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Prior Authorizations

Physical & Behavioral Health

Find all the forms and information you need here for submitting prior authorizations for physical & behavioral health services, including diagnostic and treatment procedure codes.

Providers who are not participating in the YCCO network must submit prior authorization for all services.

Effective 8/1/2025: The referral PA currently in use for behavioral health payment of outpatient services will no longer be required for YCCO participating providers. More information and additional information related to behavioral health services is located below in the Behavioral Health & Wraparound Services section.

Change to Prior Authorization (PA) Process; Provider-Initiated Requests Required

Effective Date: November 15, 2025

YCCO Utilization Management (UM) team will no longer create prior authorizations (PAs) from the PCC census. Providers are required to initiate all referral and PA requests.

This change aligns with OAR 410-130-0200(2), which states:

“Providers must obtain prior authorization from the OHP payer, either fee-for-service or the coordinated care organization, that shall be responsible for payment at the time the service is delivered.”

It is further supported by OAR 410-141-3835, which requires managed care entities to maintain policies for processing authorization requests received from providers, and OAR 410-120-1280, which defines failure to obtain required authorization as a provider error.

How to Submit a Prior Authorization (PA)

Submit a prior authorization request for medical services electronically in the provider portal (CIM), or complete the Prior Authorization Request form that can be faxed to the UM Team.   Information about what services require preauthorization is located in CIM. Transplant services require a special PA Form below is the link to this form.

PA Requirements

The YCCO PA List does not contain all codes that require authorization, the Prioritized List indicates clinical review requirements that also require prior authorization. The DMAP Line Search located in CIM also provides Prioritized List information.

Expedited Request

Expedited request must have clinical information that indicates that taking the time for a standard resolution could seriously jeopardize the member’s life, health, or ability to attain, maintain, or regain maximum function. 

PA Forms

Physical Health PA Forms

Behavioral Health PA Forms

Diagnostic and Treatment Procedures

For a complete list of diagnostic and treatment procedures (CPT code grid) please see the Provider Services tab in CIM. There are certain ancillary guideline notes that apply to services (e.g. tobacco cessation for elective procedures).

Radiology – Advanced Imaging & Cardiology Imaging – Cardiac Implantable

You must submit authorizations for some types of imaging via EviCore. Please use the button below for access and to submit a request.

EviCore

Effective 4/1/2025:

Please see the below changes to the prior authorization requirements for high cost imaging.

  • Removal of prior authorization requirements for a select set of Echocardiography codes the PA List will indicate PA termination dates.
  • Implementation of a bundled authorization process for diagnostic imaging studies. This will occur at the point of first contact by a requesting provider when the provider attests that the radiology procedure is for restaging of cancer. This will create efficiencies in the submission process and reduce provider burden by eliminating the need for the provider to request multiple imaging authorizations throughout the surveillance of a patients chemotherapy. Please see attached for more details.
  • Radiology authorization procedure codes, units, and timespans:
    • CPT Code
      • 70553 (MRI Brain with and without contrast)
      • 71260 (CT Chest with contrast)
      • 74160 (CT Abdomen with contrast)
      • 74177 (CT Abdomen and Pelvis with contrast)
    • Number of Units
      • 6 units are authorized and recommended to be used at a frequency of 1 unit every 2 cycles of chemotherapy
    • Timespan; Valid From and Valid Through
      • The standard approval time period is set for 365 days

PA Reminders:

  • Check the service code against the YCCO PA list to determine considerations for submitting the code. If the code does not exist on the PA list, it does not mean that a PA is not required.
  • The YCCO PA List does not contain all codes that require authorization, the Prioritized List indicates clinical review requirements that also require prior authorization. The DMAP Line Search located in CIM also provides Prioritized List information.
  • No PA requirement for first and only request for a diagnostic service
    • Example: colonoscopy for those that meet cancer screening guidelines on prioritized list Colorectal cancer screening is included on Line 3 for average-risk adults aged 45 to 75, using one of the following screening programs:
      • Colonoscopy every 10 years
      • Flexible sigmoidoscopy every 5 years
      • Fecal immunochemical test (FIT) every year
      • Guaiac-based fecal occult blood test (gFOBT) every year
    • Subsequent requests for same diagnostic service (not in a series) and same diagnosis will require a PA to be submitted with YCCO
      • Example: second colonoscopy
    • First PA is required in a planned series of diagnostic studies, such as with a cancer diagnosis. The series of diagnostic studies will be authorized per the first PA, if medically necessary.

Medical Management Service Authorizations

Guidelines for requesting medical management service authorizations are outlined below. Initially, check current and active Prior Authorization list (located above) to see if procedure code is noted.

  1. If procedure code is on the Prior Authorization list, then submit Prior Authorization request via CIM, fax, or email (forms located on this page). CIM – https://cim3.phtech.com/cim/login YCCO Utilization Management Fax: 503-850-9398 YCCO Utilization Management Email utilizationmanagement@yamhillcco.org
  2. If procedure code is NOT on the Prior Authorization list, then check prioritized line (providers can use the Line Search tool within CIM)
    1. If procedure code and diagnosis are funded and above the line, then no prior authorization is needed.
    2. If procedure code and diagnosis are funded and above the line, but guideline notes indicate medical criteria must be met to provide services (e.g. tobacco cessation for elective procedures), then prior authorization is needed.
    3. If procedure code and diagnosis are not funded and fall below the line, or are not ranked (“no results found” in CIM), then submit prior authorization request via CIM and note on the request “benefit exception review for medical necessity consideration”.
Go to CIM

Durable Medical Equipment (DME)

For information on DME call Providence Home Services at 503.215.4663

Guidelines for DME:

  • Check current PA list within CIM or YCCO’s website
    • If procedure code is on the PA list, submit PA request via CIM
    • If procedure code is NOT on the PA list, check prioritized line
    • Check prioritized line (providers can use the Line Search tool within CIM)
  • If procedure code and diagnosis are funded and above the line, no PA is needed
  • If procedure code and diagnosis are funded and above the line, but guideline notes indicate medical criteria must be met to provide services (e.g. Tobacco cessation for elective procedures), PA is needed
  • If procedure code and diagnosis are not funded and fall below the line, or are not ranked (“no results found” in CIM), submit PA request via CIM

Dental Health

Forms and submission process for dental service prior authorizations administered by Capitol Dental Care can be found at:

Visit Capitol Dental Care

Pharmacy/Medications

Medication requiring a prior authorization will be indicated on the formulary.

The formulary link provides all necessary forms and additional information related to pharmacy services.

Denial & Claim Guidance

Prior Authorization Denials

Providers must work with members to utilize the member appeal process for this type of denial. Appeals on behalf of the member must have written authorization from the member. Learn more about the member appeal process by visiting our Denial & Claim Guidance page.

Questions about Denials and Claims? Visit our Denial & Claim Guidance page .