Please note: the Pharmacy policies and forms have moved to the Pharmacy benefits and resources page.
Policies and forms
- Criteria used for utilization management decisions for CareOregon Advantage (COA) and CareOregon OHP.
- 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
Authorization guidelines
- Eligibility: Use the Provider Portal to verify a member's eligibility with CareOregon Advantage.
- CareOregon Utilization Management Procedure Handbook
- Changes are posted on the 15th day of the calendar month (or the next business day)
- 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)
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)
