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Prior Approval

What Is Prior Approval?

Some medical services, surgical procedures, and medications require IHN-CCO’s written approval before you can get them. This process is called prior authorization, also called prior approval. It basically means that your provider has to ask permission to prescribe you a drug or have you undergo a treatment, service, or surgery that isn’t covered by your health plan.

How Does It Work?

Your provider fills out a form requesting permission to give you a certain drug, treatment, service, or surgery. If approved, it will be covered to some extent by IHN-CCO. If not, IHN-CCO may recommend an alternative that is covered, or you may opt to get the drug, treatment, service, or surgery anyway and cover the costs yourself. 

What Requires Approval?

IHN-CCO reviews and updates its Prior Approval List annually.

Prior Authorizations may be needed for some health services. The health plan uses guidelines/rules to review prior authorization requests. Guideline/rule resources can be accessed using the links below.

MCG Guidelines

Some medical services, procedures, supplies and equipment require IHN-CCO written approval before being performed or supplied. All coverage is limited by Oregon Administrative Rules and the Oregon Health Evidence Review Commission (HERC) Prioritized list may review and deny services that are not medically appropriate.

IHN-CCO may review and deny services that are not medically appropriate.

Medically appropriate services and medical supplies are considered required for prevention, diagnosis or treatment of a medical or mental health condition or injury, and which are:

  • Consistent with the symptoms of a health condition or treatment of a health condition.
  • Meet standards of good health practice, are generally accepted by the medical community, use evidence-based medicine and are considered effective.
  • Not only for the convenience of the member or a provider of the service or medical supplies.
  • The most effective of the medical services or medical supplies that can be safely provided to the member.
  • In IHN-CCO’s determination as based on available information and documentation, according to the terms of the Plan.

2024 Prior Approval List (English).
2024 Prior Approval List (Español).

2025 Prior Approval List (English).
2025 Prior Approval List (Español).

For a complete list of services that require approval, please contact your dental plan directly.

Advantage Dental Services
866-268-9631 (TTY 866-268-9617)
advantagedental.com

Capitol Dental Care
800-525-6800 (TTY 800-735-2900)
capitoldentalcare.com

Oregon Dental Services
800-342-0526 (TTY 800-342-0526 x711)
modahealth.com/ohp

Willamette Dental Group
855-433-6825 option 3 (TTY 800-735-1232)
willamettedental.com

Some of your prescription drugs may require prior authorization. To find out if your medication requires prior authorization, please search our drug list.

Related Information

How to Handle Non-covered Services

View OHP’s Prioritized List of Health Services

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