Inpatient stay review process changing Oct. 1
Effective October 1, 2026, CareOregon will begin conducting concurrent reviews for inpatient stays at DRG hospitals. Rather than approving an entire stay at time of admission, CareOregon will review the member’s condition for ongoing medical necessity.
The review schedule may vary according to the diagnosis, acuity, anticipated length of stay, clinical progress, and identified discharge barriers. CareOregon will request updates at intervals appropriate to the individual case. For facilities where CareOregon has access to the electronic medical record (EMR), no additional action is required. If CareOregon does not have EMR access, facilities may need to provide documentation more frequently to support continued stay reviews.
If a continued stay is denied and a member is discharged as a result, members can submit an appeal. As of March 1, 2025 CareOregon no longer accepts provider reconsiderations (also known as peer-to-peer) for denied prior authorization (PA) requests for our Medicaid members. This policy change was driven by the Oregon health Authority’s (OHA) decision that CCO-implemented reconsideration processes conflict with regulations and impact a member’s right to appeal. More information regarding this can be found here: Provider Policy Change: March 1, 2025 removal of provider reconsiderations
Information on Medicare's provider appeal process can be found online at CMS.gov
Why is CareOregon making this change?
CareOregon is making this change to support consistent, timely review of inpatient stays and confirm that continued inpatient care remains medically necessary. This helps ensure members receive care at the appropriate level for their needs, while aligning our process with clinical guidelines and standard utilization management practices.
Questions about this change?
Contact Provider Customer Service at 503-416-4100. For questions about a complex discharge barrier, hospitals should use their established CareOregon care coordination, Regional Care Team contact pathway.