Provider Forms, Policies & Documents

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

Policies – General

Criteria used for utilization management decisions for CareOregon Advantage (COA) and CareOregon OHP.

 

Policies – Pharmacy

• CareOregon OHP Prior Authorization Use Criteria (Updated 1/1/2012) 
• 2012 CareOregon Advantage Medicare Part D Prior Authorization Criteria (Use criteria for the drugs on the 2012 CareOregon Advantage Formulary that require prior authorization.)
• 2010 Medications Billed to the Medical Benefit Prior Authorization Criteria
• CareOregon Advantage 2012 Step Therapy Criteria
• CareOregon Advantage 2012 QLL Criteria

 

Forms – Pharmacy

• Prior Authorization and Formulary Exception Request Form (OHP and Medicare)
• Prior Authorization and Formulary Exception Request Form (Provided by Medicare)
• Injectable Authorization Form
• Hepatitis C Treatment Medication Request Form
• Nutritional Supplement Medication Request Form
• Sample Medication Contract (OHP and Medicare)
• Synagis Medication Request Form
• Wellpartner Mail Order Form

 

Policy Updates & Other Forms - Pharmacy

• Notice: Prior Authorization Required for Select Chemotherapy (December 21, 2011)
• Notice: Prior Authorization Required for Epo Products (December 21, 2011)
• Authorization Overview/Pharmacy (April 15, 2011)
• Authorization Guidelines - Injectable Drugs (December 20, 2011)
• Authorization Guidelines - Injectable Drugs for Bleeding and Clotting Disorders (December 16, 2011)
• Correction: OHP Injectable Mental Health Medications Billed via the Medical benefit (September 23, 2010)
• Pharmacist-Administered Flu Vaccine Policy (September 19, 2011)
• Pharmacy Network Notice: PBM change to Express Scripts, Inc. (December 3, 2009)
• Pharmacy Payer Sheet - Medicaid 2010 (December 28, 2009)
• Pharmacy Payer Sheet - Medicare 2010 (January 14, 2010)

 

Authorization Guidelines and Forms

Authorization Overview

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

• Authorization Overview Document

 

• Authorization Guidelines by Plan

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

 

Diagnostic and Treatment Procedures - CPT Code Grid

Authorization guidelines by CPT code for all the CareOregon Health Plans (Plus and Standard) and CareOregon Advantage (Plus and Star).

 

DME - Authorization & Code Lists

• DME Code/Modifier 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)

• National Drug Code (NDC) Requirements FAQs
• Comorbid conditions FAQs
• DME and Supplies FAQs
• Injectable and Infusion Drugs FAQs
• Mental Health Transition FAQs
• Prior Authorization Requirements FAQs

 

Authorization Request Forms

• Authorization Form for DME, Home Health and Home Infusion (OHP and Medicare) 
• Facility Authorization Form (OHP and Medicare)
• Office/Clinic Authorization Form (OHP and Medicare)
• Limb Prosthetic Prior Authorization Form (OHP and Medicare) 

 

OHMS Providers Only

• Prior Authorization Form
• Authorization Form for DME, Home Health and Home Infusion
• Hospital Authorization form

 

Miscellaneous Policies and Forms

• Complex Care Case Management Referral (OHP and Medicare)
• Appointment of Representative Form (Medicare)
• Interpreter Request Form (OHP and Medicare)
• Therapies (Occupation, Physical and Speech) - OHP Plus
• Provider Claim Appeal Form (OHP and Medicare)
• Patient Responsibility for Uncovered Services Form (OHP)
• Synergy Care Coordination Referral (Diabetes and Depression only)