Medical Management Policies and Forms

This page has updates to CareOregon medical policies, forms and Medical Management guidelines.

Criteria for Utilization Management Decisions

Please click the link below to review the criteria used for utilization management decisions for CareOregon Advantage (COA) and CareOregon OHP. Click here to view the criteria in a PDF format.

Authorization Guidelines

Injectables billed under the medical benefit require prior authorization. Go to the Pharmacy page to find the CareOregon Formulary, updates and forms.

Authorization Overview

The Authorization Overview has information on verifying a member’s eligibility with CareOregon and using the Prioritized List. Changes are posted to this page on the 15th day of the calendar month or the next business day.

Authorization Guidelines by Plan

• Oregon Health Plan (OHP) Plus
• Oregon Health Plan (OHP) Standard
• CareOregon Advantage Plus and Star

Diagnostic and Treatment Procedures - CPT Code Grid

Revised to include, for all the CareOregon Health Plans, Plus, Standard and Advantage Plus and Star, the authorization guidelines by CPT code.

DME - Auth & Code lists

• DME Code/Modifier resource (OHP and Medicare)
• DME No Auth Required List (OHP and Medicare)
• DME of Immediate Need (OHP and Medicare)

Frequently Asked Questions (FAQ's)

• Comorbid conditions FAQ's
• DME and Supplies FAQ's
• Prior Authorization Requirements FAQ's

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)

Miscellaneous Policies and Forms

• Complex Care Case Management Referral (OHP and Medicare)
• Appointment of Representative Form (Medicare)
• DME Change Of Vendor Request Form (OHP and Medicare)
• Interpreter Request Form (OHP and Medicare)
• Patient Responsibility for Uncovered Services Form (OHP)
• Provider Claim Appeal Form (OHP and Medicare)
• Therapies (Occupation, Physical and Speech) - OHP Plus 

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