Provider Forms, Policies and Documents

This page includes Columbia Pacific's medical policies, forms and medical management guidelines. Because CareOregon administers claims and other functions for Columbia Pacific CCO, the following forms are from CareOregon.

Policies – General
Criteria used for utilization management decisions

Policies – Pharmacy

• OHP Prior Authorization Use Criteria 

 Forms – Pharmacy

• Prior Authorization and Formulary Exception Request Form (OHP and Medicare)
• Injectable Authorization Form
• Chemotherapy Prior Authorization and Formulary Exception Request Form (OHP)
• Hepatitis C Treatment Medication Request Form
• Nutritional Supplement Medication Request Form
• Synagis Medication Request Form
• Wellpartner Mail Order Form (OHP and Medicare)

 Policy Updates & Other Forms - Pharmacy

• Notice: Prior Authorization Required for Select Chemotherapy (December 21, 2011)
• Notice: Prior Authorization Required for Epo Products (December 21, 2011)
• Authorization Overview/Pharmacy (April 15, 2011)
• Authorization Policy - Injectables/Medications Administered Under the Medical Benefit (January 22, 2013)
• Authorization Policy - Injectable Drugs for Bleeding and Clotting Disorders (April 9, 2012)
• Injectable Medications Allowable on Pharmacy Benefit
• Pharmacist-Administered Flu Vaccine Policy (September 19, 2011)
• Pharmacy Payer Sheet - Medicaid 2013 (December 27, 2012) 

Authorization Guidelines and Forms

Authorization Overview

Use the Provider Portal to verify a member’s eligibility with Columbia Pacific.

• Authorization Overview Document

 Authorization Guidelines by Plan

Changes are posted on the 15th day calendar month (or the next business day).

Diagnostic and Treatment Procedures - CPT Code Grid

• Authorization guidelines by CPT code

DME - Authorization & Code Lists

• DME Change of Vendor Request Form (OHP and Medicare)

Frequently Asked Questions (FAQ's)

• Comorbid conditions FAQs
• Dental Transition FAQs
• DME and Supplies FAQs
• Injectable and Infusion Drugs FAQs
• National Drug Code (NDC) Requirements FAQs
• Prior Authorization Requirements FAQs

Authorization Request Forms

• Authorization Form for DME, Home Health and Home Infusion
• Facility Authorization Form
• Office/Clinic Authorization Form
• Limb Prosthetic Prior Authorization Form

• Oregon Medicaid ID Enrollment Form
• Referral Form - CareOregon Dental
• Referral Form - Early Intervention/Early Childhood Special Education (EI/ECSE)* Birth to Age 5
• Complex Care Case Management Referral (OHP and Medicare)
• Interpreter Request Form (OHP and Medicare)
• Therapies (Occupation, Physical and Speech) - OHP Plus
• Provider Claim Appeal Form (OHP and Medicare)
• Patient Responsibility for Uncovered Services Form (OHP)
• Synergy Disease Management Care Coaching