PHP+Provider+Prior+Authorization+Info+for+Availity - Prior Authorization (PA) Requirements and Instructions (Providence Health Plan)

Sep 17, 2026

June 2026 guidance outlines the medical prior authorization (PA) process, also referred to as medical necessity review, for Providence Health Plan Powered by Collective Health. It explains when inpatient admissions require PA, key exceptions with time thresholds, and the 48-hour PA request rule after inpatient admission from emergency or urgent care. It also details how to determine outpatient PA using plan-specific PA code lists by wrap network and location, then how to submit PA requests for inpatient, outpatient, and certain DME through the correct submission pathways.

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Prior authorization (PA): Requirements and instructions

How to check if inpatient care requires PA

How to check if outpatient care requires PA

How to request PA for inpatient or outpatient care

Understanding the Providence Health Plan service area

What is a service area?

How does service area affect the PA process?

How to know if you’re inside the Providence Health Plan service area

JUNE 2026 Prior authorization (PA): Requirements and instructions This document explains the medical PA process – sometimes called medical necessity review – for Providence Health Plan Powered by Collective Health. For information about PA for prescription drugs billed to the pharmacy plan, please see Self-funded Pharmacy Resources. How to check if inpatient care requires PA All inpatient admissions require PA, including: ● Observation stays that exceed 47 hours. ● Acute inpatient hospital admissions, including obstetric admissions that exceed federal mandate (2 days for vaginal, 4 days for C-section births) ● Long-term acute hospital admissions ● Inpatient mental health and/or substance use disorder admissions ● Inpatient rehabilitation facility admissions ● Residential treatment facility admissions ● Skilled nursing facility (SNF) admissions Exceptions: The following inpatient services do not require PA. ● Observation stays that are 47 hours or less. ● Maternal hospital stays under 48 hours after vaginal delivery or 96 hours after cesarean. ● Newborn hospital stay under 96 hours following admission. ● For Intel plans only: PA is not required for inpatient care when the provider is contracted with the speciﬁc Providence Health Plan network on the member's ID card. Providers not contracted with that network—including those contracted with Cigna—must request PA. Note: If an emergency or urgent care visit leads to an inpatient admission, then PA must be requested within 48 hours. JUNE 2026 How to check if outpatient care requires PA To determine if an outpatient service, item, or medication requires PA, you must identify which PA code list applies to the member’s plan. Use the following table to ﬁnd the appropriate list. You may need to refer to the member’s ID card to identify the wrap network and plan sponsor. If you need help understanding if you're in or out of the Providence Health Plan service area, please see page 4. | Wrap network | Plan sponsor | Location (see pg. 4) | PA code list | | --- | --- | --- | --- | | First Choice
Health Network (FCHN) | All plan sponsors | All locations | List 1: Standard PA Code List | | Cigna | Public Employees’Beneﬁts Board (PEBB) | In-area | List 2: PEBB PA Code List | | | | Out-of-area | List 4: Cigna PA Code List | | | Intel | In-area | Are you contracted with the speciﬁc Providence Health Plan network on the member's ID card?
● Yes: List 3: Intel PA Code List
● No: List 1: Standard PA Code List | | | | Out-of-area | Are you contracted with Cigna?
● Yes: List 5: Intel Cigna PA Code List
● No: List 4: Cigna PA Code List | | | All other plan sponsors | In-area | List 1: Standard PA Code List | | | | Out-of-area | List 4: Cigna PA Code List | These lists may be subject to exclusions based on beneﬁt and contract terms. JUNE 2026 How to request PA for inpatient or outpatient care Once you have conﬁrmed a PA is required, use the table below to determine where to submit your PA request. These instructions also apply to PA requests for durable medical equipment (DME) from suppliers contracted with Integra. | Wrap network | Location (see pg. 4) | Where to submit a PA request | | --- | --- | --- | | First Choice
Health Network (FCHN) | All locations | Submit requests to American Health Holding*
● [Online:](Online: collectivehealth.getprecert.com)[ ](Online: collectivehealth.getprecert.com)[collectivehealth.getprecert.com](Online: collectivehealth.getprecert.com)
○ You can’t upload clinicals via this portal. Fax clinicalsto 844-545-1622 and include the reference number.
● Fax: Complete the form: Request for prior authorization and fax it to 844-545-1622.
● Phone: For faster service, call the Prior Authorization number on the back of the ID card. Otherwise call 855-383-3585 and select “Medical Authorizations.”
*Pharmacy PAs: If a code list says the PA must be submitted to PHP Pharmacy or the designated

FAQs

Which inpatient admissions require prior authorization (PA)?

All inpatient admissions require PA, including observation stays over 47 hours, acute inpatient admissions (including specified obstetric timelines), long-term acute hospital admissions, inpatient mental health and/or substance use disorder admissions, inpatient rehabilitation facility admissions, residential treatment facility admissions, and SNF admissions.

When can providers request PA after an emergency or urgent care visit leads to an inpatient admission?

If an emergency or urgent care visit leads to an inpatient admission, PA must be requested within 48 hours.

How do you determine which PA code list applies to outpatient services?

Identify which PA code list applies to the member’s plan by determining the wrap network and plan sponsor, which may require information from the member’s ID card. Use the table to select the correct standard, PEBB, Cigna, Intel, or other list based on in-area vs out-of-area and network contracting.

Sep 17, 2026

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