1. health and fitness

2014
OREGON’S HEALTH CO-OP
PROVIDER MANUAL
PROVIDER MANUAL | 2014
1. INTRODUCTION
Contents
1. Introduction.............................................................. 1
2. Membership..........................................................3
3. Resources...............................................................8
4. Primary Care and Specialty Care..... 13
5. Prior Authorizations or
Preauthorizations........................................... 15
6. Billing and Payment........................................ 18
7. Quality Improvement
and Credentialing.........................................23
8. Pharmacy Program........................................ 31
Oregon’s Health CO-OP
Oregon’s Health CO-OP is a new type of
nonprofit health insurance company: a
Consumer Operated and Oriented Plan enabled
under the Affordable Care Act.
We’re building a movement with providers,
individuals, families and employers who believe
the insurance industry can do better: where
health insurance is driven by the members, in
their communities; where everyday people have
a voice, and health insurance companies listen.
And where profits are returned to the members
through lower premiums, more benefits and
improved services.
Our Envision Statement
At Oregon’s Health CO-OP, we dare to stand for justice, for
hope, for clean air, better schools and fresh water.
Together, we dare to deliver on the promises of the Affordable
Care Act. This is a dream that affords every Oregonian access
to excellent health care. To do it, we will offer services and
insurance products unlike anything you’ve seen in our
industry.
We are focused on positive change. Some have an agenda
while we have friends who deserve better care. So to the
naysayers we reply: Everyone is welcome at the CO-OP.
Join us.
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OREGON’S HEALTH CO-OP
Oregon’s Health CO-OP Priorities
• Prevention
• Members’ access to the information and
care they need, and in the way they want it
• Patients and providers working together
for better health
• Cultural competence
• Strategies to reduce providers’
administrative burden
• Clear, predictable medical costs
for members
• Improved health for all Oregonians
Oregon’s Health CO-OP Mission
Guided by our members and our board of
directors, Oregon’s Health CO-OP provides
excellent health coverage that’s easy to use
and understand. By reinvesting profits in our
members, we improve service, reduce costs
and ensure that members are protected for
the long term.
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Oregon’s Health CO-OP
Care Philosophy
Our role is to give a voice to our members and
facilitate their engagement with you, their health
professionals.
Members, providers and the health plan will:
• Take the best possible care of each other.
• Keep costs down through low
administrative, medical and
pharmacy costs.
All may choose to have a role in governing and
operating this health plan.
PROVIDER MANUAL | 2014
2. MEMBERSHIP
Any Oregon resident or Oregon-based employer
is eligible to enroll in our plans. We accept
applications directly, through insurance brokers,
and through Cover Oregon, the state’s online
health insurance marketplace or exchange.
Members’ Rights and
Responsibilities
Oregon’s Health CO-OP members are entitled to
be treated in a manner that respects their rights,
while also addressing their responsibilities. All
rights and responsibilities may be extended to
any person who may have legal responsibility
to make decisions on their behalf regarding
medical care.
Member Rights
• To refuse treatment, and in turn, be
informed of the medical consequences
of this action.
• To refuse to sign a consent form if they do
not clearly understand its purpose, or to
cross out any part of the form they do not
want applied to their care.
• To change their mind about any treatment
for which they have previously given
consent.
• To be informed of policies regarding
Advanced Directives (living wills) as
required by state and federal law.
• To exercise these rights regardless of
race, color, national origin, ethnicity,
ancestry, religion, gender, marital status,
sexual orientation, mental or physical
disability, medical condition or history,
age, source of payment for care, or any
other category deemed protected under
state and federal law.
• To be treated with respect, dignity,
compassion, and to be given the right
to privacy.
• To have timely access to their providers
and to specialist referrals when medically
necessary.
• To have the expected consideration
of privacy concerning their care and
confidentiality in all communications
and in their medical records.
• To receive continuity of care and
advance notice of the time and location
of appointments, and of the providers
providing care.
