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
• ARCHIVES: CPT and DME No Auth Lists and Guidelines

DME: Authorization and code lists

• DME No Auth Required List (OHP and Medicare)
• DME of Immediate Need (OHP and Medicare)
• DME Change of Vendor Request form (OHP and Medicare)
• ARCHIVES: CPT and DME No Auth Lists and Guidelines

Frequently asked questions (FAQs)

• Comorbid conditions FAQ
• DME and supplies FAQ
• National Drug Code (NDC) requirements FAQ
• Surgical Procedure Anatomical Modifier Rule

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

Medicare behavioral health policy and form

• Admission Through Discharge Checklist

Miscellaneous policies and forms

• Oregon Medicaid Practitioner Application form
• Oregon Medicaid Organization 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
• Direct Member Reimbursement form (prescription drugs)
• Health-Related (Flex) Services Policy and Request form
• Health-Related Services: Hotel Liability form
• Health-Related Services: Hotel request checklist
• Health-Related Services: Budget worksheet
• 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 immunizations
• Alcohol and drug misuse (SBIRT)
• Assessments for children in DHS custody
• Breast cancer screening
• 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
• Controlling high blood pressure
• Depression screening and follow-up plan
• Diabetes: Eye exam
• Diabetes: HbA1c poor control
• Diabetes care: Nephropathy monitoring
• Disparity measure: Emergency department utilization for individuals experiencing mental illness
• HOS: Improving bladder control
• HOS: Monitoring physical activity
• HOS: Reduce the risk of falling
• Initiation and Engagement of Alcohol and Other Drug Abuse or Dependence Treatment (IET)
• Inpatient and emergency department utilization for ambulatory care sensitive conditions
• Meaningful Access to Health Care Services for persons with limited English proficiency
• Medication adherence for cholesterol statins
• Medication adherence for diabetes medications
• Medication adherence for hypertension
• Oral evaluation for adults with diabetes
• Osteoporosis
• Statin therapy for patients with cardiovascular disease
• Timeliness of prenatal and postpartum care

More resources

• 2021 CareOregon Quality Metrics Toolkit
• 2021 CareOregon PCPM Program Description - updated 1/26/21
• OHA Metrics: oregon.gov/oha/HPA/ANALYTICS/Pages/CCO-Metrics.aspx
• OHA Transformation Center: oregon.gov/oha/hpa/csi-tc/pages/index.aspx
• Medicare Star Ratings Technical Specs: cms.gov/Medicare/Prescription-Drug-Coverage/PrescriptionDrugCovGenIn/PerformanceData
• HEDIS Measures: ncqa.org/hedis-quality-measurement/hedis-measures/hedis-2018
• CMS: cms.gov/
• Value sets can be accessed through the Value Set Authority Center (VSAC) at the National Library of Medicine: vsac.nlm.nih.gov. Value sets include CPT, HCPC, ICD-9, ICD-10, SNOMED, and RXNORM codes
• Quality Improvement: ihi.org/resources/Pages/default.aspx
• Certified Health IT Product List is a resource for determining EMR reporting capacity: chpl.healthit.gov/#/search
• STOP CRC implementation guide