Policies and Forms

This page includes CareOregon’s medical policies, forms and medical management guidelines.

Forms change and are updated here on a regular basis, so please be sure to return to this page for the most up to date forms and policies.

Pharmacy Policies and Forms

Pharmacy Policies

• CareOregon OHP Prior Authorization Use Criteria (Updated 2/2020)

Pharmacy Forms

Medicaid and Medicare

• Home Infusion Prior Authorization 
• Prior Authorization and Formulary Exception Request Form (OHP only)
• Injectable Medication Administered by Provider Authorization Form
• Chemotherapy Prior Authorization and Formulary Exception Request Form (OHP)
• Hepatitis C Therapy Form (OHP Only)
• Nutritional Supplement Medication Request Form
• Sample Medication Contract (OHP and Medicare)
• Synagis Medication Request Form
• Pharmacy Provider Reconsideration Request Form

Medicare Only

• Home Infusion Prior Authorization 
• Prior Authorization and Formulary Exception Request Form (Medicare only)
• Prior Authorization and Formulary Exception Request Form (Provided by Medicare)
• Hospice Prior Authorization Form (Medicare Part D)
• Part D Vaccines Administered in the Medical Office Authorization & Reimbursement Form



Pharmacy Policy Updates & Other Forms

• Authorization Policy-Injectables/Medications Administered Under the Medical Benefit (Updated 2/2020)
• Authorization Guidelines - Injectable Drugs for Bleeding and Clotting Disorders (Updated 7/2019)



Authorization Guidelines and Forms

Eligibility

Use the Provider Portal to verify a member’s eligibility with CareOregon.

Authorization Guidelines

Changes are posted on the 15th day of the calendar month (or the next business day).

• CareOregon Medicaid and Medicare Auth Guidelines

CPT Code Grid - Diagnostic and Treatment Procedures

• Authorization guidelines by CPT code

DME - Authorization & Code Lists

• DME CodeModifier resource (OHP and Medicare)
• DME No Auth Required List (OHP and Medicare)
• DME of Immediate Need (OHP and Medicare)
• DME Change of Vendor Request Form (OHP and Medicare)

Frequently Asked Questions (FAQ's)

• Comorbid conditions FAQ
• DME and Supplies FAQs
• National Drug Code (NDC) Requirements FAQ

Authorization Request Forms

• Enteral/Parenteral Prior Authorization Form
• DME Prior Authorization Form
• HOME INFUSION Prior Authorization
• Dental Hospitalization Authorization Form (OHP and Medicare)
• Inpatient Authorization Form (OHP and Medicare)
• Retro Facility Authorization Form (OHP and Medicare)
• Retro Office Clinic Authorization Form (OHP and Medicare)
• Limb Prosthetic Prior Authorization Form (OHP and Medicare)
• SNF-IPR-LTAC Authorization Request Form (OHP and Medicare)
• RCP Authorization Request Form (OHP)
• Behavioral Health Treatment Auth Request Forms available here

Miscellaneous Policies and Forms

• Oregon Medicaid ID Application Form
• Outpatient Palliative / Advanced Illness Care Referral Form
• Referral Form - Early Intervention/Early Childhood Special Education (EIECSE) Birth to Age 5
• Care Coordination Referral Form (OHP and Medicare)
• Appointment of Representative Form (Medicare) (offsite link)
• Passport to Languages Interpreter Request Form (OHP and Medicare)
• Linguava Interpreter Request Form (OHP and Medicare)
• Provider Post Service Claim Reconsideration/Appeal Form (OHP and Medicare)
• Client Agreement to Pay for Health Services Form -Medicaid (OHP) (offsite link)
• Model Waiver of Liability - Medicare
• Oregon Health Authority Primary Care Provider Attestation (offsite link)
• PCP Re-Assignment Request Form (OHP and Medicare)
• Provider Information Form
• Member Request to Review Claim Records Form
• Health-Related (Flex) Services Policy and Request Form
• Hospital-based Credentialing Notification Form
• Member Incentive Form
• Housecall Providers Referral Form
• Housecall Providers Patient Handout
• Housecall Providers FAQ and Primary Care Referral Instructions
• Relinquishment Form