• To be informed why various tests,
treatments or procedures are ordered, to
know who is providing them and any risks
that may be associated with them.
• To participate with providers in decisionmaking regarding their health care and
treatment plans.
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OREGON’S HEALTH CO-OP
• To have an honest discussion of appropriate
or medically necessary treatment options
for their condition, regardless of cost or
benefit coverage.
• To participate, as much as possible, in
understanding their health problems,
including behavioral health, and developing
agreed-upon treatment goals.
• To have providers explain their diagnosis,
the prognosis of their condition, and
instructions required for care.
• To inform Oregon’s Health CO-OP if they feel
they are not receiving appropriate care.
Member Responsibilities
• To be on time for appointments or to
contact the provider if they’re going
to be late.
• To contact the provider right away if there’s
a need to cancel. If the provider has a
policy for assessing charges regarding late
cancellations or missed appointments,
members will be responsible for such
charges.
• To identify themselves as Oregon’s Health
CO-OP members and present their mostrecent identification card when requesting
health care services.
• To do their part to improve their own health
condition by following instructions and care
plans that they’ve agreed upon with the
provider.
• To provide, when possible, information
about their health to providers so
appropriate care may be provided.
• To review their benefit booklet to ensure
services are covered under the plan, and
to contact Customer Service with any
questions they may have about the plan.
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• To follow Plan requirements to have services
authorized before receiving medical care.
• To accept financial responsibility for any
copayments, coinsurance and deductible
that may be associated with covered
services.
Member Benefits
Oregon’s Health CO-OP member benefits
include a comprehensive set of medical services,
including but not limited to the Affordable Care
Act’s 10 Essential Health Benefits.
Summary of Covered Services:
• Primary care and preventive services
• Specialty services
• Non face-to-face services
• Inpatient services
• Maternity and newborn care
• Emergency and urgent care
• Behavioral health (mental health
and substance abuse treatment)
• Rehabilitative services
• Diagnostic testing
• Imaging
PROVIDER MANUAL | 2014
• Prescription drugs
Member Appeal
• Home health and hospice services
“Appeal” includes any grievance, complaint,
reconsideration or similar terms, and is either
a written or verbal request from a member,
the treating provider or identified personal
representative.
• Durable medical equipment and supplies
• Orthotics and prosthetics
• Ambulance transport
• Acupuncture (with our SiMPLE plans)
Member ID Cards
• Access to health care benefits, including an
adverse benefit determination made as a
result of utilization review
Plan: Name of Plan
Primary Member: Martha Member
ID Number: 12345647890DX
Member
Martha Member
George Member
Patsy Member
Eleanor Member
John Member
ID Number
12345647890DX
12345647891DX
12345647892DX
12345647893DX
12345647894DX
• Claims payment or handling for health
care services
Primary Specialist $XX / $XX
Urgent/ER $XX / $XX
Rx $X / $X / $X / $X
Deductible $XX / $XX
ohcoop.org
front
Customer Service: Local 503-488-2833, toll-free 1-855-722-8207
or TTY 1-800-73502900
Members: In an emergency, go to your nearest hospital or call 911.
VSP: 1-800-877-7195
Provider: For Prior Authorization forms: ohcoop.org/providers
Send claims to:
Mail: Oregon’s Health CO-OP
Electronic Payer ID: 21455
PO Box 40048
Portland, OR 97240
Pharmacists: For assistance, toll-free 1-855-577-6530
Catamaran - Bin: 610011 PCN: IRX Group: CORCOOP
This card is for identification only and does not certify eligibility.
back
An appeal may apply to any of the following:
• Matters pertaining to the contractual
relationship between a member and
Oregon’s Health CO-OP
• Other matters as specifically required
by law or regulation
Guidelines
Level One and Two Appeals
and External Review
Oregon’s Health CO-OP offers two levels
of internal appeal. After internal levels are
exhausted, the appeal may be eligible for
external review by an independent review
organization.
