Reporting
Prior Authorization Data
Health Share must share some information with members. This information is to help us be clear about the work we do and the services we provide to members. On this page you can find information about prior authorizations, which are approvals you need to get some types of care.
Prior Authorization at Health Share of Oregon (2025)
What is prior authorization?
Sometimes Health Share needs to approve a service before it is provided. This helps make sure care is safe, appropriate, and covered. Prior authorization is often shortened to the letters “PA”.
List of Services that Need Prior Authorization (PA)
| Service That Needs Prior Authorization (PA) | Description |
|---|---|
| Out of Network Care | If the provider is out of network, you must get prior authorization first. |
| Lab Testing | Lab tests use samples from your body to check for health problems. Most basic tests don’t need prior authorization. Some special tests, like genetic tests, do. |
| Surgeries | Planned surgeries need prior authorization, including inpatient (overnight) and outpatient (same-day) procedures. Emergency surgery does not need prior authorization. |
| Skilled Nursing, Long‑Term Acute Care, Residential Rehabilitation | Overnight stays in a facility where you receive care need prior authorization. |
| Imaging | MRIs and CT scans need prior authorization. Basic imaging, such as x‑rays or ultrasound, does not. |
| Durable Medical Equipment (DME) | Prior authorization is needed for medical equipment and supplies such as wheelchairs, CPAP machines, blood sugar monitors, and hearing aids. |
| Medical Therapies | Non‑surgical treatments require prior authorization, including Physical Therapy (PT), Occupational Therapy (OT), speech therapy, chiropractic care, and acupuncture. |
| Dental Care – Orthodontics | Braces to straighten teeth need prior authorization. |
| Dental Care – Dentures | Inserts that replace missing teeth need prior authorization. |
| Dental Care – Restorations & Endodontics | Services such as crowns and root canals used to repair damaged teeth need prior authorization. |
| Mental Health (MH) Treatment | More intensive mental health services require prior authorization, including ACT, ABA, Intensive Outpatient, and Residential services. |
| Substance Use Disorder (SUD) Treatment | Intensive SUD services need prior authorization, including Day Treatment and Residential care. |
| Non‑Emergent Medical Transport (NEMT) | Transportation or mileage reimbursement must be arranged before appointments. |
| Health‑Related Social Needs (HRSN) | Includes supports such as home adjustments for extreme weather, housing support, and nutrition services, which require prior authorization. |
Services that Don’t Need Prior Authorization
You don’t need any prior authorization for these services.
No prior authorization needed:
Emergency room or urgent care visits
Doctor or primary care provider visits
Mental health care visits for therapy or counseling
Getting a second opinion from another provider
Prior Authorization Results 2025
| What We Measure | What We Found |
|---|---|
| Standard (non‑urgent) requests approved | 88.7% |
| Standard (non‑urgent) requests denied | 11.3% |
| Requests approved after an appeal | 2.0% |
|
Requests that needed more time and were approved (includes standard and expedited requests) |
0.5% |
| Urgent requests approved | 95.0% |
| Urgent requests denied | 5.0% |
| Average decision time for standard requests | 4 days |
| Typical (median) decision time for standard requests | 3 days |
| Average decision time for urgent requests | 20 hours |
| Typical decision time for urgent requests | 12 hours |
What’s the difference between the median and the average? The average is found by adding up all the numbers and dividing by how many there are, and a very high or very low number can pull the average up or down. The median is the middle number when all values are listed from smallest to largest, and shows what is typical.
What this means for members
Most requests for care are approved.
Urgent requests are approved almost all of the time.
Some decisions take longer when more information is needed.
Most standard requests are decided within 4 days.
Most urgent requests are decided within 1-2 days