The PHP prior authorization form comes in two versions: one for medical services and durable medical equipment, and a separate one for prescription drugs. Providence Health Plan routes each to a different review team at a different fax number, so the first step is picking the right form for the benefit involved. Both ask for patient identification, provider identification, diagnosis and procedure codes, and a clinical explanation of why the service is medically necessary.
Which Form You Need
Medical services, procedures, surgeries, and durable medical equipment use the medical Prior Authorization Request Form. Self-administered drugs filled at a pharmacy use the Prescription Drug Prior Authorization Request Form. Drugs that a provider administers in a clinical setting, such as infusions and clinician-given injections, fall under the medical benefit and use the pharmacy form’s medical-benefit fields for site of care.1Providence Health Plan. Self-funded Pharmacy Resources
Before you start filling anything out, confirm the service actually needs prior authorization. PHP publishes a Prior Authorization Requirements List that spells out the CPT and HCPCS codes requiring approval, covering categories like spinal procedures, prosthetic implants, hospital beds and support surfaces, seat lift mechanisms, electrical nerve stimulators, transprostatic implants, and vascular embolization for liver tumors.2Providence Health Plan. Prior Authorization Requirements List Some codes only trigger the requirement when paired with specific diagnosis codes, so check procedure and diagnosis together.
One routing boundary worth knowing up front: for certain clinical programs, PHP delegates prior authorization reviews to eviCore by Evernorth. Those requests go through the eviCore portal, not to PHP directly.3eviCore by Evernorth. Providence Health Plan Provider Resources The code list or PHP’s provider resources page will tell you which pathway applies.
Filling Out the Medical Form
Patient Information
Enter the member’s full name and Member ID. The Member ID is the subscriber’s P Number from the insurance card, an 11-digit number whose last two digits indicate whether the cardholder is the primary subscriber or a dependent.4Providence Health Plan. 2025 PEBB Member Resource Guide Add the member’s date of birth as a secondary identifier.
Requesting Provider
The form needs the ordering provider’s name, specialty, 10-digit National Provider Identifier (NPI), Tax Identification Number, office address, phone, and fax.5Providence Health Plan. Prior Authorization Request Form The NPI is the universal 10-digit identifier assigned to healthcare providers under HIPAA and is required on standard insurance transactions.6Centers for Medicare & Medicaid Services. National Provider Identifier Standard If the service will be performed somewhere other than the ordering provider’s office, add that facility’s information too. Network status and the member’s cost-sharing can depend on it.
Diagnosis and Procedure Codes
Every request must carry ICD-10 diagnosis codes describing the patient’s condition and CPT or HCPCS codes identifying the service, procedure, or equipment.5Providence Health Plan. Prior Authorization Request Form Use the most specific codes available. A generic code where a precise one exists invites either a denial or a request for additional information, each of which costs days.
Clinical Justification
The form asks for a clinical narrative explaining why the requested service is medically necessary for this patient. Attach recent office notes, diagnostic test results, imaging reports, and lab work that back up the request. If the patient has tried and failed first-line therapies, document those attempts specifically: the drugs or treatments used, dosages, duration, and the reason each failed. Allergies, contraindications, documented treatment failure, or unsafe side effects are the kinds of details reviewers look for before approving a step up to a more expensive or restricted option. The clinical narrative is where most prior authorizations are won or lost.
Filling Out the Prescription Drug Form
The pharmacy form shares the patient and provider identification fields with the medical form but adds drug-specific information: drug name and strength, ICD-10 diagnosis code, quantity, directions for use, and length of therapy.7Providence Health Plan. Prescription Drug Prior Authorization Request Form A dedicated section lists drugs the patient previously tried, with dosages. That section is where step therapy documentation goes, and skipping it is the fastest way to get a denial on a non-preferred drug.
If the prescription will be dispensed at a retail or specialty pharmacy, enter the pharmacy name, phone, and fax. If the drug will be given in a clinical setting under the medical benefit, enter the site of care’s location, address, NPI, and Tax ID instead.7Providence Health Plan. Prescription Drug Prior Authorization Request Form Include the medical rationale for the requested drug, explain why a formulary alternative is not acceptable, and attach chart notes and supporting labs.
Pharmacy prior authorizations can also go in electronically through CoverMyMeds or SureScripts rather than on paper.7Providence Health Plan. Prescription Drug Prior Authorization Request Form Electronic submission is usually faster than fax.
Where to Send the Completed Form
Medical Requests
Fax the medical form to 503-574-6464 locally or 800-989-7479 toll-free.5Providence Health Plan. Prior Authorization Request Form For questions about a medical prior authorization, call 503-574-6400 or 800-638-0449. Providers can also submit through the PHP provider portal, which returns a transaction reference number for tracking. For services managed by eviCore, use the eviCore provider portal instead.3eviCore by Evernorth. Providence Health Plan Provider Resources
Pharmacy Requests
Pharmacy prior authorizations go to a different destination. Fax to the number printed on the pharmacy form itself, not the medical fax lines above, or submit electronically through CoverMyMeds, SureScripts, or PHP’s online pharmacy exception request portal.1Providence Health Plan. Self-funded Pharmacy Resources Routing a pharmacy request to the medical fax, or the reverse, is one of the most common submission errors and adds days to the review.
Keep the fax confirmation page or the electronic submission receipt. If a question comes up later about whether or when the request arrived, that confirmation is the proof.
What Happens After You Submit
Standard medical requests get a decision within two business days after Providence receives the completed request. If reviewers need more information, they notify the requester within those same two business days, and the provider then has 15 calendar days to send the additional documentation. Providence completes its review within two business days of receiving that information. If nothing arrives within the 15-day window, the request is denied.8Providence Health Plan. PHP Prior Authorization Request Form – The Prior Authorization Process
Urgent requests, meaning situations where a delay could seriously harm the patient, get a response within 72 hours. If more information is needed, Providence notifies the requesting provider within 24 hours, and the provider has 48 hours to respond. The final decision comes within 48 hours of receiving that information, or 48 hours after the deadline passes if nothing is submitted.9Providence Health Plan. Understanding Our Claims and Billing Processes
Both the provider and the member get notified of the outcome. Providers usually see the update in the online portal first; members receive a formal letter by mail. The notification states whether the service is approved, denied, or pending additional information. To check status, call PHP member services at 503-574-7500 or 800-878-4445.10Providence Health Plan. Customer Support
If the Request Is Denied
When a request is heading toward denial or has already been denied, the treating physician can request a peer-to-peer review, a direct phone conversation with the plan’s medical director. These calls are typically scheduled within 24 to 72 hours of the request, so schedule promptly when the option is offered. Missing the window can result in a final denial.
After a formal denial, federal rules under the Affordable Care Act give the member 180 days from the denial notice to file an internal appeal, with the right to an external review by an independent review organization if the internal appeal is also denied.11eCFR. 45 CFR 147.136 – Internal Claims and Appeals and External Review Processes12HealthCare.gov. External Review An expedited track is available when a standard timeline would jeopardize the patient’s health.13HealthCare.gov. Internal Appeals