Provider Resources

This section includes the most commonly needed information for providers.

Becoming a CareOregon Provider

CareOregon provides plan services to three Coordinated Care Organizations (CCO) and offers a Medicare Advantage plan supporting and enhancing sensible, localized, coordinated care.

If you are interested in becoming a contracted provider, please review our credentialing requirements (outlined in our CareOregon Provider Manual).

If you have additional questions, or would like to learn more about requesting consideration for a contract, please contact Customer Service at 800-224-4840 or 503-416-4100. You may also complete the New Contract Requests form here. Please be certain to include all applicable fields for consideration.

Thank you for your interest in joining CareOregon’s provider panel!

Policies and Forms

This section includes medical policies, forms and medical management guidelines for physical and behavioral health. Some documents are provided by CareOregon, the health insurance provider that works with Columbia Pacific. For dental health information, visit the provider page of the appropriate plan:

• Advantage Dental
• CareOregon Dental
• ODS
• Willamette Dental Group

Behavioral health guidelines and forms

• Treatment Authorization form (applied behavioral analysis services)
• Behavioral Health Outpatient Provider requirements 
• Behavioral Health Documentation Standards
• Behavioral Health Utilization Management Procedure Handbook

Behavioral Health Delegated Credentialing

• Delegated Credentialing Provider Roster Template
• Credentialing Changes FAQ
• Delegated Credentialing Training Tool

Opioid prescribing guidelines

• Persistent Pain and Opioid Prescribing guidelines (PDF)

Policies: General

• Criteria used for utilization management decisions

Policies: Pharmacy

• Prior Authorization and Formulary Exception Request form
• Injectable Authorization form
• Hospice Prior Authorization form
• Chemotherapy Prior Authorization and Formulary Exception Request form
• 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 (August 1, 2019)
• Authorization policy: Injectable Drugs for Bleeding and Clotting Disorders (July 1, 2019)

Authorization guidelines and forms

Eligibility

Use theProvider Portal to verify a member’s eligibility with Columbia Pacific CCO.

Authorization guidelines 

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

• Medicaid and Medicare Authorization guidelines

Diagnostic and treatment procedures: CPT code grid

• Authorization guidelines by CPT code

DME: Authorization and code lists

• DME No Auth Required list
• DME Change of Vendor Request form 

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 
• SNF-IPR-LTAC Authorization Request form (OHP and Medicare)
• RCP Authorization Request form (OHP)

Frequently asked questions (FAQs)

• Comorbid conditions FAQs
• DME and supplies FAQs
• National Drug Code (NDC) requirements FAQs
• Surgical Procedure Anatomical Modifier Rule

Miscellaneous policies and forms

• Oregon Medicaid Practitioner Application form
• Oregon Medicaid Organization Application form
• Referral form: CareOregon Dental
• Referral form: Early Intervention/Early Childhood Special Education (EI/ECSE)* birth to age five
• Complex Care Case Management Referral
• Interpreter Request form
• Provider Claim Appeal form
• Client Agreement to Pay for Health Services form: Medicaid (OHP)
• Oregon Health Authority Primary Care Provider Attestation
• PCP Re-Assignment Request form (OHP and Medicare)
• Health-Related (Flex) Services Policy and Request form
• Health-Related Services: Hotel Liability form
• Health-related Services: Hotel request checklist
• Health-related Services: Budget worksheet
• Health-Related Services: States of Emergency Request form instructions
• Health-Related Services: States of Emergency Request form
• Model of care training: Presentation (PPTX) | Attestation (DOCX)
• Hospital-based Credentialing Notification form
• Member Incentive form
• 2021 CPCCO PCPM Program Description - updated 1/26/21

Health-related services

When members have health needs that aren’t covered by a health plan or other services, Columbia Pacific CCO offers funds for health-related services (HRS). HRS must be consistent with a member’s treatment plan, as developed by their primary care team or other treatment providers. The services will be documented in the member’s treatment plan and clinical record. For that reason, members without a current provider relationship need to establish one in order to receive health-related services funds.

What HRS covers

These funds cover items or services that aren’t covered under standard health plan services, but will improve a person’s health. Health plans cover provider visits, pharmacy benefits and durable medical equipment. Durable medical equipment (DME) is a covered benefit, which means equipment that would be covered as DME is not eligible for HRS funds. (For a list of items covered by DME with no authorization required, click here.)

Health-related services funds cover services like:

• Helping a person get a cell phone if having one will give them better access to their providers.
• Transit passes for members who need transportation for health-related needs beyond covered appointments.
• Buying an air conditioner for a person whose health is affected by the warmth and airflow in their home.
• Vouchers for a yoga studio for a person whose back pain will be helped by an exercise class.
• A class on cooking healthy meals for a person with diabetes.

This is not an exhaustive list. Any requested items will be evaluated for consistency with a member’s health needs and treatment plan.

Requesting HRS funds

Limitations of health-related services: The Oregon Administrative Rules restrict health-related services to items not paid for with grant money, funding separate from CCO contract revenue, or normal clinical service billing. In other words, health-related services may be used only if other funding is not available. Before you make a request, please be sure there is no other funding available.

