Provider Manual
The CareOregon Provider Manual can be used by CareOregon/Oregon Health Plan and CareOregon Advantage/Medicare contracted providers. The manual has information on the following topics:
- Membership
- Benefits
- Referrals and authorizations
- Billing and payment
- Interpretation
- Transportation for OHP members
- Provider Relations Specialists
- Primary care
- Medical records
- Quality improvement
- Credentialing
- Medicare Advantage
- Clinical practice guidelines
If you have questions, please contact your provider relations specialist .
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).
CPT code grid: Diagnostic and treatment procedures
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)
- 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
- Traditional Health Worker Provider Enrollment form
- Doula Enrollment form
- Member Request to Review Claim Records form
- Direct Member Reimbursement form (prescription drugs)
- Member COVID-19 At Home Test Reimbursement form
- Health-Related (Flex) Services Policy
- Health-Related (Flex) Services request form
- Health-Related Services: K Plan Letter request
- Health-Related Services: Hotel Liability form
- Health-Related Services: Hotel request checklist
- Health-Related Services: Budget worksheet
- Health-Related Services: States of Emergency Request form instructions
- Health-Related Services: States of Emergency Request form
- Hospital-based Credentialing Notification form
- Member Incentive form
- Member incentives frequently asked questions
- Housecall Providers referral form
- Housecall Providers patient handout
- Housecall Providers FAQ and primary care referral instructions
- Relinquishment form
- COA Notice of Medicare Non-Coverage template - English
- COA Notice of Medicare Non-Coverage template - Spanish
2022 Metrics Medicaid Toolkit
- Adolescent immunizations
- Alcohol and drug misuse (SBIRT)
- Assessments for children in DHS custody
- Child and adolescent well-care visits (WCV)
- Childhood immunization status
- Cigarette smoking prevalence
- Depression screening and follow-up plan
- Diabetes: HbA1c poor control
- Initiation and Engagement of Alcohol and Other Drug Abuse or Dependence Treatment (IET)
- Meaningful Access to Health Care Services for persons with limited English proficiency
- Oral evaluation for adults with diabetes
- Preventive dental or oral services - Ages 1-5 & 6-14
- Social-emotional health metric
- Timeliness of prenatal and postpartum care
2021 Metrics Toolkit
- 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
- 2022 Medicaid Metrics toolkit
- 2021 CareOregon Quality Metrics Toolkit
- 2022-23 CareOregon PCPM Program Description
- 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
- 2022 IET Billing guide
- 2022 IBH IET At a Glance
- Words matter
- Recovery oriented language guide
- Diabetes and oral health: Improve patient outcomes
- Pediatric oral health
- Primary care integration holds untold possibilities when we look at the ways member subpopulations could benefit from greater collaboration among their physical, dental and behavioral health providers. In 2019, Health Share of Oregon tasked CareOregon
to create the Diabetes Integration Project, a long-term project for members diagnosed with both type II diabetes and severe and persistent mental illness. Here’s a summary of those efforts, led by the CareOregon Innovation Team, and
ways these principles can be applied to other provider groups:
Diabetes Integration Project 2019-2021. - Diabetes Oral Health Program - Integration Toolkit
- Maternity Oral Health Program - Integration Toolkit
- Pediatric Oral Health Program - Integration Toolkit