Provider Forms and Resources Attention Providers: retroactive authorization requests may be submitted for consideration up to 90 days from DOS and must include valid justification as to why prior authorization was not sought; member must have been eligible on DOS. Retroactive service requests with an associated denied claim on file must follow the claims appeal process and are not subject to filing a retroactive service request
Administrative
- Provider Manual
- Flex Fund Request Form
- Oregon Medicaid ID Application Packet
- Fraud and Abuse Policy
- Member Rights Protection and Responsibilities Policy and Procedure
- Website Privacy Policy
- Prior Authorization Data
Community Resources
- Adapt/ Behavioral Health
- Advantage Dental
- Bay Cities Ambulance
- Coos Health and Wellness – Mental Health
- Coos Health and Wellness – Public Health
Provider Resources for Members
- Oregon Advance Directive User Guide
- Su guía para la Directiva anticipada de Oregon para la atención médica (Oregon Advance Directive User Guide Spanish Version)
- State of Oregon Advance Directive
- Directiva Anticipada (Estado De Oregon) (Advance Directive Spanish Version)
- Advance Directive Booklet
- Member Education Request Form
- Provider Claim Appeal Form
- Provider Authorization Appeals P2P Notice
- Provider Peer to Peer Request Form
Care Coordination (CC)
Tobacco Cessation
**Expedited Request: By selecting expedited request, you are implying that following a standard timeframe could seriously jeopardize this members’ life or health. (A retro request is not an expedited request).
Authorization Change Request Form
Physical Health
- Home Health Authorization Form
- Hospice Authorization Form
- Hospital Length Of Stay Authorization Form
- Prior Authorization Service Request
- Rick’s Medical Supply DME Prescription Form
- HEP C: (Only required for treatment naive)
- Bariatric Surgery:
- Bariatric Phase 1 is no longer required for Bariatric Surgery. Referral to local surgeon does not require a prior authorization. Please review the Bariatric Surgery Readiness Checklist Form and OHP Guideline 8 for more information.
Behavioral Health
Customer Service
- High Risk Pregnancy Checklist Form
- Maternity Case Management Flyer
- Oncology Notification Form
- Pregnancy Notification Form
Pharmacy
Oregon Health Plan
- Apply to be an Oregon Health Plan (OHP) Provider
- Coordinated Care Organization (CCO) Incentive Measures
- Insurance Reporting Application
- Oregon Health Plan OARs (Administrative Rules)
- Oregon Heatlh Plan Policies, Rules and Guidelines
- Oregon Health Plan Tools for Providers
- Prioritized List of Health Services
- Searchable Prioritized List of Health Services
- Diagnostic Procedure Codes List
- OHA 2993 – Language Access Statement
- OHA 2996 – Nondiscrimination Policy
- OHP 3165 – Client Agreement to Pay for Health Services
- OHP 3165 (Large Print) – Client Agreement to Pay for Health Services
- 3165 – Acuerdo de pago por parte de clientes del OHP por servicios médicos (Client Agreement to Pay for Health Services – Spanish version)
- OHP 3166 – Client Agreement to Pay for Pharmacy Services
- OHA 3010 – Release Of Information
- OHA Hysterectomy Consent – Form he0741
- Consent to Sterilization (21 and older) – Form HHS-687
- Consent to Sterilization (Spanish)(21 and older) – Form HHS-687-1
- Consent to Sterilization (Ages 15-20) – Form he0742b
- OHP 3047 – Augmentative Communication Device Selection Report Summary