Provider updates

Effective March 1, 2025, CareOregon will no longer be able to accept provider reconsiderations for denied prior authorization (PA) requests for our Medicaid members.

• Provider reconsiderations include peer-to-peer calls and reconsideration requests that occur after a PA is denied, in an attempt to change the decision.
• Claims reconsiderations are still allowed for providers disputing claim denials.
• This change does not affect Medicare reconsiderations. Information on Medicare’s process can be found online at CMS.gov. See the 2024 Medicare C D Appeals Guidance Update for more information.

Why this is happening

In 2023, the Oregon Health Authority (OHA) and its external review organization, Health Services Advisory Group (HSAG), determined that a CCO-implemented reconsideration process conflicts with regulations and impacts a member’s right to appeal.

• Once a member receives a PA denial, Notice of Adverse Benefit Determination (NOABD), the member has the right to file an appeal.
  • A member may appoint someone else, such as a provider, as their representative to file an appeal on their behalf by signing an appointment of representative (AOR) form.
  • Any provider appeal submitted without member consent will be dismissed. 
• The OHA has clarified second requests (within 60 days) are not allowed, even if new information is present. 
  • New information can be coordinated with the member, or their representative, during the appeal process.
  • Providers may submit a new request 60 days after the initial request.
• CareOregon’s medical directors may reach out to a provider to discuss a PA request before making their decision. We encourage providers to make themselves available for these attempts.

Tips for avoiding unnecessary PA denials

Submit all appropriate documentation with your request to help ensure reviews are processed accurately and timely.

• Include supporting labs, imaging, and/or recent chart notes which led to the request.
• Provide applicable information with the original request. This will assist in reducing administrative burden and ensure necessary services/items are approved quickly.
• Respond in a timely manner if you receive a request from CareOregon for additional information. This will help avoid an unnecessary denial.
  • If additional time is needed to gather supporting documentation, a provider may cancel a PA request and resubmit when the information is available. Providers can make cancellation requests via the same pathway used for submitting the PA.
  • For non-pharmacy PA requests, CareOregon makes three attempts to obtain additional missing information needed to review a PA request.
  • For pharmacy PA requests, the OHA and CMS give a maximum of 72 hours total for CCOs to make a decision. This limits CareOregon’s ability to obtain missing information once a request is started.
    • Check to see if the drug in question has PA criteria or step therapy criteria. If the drug is non-formulary, review alternative drugs listed on our formulary.
      • Alternative drugs on the formulary will be required first. Identifying them as failed or providing a medical reason for why they are not appropriate will be required.

Tips on how members can appeal

• Members can appeal both verbally and/or in writing. Detailed information on member appeal rights is sent with all PA denial notices (NOABD). Providers also receive a copy of the member’s NOABD including the member instructions for filing an appeal or assigning another person, including a provider, as their representative.
  • Members must sign a completed Appointment of Representative (AOR) form to appoint a representative. A signed form allows any individual, including a provider, to file an appeal on behalf of the member.
    • Any appeal request that is submitted by someone other than the member and is missing an AOR will be considered invalid.
    • An appeal dismissal letter will be sent to the member informing them that an appeal request was made but could not be processed without an AOR. An AOR form will be included with the dismissal letter, and the member can complete the form and submit it to allow the appeal request to be processed.
    • The AOR form can be found on CareOregon’s website by searching “Appointment of Representative form”.
  • If a member is within 120 days of an upheld appeal, they or their assigned representative can pursue the Administrative Law Judge (ALJ) Hearing process to have the decision reviewed.

If you have questions about this change, please contact Provider Customer Service at 503-416-4100, option 3.

Thank you for all you do for our members.

CareOregon Network Operations & Engagement

CareOregon notifies our provider network of important updates using email. To sign-up for these email alerts, email careoregonalerts@careoregon.org and include your name, affiliated organization, and job title.