Contact Us

For all prior authorization questions, please contact us at PriorAuthorizations@umpquahealth.com

Submitting a Prior Authorization

Umpqua Health Alliance offers providers the ability to submit, check the status and manage your prior authorization (PA) requests online. By signing up for access to our Community Integration Manager (CIM), you can eliminate paperwork and faxing associated with the authorization process. You will also have direct email access to our Member Services, Prior Authorization (PA), and Claims teams that can assist you with questions of member eligibility, and monitoring PA and claims status’.

UHA requires all in-network providers to submit PA requests through CIM.

• Follow these Instructions if you need help on how to sign up for CIM access.
• Step-by-step instructions for how to submit a PA are located in our Utilization Management & Service Authorization Handbook.
• To access the provider portal, click this link: https://cim1.phtech.com/cim/login.

Medical, Behavioral health & DME Authorizations

Check out our Medical, Behavioral and SUD Prior Authorization Form for clarification on UHA’s prior authorization (PA) turnaround times, criteria and other requirements and helpful information. Additionally, the Behavioral health Prior Authorization Provider FAQ can help with frequently asked questions on submissions for mental health and substance use disorder (SUD) services.

In-network providers must submit PA requests through CIM. See the Submitting a Prior Authorization section above for how to sign up. All communications and notifications will be sent securely within CIM. Out-of-network requests must be completed on the Medical, Behavioral and SUD Prior Authorization Form. All submissions, via CIM and fax must include medical notes, prescriptions, and supporting documentation with the request. These notes must be current within six months of the submission.

Special Financial Arrangements (SFA) and Single Case Agreements (SCA) must be requested on the PA. In-network providers claims will be paid at their contracted rate unless otherwise indicated. Items without rate (manual) must be sent with a requested/billed rate or may be denied until more information can be provided.

An approved authorization is not a guarantee of payment. Payment is based on benefits in effect at the time of service, member eligibility and medical necessity/appropriateness.

UHA may not authorize services under the following circumstances:

• The request received by UHA was not complete;
• The provider did not hold the appropriate license, certificate, or credential at the time services were requested;
• The recipient was not eligible for Medicaid at the time services were requested;
• The provider cannot produce appropriate documentation to support medical appropriateness, or the appropriate documentation was not submitted to UHA;
• The services requested are not in compliance with OAR 410-120-1260 through 410-120-1860.

Any requests for authorization after 30 days from the date of service (90 days for Behavioral Health services) requires documentation from the provider that indicates why authorization could not be obtained within the required timeframe from the date of service.

Prior Authorization (PA) Grids

Prior Authorization (PA) Grids outline the items and services that require a PA. These documents are searchable by code. Services not reflected on these authorization grid will require an PA.

Prior Authorization – Overview

• Prior Authorization Grid – DME
  • DME Vendor Grid
• Prior Authorization Grid – Imaging
• Prior Authorization Grid – Behavioral Health (MH/SUD)
  • Behavioral Health Prior Authorization Provider FAQ
• Prior Authorization Grid – Therapies

Pharmacy Authorizations

Visit the Pharmacy Services page for pharmacy-related prior authorization guidelines and requirements.

Additional Resources

• Utilization Management & Service Authorization Handbook
• Behavioral Health Prior Authorization Provider FAQ
• Clinical Practice Guidelines
• HERC Guidelines
• Prioritized List of Health Services
• DMAP Fee Schedule
• Oregon Health Plan for Providers
• Early and Periodic Screening, Diagnosis and Treatment (EPSDT) criteria
• Claim Reconsiderations & Provider Appeals
• Member Appeals
• Provider Directory

Visit our Provider Training  page for more information, including the Provider Handbook, UHA policies, required, recommending, and other training opportunities.

Sign up for our Provider Newsletter  for changes and updates.

Forms

• Medical, Behavioral and SUD Prior Authorization Form
• Informed Consent Form – Hysterectomy Consent
• Informed Consent Form – Hysterectomy Consent (Spanish)
• Informed Consent Form – Consent to Sterilization for Members 21+
• Informed Consent Form – Consent to Sterilization for Members 21+ (Spanish)
• Informed Consent Form – Consent to Sterilization for Members 15 – 20
• Informed Consent Form – Consent to Sterilization for Members 15 – 20 (Spanish)

Contacts

Need help? Depending on your need, contact the appropriate UHA department below for assistance:

• Prior Authorizations
• Claims
• Appeals and Grievances
• Provider Network
• Behavioral Health & Case Management
• Third Party Recovery
• Quality and Health Equity
• Transition of Care
• Compliance
• Customer Care
• Flexible Services