Level One Internal Appeal
The member or the member’s representative
has the right to request an appeal within one
hundred eighty (180) days of receiving written
CO-OP Member ID Card-11.07.13
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OREGON’S HEALTH CO-OP
notification of an adverse benefit determination.
If a member chooses to file an appeal, Customer
Service will assist the member by accepting
information over the phone about the appeal.
Members may also submit their appeal in a
written letter.
If the appeal involves a pre-service authorization
denial, it should be submitted in writing to:
Oregon’s Health CO-OP Quality Improvement
Appeal Coordinator
PO Box 40048
Portland, OR 97240
Fax: 503-416-8118
If the appeal involves a post-service claim denial,
it should be submitted in writing to:
Oregon’s Health CO-OP Claims
Reconsideration/Claims Appeals
PO Box 40048
Portland, OR 97240
Attn: CO-OP Claims Appeals Coordinator
Fax: 503-416-1301
We’ll acknowledge receipt of an appeal,
in writing, within seven (7) calendar days. Internal appeals are reviewed by an employee
or employees who were not involved in, or
subordinate to anyone involved in, the initial
decision.
Upon completion of the review, the Appeal
Coordinator will send a written response to the
member. Appeals involving pre-service issues
are responded to within fifteen (15) days.
• Investigational post-service issues are
responded to within twenty (20) working
days.
• Expedited reviews are responded to within
seventy-two (72) hours of the receipt of the
request.
If the decision is not in the member’s favor,
the member or member representative will be
informed of the right to further appeal.
Level Two Internal Appeal
The member or the member’s representative
may file a Level Two appeal. Requests for a Level
Two appeal must be submitted within sixty (60)
days of the receipt of an adverse determination
at the first level. The member or member’s
representative may submit written materials
in support of the appeal. Documentation is
compiled by the Appeal Coordinator then
presented to an internal appeal panel. The
panel’s voting members will not have been
previously involved with the case. A written
response is sent to the member in:
• Fifteen (15) calendar days for pre-service
issues.
• Twenty (20) working days for post-service
investigational procedures.
• Thirty (30) days for all other appeals.
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PROVIDER MANUAL | 2014
If the decision is not in the member’s favor, the
member is informed of the right to file for review
by an Independent Review Organization (IRO).
External Review
If the member has exhausted the internal appeal
process (or has been deemed to have done so)
and remains dissatisfied, and the issue is one
of medical necessity, investigational supplies
or services, continuity of care or whether a
course or plan of treatment is delivered in
an appropriate health care setting and with
the appropriate level of care, the member or
member representative may request external
review within one hundred eighty (180) days of
receipt of the previous level’s determination.
An IRO is an independent organization
employing physicians and other medically
qualified individuals or experts. It acts as the
decision maker for external appeals (regular or
expedited), through assignment to the Plan via
state regulatory requirements.
The Independent Review Organization
will provide to the member and/or appeal
representative in writing:
• Its decision
• A full description of its rationale
Oregon’s Health CO-OP agrees to be bound
by the decision of the Independent Review
Organization.
The member or member representative may
request external review by submitting the
request to either Oregon’s Health CO-OP or
to the state’s Director of the Department of
Consumer and Business Services. The Appeal
Coordinator/specialist will notify the Oregon
Insurance Division of the receipt of a request for
external review, and the Division will then assign
the request to the next Independent Review
Organization (IRO) on a rotating list. The appeal,
including all documentation, will be delivered to
the IRO within six (6) working days of assignment
by the state. 7
OREGON’S HEALTH CO-OP
3. RESOURCES
Care Management
The Oregon’s Health CO-OP Care Management
Group can help providers in caring for members
with complex or co-morbid health care
needs, including mental illness and chemical
dependency.
Care Management Program Referrals
Potential candidates for Care Management
service referral include:
• Members with complex care needs and
difficulty with self-management skills
• Members transitioning home from a hospital
or other inpatient facility
• Members who need support in establishing
and maintaining provider relationships
The team of registered nurse case managers,
behavioral health specialists and health care
coordinators offers case management and care
coordination services.
