Provider Authorization Grid


Welcome to our online Authorization Grid. The following grids allow you to identify procedures or services that require preauthorization from PacificSource Medicare.

The following grids ONLY identify procedures or services that require preauthorization from PacificSource Medicare.

Out-of-network providers must request prior authorization on ALL services for Essentials HMO and MyCare HMO members.

Please note: This grid does NOT identify whether procedures or services are or aren't covered. Codes may change in the future but the underlying procedure or service requiring authorization will not change without proper notification.

For information about how our clinical policies are developed please see:

PacificSource Clinical Decision Resources

Quick Search: For dates of service on or after 1/1/2017



Printable Grids


Dates of service on or after 1/1/2017

Dates of service 1/1/2016 - 12/31/2016