Making a health-related services request: Any health care provider, primary care team, care coordination staff member working directly with members, or other subcontractors of Columbia Pacific’s network may request the use of HRS for a member. Columbia Pacific encourages our community-based organization (CBO) partners to help our shared members access HRS. CBOs can work with members and their treatment providers to identify the need, and the provider can submit a request.

All HRS requests must include medical documentation (care plan, progress notes, chart notes, etc.) and information about the member’s diagnosis.

There are two ways to submit requests for health-related services:

1. Use our standard Health-Related Services Flexible Services Funding Request form to make requests for cell phones, hotel rooms or other health-related services for individual members:
   • Items that are needed on a repeating basis — like monthly transit passes or gym memberships, extensions of hotel stays, etc. — require the submission of a Funding Request form each month.
   • Urgent requests will be fulfilled in two to five business days. Standard requests will be fulfilled in 10-14 business days.
   • For hotel stays, click here to download our hotel liability form that members must fill out and click here to download our hotel request checklist.
   • If a member lives in an area being impacted by a current state of emergency and needs a hotel, our State of Emergency Flex Request may be the quickest way to assist the member. Please see the instructions for more information.
2. Bulk items are available to help clinics and providers ensure a constant supply of the following items:
   • Cell phones and phone minutes
   • Transit passes
   • Sleeping bags
   • Shelter materials (tents and tarps)
   • City Team shelter vouchers
   • Personal hygiene products
     • This includes (but is not limited to) shampoo, conditioner, body and face washes, soap and feminine hygiene products
     • Some items are not included, like (but not limited to) PPE, incontinence supplies, diapers, sunscreen, sanitary wipes, disinfectant wipes, thermometers, durable medical equipment (DME) or COVID-19-specific items, as described above
   If these bulk items are purchased by providers/clinics, you must submit a Bulk Request Tracking document and itemized invoices to be reimbursed. To request that items be purchased by Columbia Pacific (and then delivered to providers or clinics), fill out our Bulk Purchase Request form.
   • Bulk requests may take up to 14 business days for review and delivery.
   • Clinics and county teams may make bulk requests one time per month.
   • Requests should be submitted by supervisors or managers.
   • Clinics/teams are required to submit a Bulk Request Tracking document with member details before new orders can be fulfilled.
 

Evaluating requests

Columbia Pacific evaluates all completed request forms based on:

• The member’s eligibility and whether the request fits their treatment plan.
• A sustainability plan to support the member’s ongoing needs, because CCOs may not be able to support these needs in the long term.
• Whether other community resources or safety net funds (besides HRS) were pursued before the request was made.

We provide members with a written outcome and copy the requesting provider (and member representatives, if applicable). Often, this involves asking for more information about the member, which may include the member's budget information. Requests cannot be fulfilled until all information is received.

Depending on the nature of the request, if more details about the budget is indicated, this form can be used to provide that information.

Questions? Email us at social.determinants@careoregon.org.

Quality Metrics Toolkit

Individual measures

• Adolescent immunizations
• Alcohol and drug misuse (SBIRT)
• Assessments for children in DHS custody
• Breast cancer screening
• Care for older adults: Functional status assessment
• Care for older adults: Medication review
• Care for older adults: Pain screening
• Childhood immunization status
• Cigarette smoking prevalence
• Colorectal cancer screening
• Controlling high blood pressure
• Depression screening and follow-up plan
• Diabetes: Eye exam
• Diabetes: HbA1c poor control
• Diabetes care: Nephropathy monitoring
• Disparity measure: Emergency department utilization for individuals experiencing mental illness
• HOS: Improving bladder control
• HOS: Monitoring physical activity
• HOS: Reduce the risk of falling
• Initiation and Engagement of Alcohol and Other Drug Abuse or Dependence Treatment (IET)
• Inpatient and emergency department utilization for ambulatory care sensitive conditions
• Meaningful Access to Health Care Services for persons with limited English proficiency
• Medication adherence for cholesterol statins
• Medication adherence for diabetes medications
• Medication adherence for hypertension
• Oral evaluation for adults with diabetes
• Osteoporosis
• Statin therapy for patients with cardiovascular disease
• Timeliness of prenatal and postpartum care

More resources

• 2021 CareOregon Quality Metrics Toolkit
• 2021 CareOregon PCPM Program Description - updated 1/26/21
• OHA Metrics: oregon.gov/oha/HPA/ANALYTICS/Pages/CCO-Metrics.aspx
• OHA Transformation Center: oregon.gov/oha/hpa/csi-tc/pages/index.aspx
• Medicare Star Ratings Technical Specs: cms.gov/Medicare/Prescription-Drug-Coverage/PrescriptionDrugCovGenIn/PerformanceData
• HEDIS Measures: ncqa.org/hedis-quality-measurement/hedis-measures/hedis-2018
• CMS: cms.gov/
• Value sets can be accessed through the Value Set Authority Center (VSAC) at the National Library of Medicine: vsac.nlm.nih.gov. Value sets include CPT, HCPC, ICD-9, ICD-10, SNOMED, and RXNORM codes
• Quality Improvement: ihi.org/resources/Pages/default.aspx
• Certified Health IT Product List is a resource for determining EMR reporting capacity: chpl.healthit.gov/#/search
• STOP CRC implementation guide
• Diabetes and oral health: Improve patient outcomes