCS code(s) (if a procedure is requested); and
  • Attached copies of legible and relevant chart notes, lab or radiology reports, etc

Download THA PCP/Specialist Referral Form (PDF) »

THA Drug Prior Authorization Form

This form must be used for all THA member medication pre-authorizations. The form must be filled out completely and accurately to ensure timely processing. The form should include at a minimum:

  • The member’s name, THA ID number, and birth date;
  • The name and contact information for all involved healthcare providers;
  • A current ICD-10 code diagnosis that accurately reflects the condition for which the member is seeking medication;
  • The name, dose, and directions for use of the medication being requested;
  • Notification of the member’s current medication use and related or step therapy medications; and
  • Attached copies of legible and relevant chart notes, lab or radiology reports, etc.

Download THA Drug Prior Authorization Form (PDF) »

 

THA Durable Medical Equipment Prior Authorization Form

This form must be used for all THA member medical equipment pre-authorizations. The form must be filled out completely and accurately to ensure timely processing. The form should include at a minimum:

  • The member’s name, THA ID number, and birth date;
  • The name and contact information for all involved healthcare providers;
  • A current ICD-10 code diagnosis that accurately reflects the condition for which the member is seeking medical equipment;
  • The name, units, and directions for use of the medical equipment being requested; and
  • Attached copies of legible and relevant chart notes, lab or radiology reports, etc.

Download THA Durable Medical Equipment Prior Authorization Form (PDF) »

 

THA Flexible Services Request Form

Flexible Services are health related non-billable services intended to improve care delivery and Oregon Health Plan (OHP) Medicaid member health. Flexible services are unable to be reported using CPT or HCPCS codes. If a service has a CPT or HCPCS code, it may not be provided using Flexibles Services even if it is not a covered benefit.

Flexible Services are cost effective alternatives to traditional services and may include, but are not limited to, classes, programs, equipment, appliances or special clothing or footwear.

Examples of Flexible Services, per Oregon Health Authority, include, but are not limited to:

  • Training/education for health improvement or management (e.g., class on healthy meal preparation or diabetes self-management)
  • Self-help or support group activities (e.g., post-partum depression programs, Weight Watchers groups)
  • Care coordination, navigation or case management activities (not covered and billable under OHP benefits)
  • Home/living environment items or improvements (non-DME items to improve mobility, access, hygiene or other improvements to address a particular health condition)
  • Transportation not covered under OHP benefits
  • Programs to improve general community health
  • Housing supports related to social determinants of health (e.g., shelter, utilities, critical repairs)

To request Flexible Services for a Health Share/Tuality Member:

  • A Flexible Services Request form must be sent to the THA Referral & Authorizations department via fax at 503-681-1823. THA Referral Coordinators will review request for completion and forward request to THA Nurse Case Managers. 
  • THA Nurse Case Managers will review request and make a final determination.

Download THA Flexible Services Request Form (PDF) »