Provider forms, policies and documents
This page includes CareOregon’s medical policies, forms and medical management guidelines for both Medicare and Medicaid lines of business.
Policies – General
- Criteria used for utilization management decisions for CareOregon Advantage (COA) and CareOregon OHP.
Policies: Pharmacy
- CareOregon OHP Prior Authorization Use criteria (updated January 1, 2023)
- CareOregon Advantage Prior Authorization criteria
- CareOregon Advantage Step Therapy criteria
- CareOregon Advantage opioid policies
Forms: Pharmacy
- Home Infusion Prior Authorization
- Prior Authorization and Formulary Exception Request form (Medicare only)
- Prior Authorization and Formulary Exception Request form (provided by Medicare)
- Injectable Medication Administered by Provider Authorization form
- Hospice Prior Authorization form
- Part D Vaccines Administered in the Medical Office Authorization and Reimbursement form
- Chemotherapy Prior Authorization and Formulary Exception Request form (OHP)
- Hepatitis C Therapy form (OHP Only)
- Nutritional Supplement Medication Request form
- Synagis Medication Request form
- Opioid Prior Authorization form Dynamic PA (OHP only)
- Pharmacy Provider Reconsideration Request form
Policy updates and other forms: Pharmacy
- Authorization Policy-Injectables/Medications Administered Under the Medical Benefit (Updated 1/2023)
- Authorization Guidelines - Injectable Drugs for Bleeding and Clotting Disorders (Updated 4/2022)
Authorization guidelines and forms
Eligibility
Use the Provider Portal to verify a member's eligibility with CareOregon Advantage.
Authorization guidelines
Changes are posted on the 15th day of the calendar month (or the next business day).
Diagnostic and treatment procedures: CPT code grid
Authorization guidelines by CPT code for all CareOregon Medicaid plans and the CareOregon Advantage Plus plan.DME: Authorization and code lists
- DME CodeModifier 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 (FAQs)
- Comorbid conditions FAQ
- DME and supplies FAQ
- National Drug Code (NDC) requirements FAQ
- Surgical Procedure Anatomical Modifier Rule
Authorization request forms
- Enteral/Parenteral Prior Authorization form
- DME Prior Authorization form
- HOME INFUSION Prior Authorization
- Dental Hospitalization Authorization form (OHP and Medicare)
- Inpatient Authorization form (OHP and Medicare)
- Retro Facility Authorization form (OHP and Medicare)
- Retro Office Clinic Authorization form (OHP and Medicare)
- Limb Prosthetic Prior Authorization form (OHP and Medicare)
- SNF-IPR-LTAC Authorization Request form (OHP and Medicare)
Miscellaneous policies and forms
- Oregon Medicaid Practitioner Application form
- Oregon Medicaid Organization Application form
- CareOregon Dental Referral/Prior Authorization Form
- The Dental Flex Card: What practices need to know
- Outpatient Palliative Care Referral form
- Referral Form: Early Intervention/Early Childhood Special Education (EIECSE) Birth to Age 5
- Complex Care Case Management Referral (OHP and Medicare)
- Appointment of Representative form (Medicare)
- How to schedule no-cost interpreting
- Provider Claim Appeal form (OHP and Medicare)
- Client Agreement to Pay for Health Services form: Medicaid (OHP)
- Waiver of Liability form: Medicare
- PCP Re-Assignment Request form (OHP and Medicare)
- Provider information form
- Member Request to Review Claim Records form
- Hospital-based Credentialing Notification form
- Member Incentive form
- Housecall Providers Referral form
- Housecall Providers patient handout
- Housecall Providers FAQ and primary care referral instructions
- Relinquishment form
- COA Notice of Medicare Non-Coverage template - English
- COA Notice of Medicare Non-Coverage template - Spanish
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