• Members who have difficulty in accessing
appropriate health care
The team’s goal is to help members achieve
the best possible outcomes from care, despite
any physical and mental health challenges or
economic obstacles that may exist.
• Members who suffer from mental health
and/or substance abuse issues
• Members who have social support needs
that interfere with their health care
Referrals to Care Management
can be made by:
Care Management CO-OP Group
• Providers
In partnership with providers, Care Management
helps members:
• Members and their families
• Navigate the health care system
• Become actively engaged in their care
• Improve self-management skills
• Manage chronic conditions
• Follow the treatment plan developed by
their provider
• Access community resources to address
social support issues
• Transition from one level of care to another
• Access appropriate end-of-life care
resources
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• Members’ authorized representatives
To make a referral:
• Call the Care Management CO-OP Group
at 503-416-1792.
• Explain the reason for the call.
• The Health Care Coordinator will either
address the service need or forward the
referral to a case manager.
PROVIDER MANUAL | 2014
Network Relations Associates
Oregon’s Health CO-OP Network Relations
Associates (NRAs) are part of the Provider
Services Department. They are assigned to
physicians and hospitals based on geographic
territories and health systems.
The Network Relations Associates are dedicated
to meeting the service needs of our contracted
clinics, facilities and vendors. They are a link
between our network providers and the
Oregon’s Health CO-OP staff.
The Network Relations staff maintains
contractual agreements to develop a
comprehensive network, ensuring member
access.
Contact a Network Relations Associate:
• If you want to become a contracted
clinic, facility or vendor with Oregon’s
Health CO-OP.
• You are already contracted and have
questions about your agreement.
Network Relations Associates provide certain
information and trainings on site. Contact
them to schedule:
• Orientation to health plan operations,
policies and procedures (upon contracting).
• Refresher orientations for new clinic, billing
or management staff as needed.
eligibility, authorizations and claims/
payment detail) and the Oregon’s Health
CO-OP website.
IMPORTANT: Email or fax updates to the
Network Relations teams about changes such as:
• New or terminated providers or clinic staff
• Locations
• Phone and fax numbers
• Email addresses.
Timely updates facilitate accurate directory
listings, mailings, correct claims payment and
system access for your staff.
Network Relations Associates collaborate with
clinicians and other partners to address health
care-related issues in the communities we all
serve. We see their role as a partnership. Do not
hesitate to contact your associate to discuss
solutions/ideas or to schedule a meeting or
training.
Want to know the name of your Network
Relations Associate or how to contact the
associate? Click here: www.ohcoop.org/
providers/who-to-contact.
If you can’t reach your Network Relations
Associate, you’re welcome to contact
Customer Service for assistance: Toll-free
at 1-855-722-8207 or in the Portland area,
503-488-2833.
• Targeted in-depth training on specific topics.
• Training on using our online resources
such as Provider Portal (verifies member
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OREGON’S HEALTH CO-OP
The Provider Portal
Medical Record Review
The Oregon’s Health CO-OP provider portal is
a confidential online system that allows clinics
and vendors to verify member eligibility and
check the status of their authorizations and
claims.
Oregon’s Health CO-OP reviews medical
records of contracted primary care providers
on a regular schedule. Oregon’s Health CO-OP
staff adheres to HIPAA-mandated confidentiality
standards.
The Provider Portal will be under construction
through 2013. Prior to Jan. 1, 2014, we’ll include
information on our website (www.ohcoop.org)
that describes the process for registration and
addresses what we believe will be frequently
asked questions. We welcome your additional
questions.
To review the National Committee for Quality
Assurance (NCQA) rules that direct the audit
process, contact your Network Relations
Associate.
Clinical Best Practices and Health
Promotion Guidelines
Oregon’s Health CO-OP, through its Quality
Improvement Committee (QIC), reviews and
adopts evidence-based practice guidelines.
