Provider Manual updates

CareOregon’s ongoing quality improvement efforts include regular updates to the provider manual. We will provide you with notice of these changes as they are made final. The seven most recent updates are here:

• We have revised our standards for patient medical records. The standards are available in Section G.1.1 of the Provider Manual.
• Practitioners are free to communicate with patients about treatment options regardless of benefit coverage limitations. See Section C.1.4.
• The benefit provisions, guidelines or criteria on which denial decisions are based are available to you upon request. Please call Customer Service. See Section C.4.7.

• CareOregon’s pharmacist and physician reviewers are available to discuss denial decisions. Please call Customer Service to schedule a time to speak with a pharmacist or physician reviewer. See Section C.4.7 and Section D.4.1.
• We have revised the Member Rights and Responsibilities statement, Section B.1.3.
• We have revised the standards for after-hours care. See Section F.5.4.

• In all cases, authorization determinations are based solely on plan benefits, medical appropriateness and least costly alternative for the service requested. CareOregon does not reward staff for denying prior authorizations or facility admission or length-of-stay authorizations. We do not use financial incentives to reward underutilization. See Section D.3.5 and Section D.4.1.

The CareOregon Provider Manual is available on our web site, or, if you prefer, you may request a paper copy by contacting Customer Service at 503-416-4100 or toll free 1-800-224-4840, Monday–Friday 8 a.m.–5 p.m.