Physical health providers

This section 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.

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 Authorization Guidelines
• CareOregon Utilization Management Procedure Handbook

CPT code grid: Diagnostic and treatment procedures

• Authorization guidelines by CPT code

DME: Authorization and 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 (FAQs)

• Comorbid conditions FAQ
• DME and supplies FAQ
• Mental health transition FAQ
• 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)

Medicare behavioral health policy and form

• Admission Through Discharge Checklist

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) 
• 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)
• Waiver of Liability form (Medicare)
• Oregon Health Authority Primary Care Provider Attestation
• 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

Individual measures

• Adolescent well-care visits
• Adult BMI assessment
• Alcohol and drug misuse (SBIRT)
• Ambulatory care: Emergency department and outpatient utilization
• Assessments for children in DHS custody
• Breast cancer screening
• CAHPS: (Access) Consumer Assessment of Healthcare Providers and Systems
• Medicare Stars CAHPS question categories
• Care for older adults: Functional status assessment
• Care for older adults: Medication review
• Care for older adults: Pain screening
• Childhood immunization status
• Cigarette smoking prevalence
• Colorectal cancer screening
• STOP CRC implementation guide
• Controlling high blood pressure
• Dental sealants
• Depression screening and follow-up plan
• Depression screening and follow-up (one-pager)
• Developmental screening
• Developmental screening sample workflows
• Diabetes: Eye exam
• Diabetes: HbA1c poor control
• Diabetes care: Nephropathy monitoring
• Disparity measure: Emergency department utilization for individuals experiencing mental illness
• Effective contraceptive use (ECU)
• ECU surveillance telephone strategies
• ECU code cheat sheet template for printing and laminating
• HOS: Improving bladder control
• HOS: Monitoring physical activity
• HOS: Reduce the risk of falling
• Inpatient and emergency department utilization for ambulatory care sensitive conditions
• Medication adherence for cholesterol statins
• Medication adherence for diabetes medications
• Medication adherence for hypertension
• Oral evaluation for adults with diabetes
• Osteoporosis
• PCPCH enrollment
• Statin therapy for patients with cardiovascular disease
• Timeliness of prenatal and postpartum care
• Weight assessment and counseling

More resources

• 2019 CareOregon quality measure toolkit - all measures
• Quality metrics toolkit measure format definitions
• CareOregon primary care payment model program description 2019-2020
• CareOregon APM Data Submission Manual 2019
• OHA metrics
• OHA Transformation Center
• Medicare star ratings technical specs
• HEDIS measures
• CMS
• Value sets can be accessed through the Value Set Authority Center (VSAC) at the National Library of Medicine — value sets include CPT, HCPC, ICD-9, ICD-10, SNOMED and RXNORM codes
• Quality improvement
• Certified Health IT product list — a resource for determining EMR reporting capacity