These define standards of practice that pertain
to improving the quality of health care for
certain diseases, diagnoses and preventive
services.
A nationally recognized body of experts reviews
these guidelines at least once every two years.
After our Quality Improvement Committee
approves them, we post the guidelines on our
website. You can access this resource at (link
coming soon).
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Here’s a description of the process:
1.Oregon’s Health CO-OP’s Quality Improvement
(QI) staff identifies a sample of contracted
clinics to be reviewed.
2.QI mails a letter with patients’ names to each
clinic. We ask clinic staff to send us a copy of
those patients’ medical records.
3.QI Coordinators (registered nurses) review
the medical records for legibility, content,
organization and completeness.
4.The Quality Improvement department mails
audit results to providers. A passing score is
90 percent or greater. A provider who does
not receive a score of at least 90 percent
is evaluated by an Oregon’s Health CO-OP
Medical Director and/or by the internal Peer
Review Committee. Oregon’s Health COOP may ask a provider to send us a written
corrective action plan. Additional audits may
occur.
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Reviewers verify that the medical records
contain the following documentation:
• Member information identified on each
page by two (2) patient identifiers.
• A problem list, with significant medical
and/or psychological illnesses.
• Presenting complaints, physical
examinations, diagnoses, treatment plans
and referrals or consultations as appropriate
to each visit.
• Lab results and diagnostic test reports.
• Prescribed medications, including dosages
and dates of initial/refill prescriptions.
Allergies and adverse reactions, or
documentation of no known allergies or
history of adverse reactions.
• Advance Directives:
›› Documentation of discussion with all
members, if condition warrants, of
advance medical planning.
›› Documentation of discussion must be
noted in a prominent location in the
medical record.
• Health education, preventive screening and
anticipatory guidance, as appropriate.
• Provider identification or signature for each
review visit note. Faxed, digital, electronic,
scanned or photocopied signatures are
acceptable. Signature stamps are not
acceptable.
Confidentiality
Health care providers who transmit or receive
health information in one of the Health
Insurance Portability and Accountability Act’s
(HIPAA) transactions must adhere to the HIPAA
Privacy and Security regulations.
Providers must provide privacy and security
training to any staff members who have contact
with individually identifiable health information.
All individually identifiable health information
contained in the medical record, billing records
or any computer database is confidential,
regardless of how and where it’s stored.
Examples of stored information include clinical
and financial data in paper, electronic, magnetic,
film, slide, fiche, floppy disk, compact disk or
optical media formats.
You may disclose health information in medical
or financial records only to the patient or legal
guardian unless the patient or legal guardian
authorizes the disclosure to another person or
organization, or a court order has been sent to
you.
Health information may only be disclosed to
those immediate family members with the
verbal or written permission of the patient or
the patient’s legal guardian. Health information
may be disclosed to other providers involved in
caring for the member without the member or
member’s legal representative’s written or verbal
permission.
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OREGON’S HEALTH CO-OP
Patients must have access to, and be able to
obtain copies of, their medical and financial
records from the provider.
Information may be disclosed to insurance
companies or their representatives for quality
and utilization review, payment or medical
management. Providers may release legally
mandated health information to state and
county health divisions and to disaster relief
agencies.
All health care personnel who generate, use,
or otherwise deal with individually identifiable
health information must uphold the patient’s
right to privacy.
Patient information (financial and clinical) must
not be discussed with anyone who is not directly
involved in the care of the patient or involved
in payment or determination of the financial
arrangements for care.
Providers’ employees (including physicians)
must not have unapproved access to their own
records or records of anyone known to them who
is not under their care.
Oregon’s Health CO-OP staff adheres to the
HIPAA-mandated confidentiality standards.
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Release of Information
Providers must obtain an authorization
to release individually identifiable health
information whenever information is released
about the patient, unless the release is for
payment, treatment of the patient, or the healthcare operations of another organization that is
providing health care or payment for health care
for the patient.
• A general release of information form is not
necessary for Oregon’s Health CO-OP and
the providers to communicate regarding
treatment or payment for treatment of
Oregon’s Health CO-OP members, according
to HIPAA privacy regulations.
• The general authorization form is not valid
for information regarding HIV, sexually
transmitted diseases, genetic, mental health
or alcohol and drug treatment information.
Do not release this information unless the
member signs an authorization specifying
that these types of records may be released.
PROVIDER MANUAL | 2014
4. PRIMARY CARE AND
SPECIALTY CARE
Responsibilities of Primary Care
Providers
Primary care providers will provide at least the
following level of service to Oregon’s Health COOP members seeking care from them:
• Maintain in the member’s record a
comprehensive problem list which lists
all medical, surgical and psycho-social
problems for that patient.
• Maintain a comprehensive medication list
that includes all prescription medications
that the member is taking and any
medication allergies. This includes
medications prescribed by specialists.
• Provide accessible outpatient care within
four weeks for any routine visit (e.g.
preventive care).
• Provide accessible outpatient care within
24 hours for any member with an urgent
problem.
• Provide access to telephone advice for
member questions 24 hours per day.
• Arrange specialty consultation with a
network consultant within four weeks for
any member with a non-urgent problem
needing such consultation.
• Arrange specialty consultation with a
network consultant within 24 hours for any
member with an urgent problem needing
such consultation.
• Have a policy and/or procedure that
arranges for and provides access to
an appropriate back-up physician or
practitioner for any leave of absence
you may have.
Access to Care: Primary
and Specialty Care
It is the policy of Oregon’s Health CO-OP to
ensure that our members have access to timely
and appropriate preventive and curative
health services that are delivered in a patientfriendly and culturally competent manner.
Oregon’s Health CO-OP requires practitioners
to have policies and procedures that prohibit
discrimination in the delivery of health care
services.
Appointment Availability and
Standard Scheduling Procedures
• Provide preventive services as recommended
by the U.S. Preventive Services Task Force
(www.uspreventiveservicestaskforce.org).
• Routine and follow-up appointments
should be scheduled to occur as medically
appropriate within four weeks.
• Provide immunizations as recommended
by the Centers for Disease Control and
Prevention (www.cdc.gov).
• Urgent care cases should be scheduled to be
seen within 24 hours or as indicated in initial
screening.
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OREGON’S HEALTH CO-OP
• Appointments for initial history and physical
assessment should be scheduled in longer
appointment slots to allow for preventive
care and health education as needed.
• Members should wait no longer than
an average of 20 minutes for scheduled
appointments.
• Appointments for initial history and physical
assessment should be scheduled in longer
appointment slots to allow for preventive
care and health education as needed.
24-Hour Telephone Access
Oregon’s Health CO-OP has a commitment to its
members to provide 24-hour phone access to
health care.
Our contracted primary care providers must
have a telephone triage system.
During Office Hours
A primary care provider (physician, naturopath,
osteopath, nurse practitioner or physician
assistant) or registered nurse triages member
calls to determine appropriate care and to assist
the member with advice, an appointment or a
referral.
After Hours
The Provider Services team conducts an annual
after-hours survey to ensure that the following
criteria are met. If you have questions,
contact a Network Relations Associate at
www.ohcoop.org/providers/who-to-contact
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After-hours access includes:
• Answering Service
›› Urgent situations: The person who
answers the phone must offer to either
page the provider on call (with the
provider then calling the member) or to
transfer the member’s call directly to the
on-call provider.
›› Emergency situations: The person who
answers the phone must tell the member
to call 911 or go to the nearest emergency
room if the member feels the situation is
too emergent to wait for the provider’s
call.
• Answering Machine
›› Urgent situations: The outgoing message
must instruct callers on how to page the
provider in urgent situations.
›› Emergency situations: The outgoing
message must provide information
to callers about accessing emergency
services, i.e., to call 911 or go to the
nearest emergency room if the member
feels the situation is emergent.
PROVIDER MANUAL | 2014
5. PRIOR
AUTHORIZATIONS OR
PREAUTHORIZATIONS
Definition
Prior Authorization or Preauthorization is
approval given by Oregon’s Health CO-OP
in advance of a proposed hospitalization,
treatment, supply purchase or other covered
service, in accordance with Oregon’s Health COOP Policies and Procedures.
Oregon’s Health CO-OP will provide
authorizations for non-emergency covered
services in the form of a Preauthorization
and shall certify or recertify lengths of stay, if
required, by telephone contact or other mutually
agreeable form of communication between the
Provider and Oregon’s Health CO-OP personnel,
according to the Policies and Procedures.
specialty or ancillary services if the specialist
or ancillary provider has not previously
seen the member.
Specialists or ancillary providers are responsible
for obtaining any required authorizations once
they have seen the member, and the service that
will be provided requires an authorization.
• For elective ambulatory surgery and facility
admissions, the admitting or performing
provider is responsible for obtaining the
authorization. The facility is responsible for
verifying that an authorization was issued.
• For urgent/emergent facility admissions,
the facility is responsible for notifying
Oregon’s Health CO-OP of the admission and
for obtaining an authorization.
• For inpatient stays, the facility is responsible
for providing Oregon’s Health CO-OP with
ongoing clinical review information daily or
as requested in order to authorize the length
of stay.
For a current listing of services requiring
preauthorization and printable authorization
request forms, please see ohcoop.org/
providers/medical-management.
• For obstetrical admissions, the facility
must notify Oregon’s Health CO-OP of all
admissions within one business day of the
member’s admission
Failure to obtain an authorization for any service
that requires one, including a facility length of
stay, will result in claim payment denial.
• For deliveries, the facility must notify
Oregon’s Health CO-OP of the date of
delivery, type of delivery and discharge date.
Hospital stays beyond federal guidelines
(two days for vaginal delivery, four days for
caesarean section) require authorization.
Preauthorization Responsibilities
Who’s responsible for preauthorizations?
Primary care providers are responsible for
obtaining any required authorizations for
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OREGON’S HEALTH CO-OP
Retroactive Authorization
Requests
Oregon’s Health CO-OP accepts retroactive
authorization requests. When requests are
submitted, an authorization decision is based
on the member’s coverage, benefit rules and
medical appropriateness criteria in effect at the
time of the service.
Because the service has already been provided,
it may take Oregon’s Health CO-OP up to fortyfive (45) days from the date of the request to
make a decision.
Providers will receive written notification when
the request is denied or approved. If a denial
determination is issued, the provider cannot
bill the member. Therefore, we recommend that
providers submit authorization requests prior to
the service being provided, whenever possible.
Regardless of whether a retroactive authorization
was issued, claims must be submitted to
Oregon’s Health CO-OP within one year
of the date of service.
Authorization Determinations
Prior authorization requests that are submitted
with complete information, including correct
coding, with relevant chart notes attached,
allow Oregon’s Health CO-OP to make timely
authorization determinations.
Oregon’s Health CO-OP may take up to fourteen
(14) calendar days to make prior authorization
determinations. Additional time, up to fourteen
(14) more days, is allowed if Oregon’s Health
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CO-OP does not immediately receive all
the information needed to make a benefit
determination. Prior authorization decisions
are based on benefit rules, guidelines and
limits, Oregon’s Health CO-OP policies and, as
appropriate, evidence-based practice guidelines.
Concurrent review determinations are made
within twenty-four (24) hours of notification.
Oregon’s Health CO-OP may deny days if
requested information is not provided in a timely
manner. Review determinations are based on
Interqual criteria for both the level of care and
length of stay.
In all cases, authorization determinations
are based solely on plan benefits, medical
appropriateness and the least costly alternative
for the service requested. Oregon’s Health
CO-OP does not reward staff for denying prior
authorizations or facility admission or length-ofstay authorizations.
Feel welcome to call the Oregon’s Health CO-OP
Customer Service Department to request the
criteria we use for authorization decisions.
Authorization Time Frames and
Number of Visits
Authorization time frames and number of visits
approved differ based on the type of service
being authorized and any benefit limits that
may exist. The authorization details for faxed
requests will be included in the authorization
response that you receive back via fax, or, for
online authorization submittals, in the response
you receive. A new authorization will be required
if the previous authorization has expired or the
number of visits has been exhausted.
PROVIDER MANUAL | 2014
Denials and Appeals of
Authorizations
Denial Determinations
• Benefit exclusion denials (benefit
specifically excluded) are made by
Oregon’s Health CO-OP staff.
• Benefit limit denials (benefit specifically
limited to number of visits or dollar
amounts) are made by Oregon’s
Health CO-OP staff.
• All other denials, including facility
admissions and lengths of stay,
are made by a Medical Director.
Appeals
A Medical Director will review all appeals within
thirty (30) days. Oregon’s Health CO-OP will
communicate a written decision on an Appeal
within forty-five (45) days of our receipt of all
documentation reasonably needed to make the
determination.
The decision to uphold the denial or approve
the requested service is sent in writing to the
member, primary care physician or requesting
provider, and specialist (when applicable) within
one week of the decision.
Decision making, which includes medical/
surgical services and equipment, pharmacy
and chemical dependency, is based only on
plan benefits and limitations, appropriate care,
coverage guidelines and rules.
Oregon’s Health CO-OP does not reward staff
for denying authorization requests, and we
do not use financial incentives to reward
underutilization.
Oregon’s Health CO-OP physician reviewers are
available to discuss denial decisions. Contact
Customer Service, 7 a.m. to 6 p.m. Monday
through Friday, to schedule a time to speak
with a physician reviewer: 503-488-2833 in the
Portland metro area or toll-free 1-855-722-8207.
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OREGON’S HEALTH CO-OP
6. BILLING AND PAYMENT
Billing Address
Provider Claims
Oregon’s Health CO-OP
PO Box 40048
Portland, OR 97240
Submit Claims
To submit claims electronically, use
EDI Payer ID 21455.
For information on billing claims electronically,
contact Emdeon toll-free at 1-877-363-3666
for EDI medical claims, and 1-888-255-7293
for EDI dental claims. Or visit
www.emdeon.com/ProviderSolutions/
provider_billingmanagement.php
to submit claims using the standard CMS
(formerly HCFA) 1500 or UB04 claim forms.
For more information, see instructions for
completing the CMS 1500 or UB04 forms at
www.cms.hhs.gov/manuals/downloads/
clm104c26.pdf and www.cms.hhs.gov/
manuals/downloads/clm104c25.pdf.
Incomplete claims are denied for resubmission
with the missing information.
Claims must include the member’s ICD9 code
to the highest level of specificity and the
appropriate procedure codes(s). See OARs
410-130-0160 and 410-120-1280.
18
Oregon’s Health CO-OP will deny claims in the
following circumstances with instructions to
resubmit the claim with a valid diagnosis code:
• Claims that use non-primary diagnosis
codes for the primary or sole diagnosis.
• Claims for services billed with an E-code as
primary or sole diagnosis.
• Claims with an invalid diagnosis or invalid
procedure or revenue code.
CMS has mandated that the ICD-9 diagnostic
coding system be replaced by the more flexible
ICD-10 CM and PCS system. The deadline for
nationwide conversion is October 2014; Oregon’s
Health CO-OP is preparing for the change. For
more ICD-10 information, including key dates,
please visit: www.cms.hhs.gov/ICD10/01_
Overview.asp#TopOfPage.
Timely Filing
Claims for covered services must be received
within one year of the date of service to be
considered eligible for payment.
Timely Payment
Oregon’s Health CO-OP agrees to pay a clean
claim within the time required by applicable
Oregon law.
ORS 743.911
ORS 743.913
PROVIDER MANUAL | 2014
A clean claim is a bill for services, line item of
service or all services for one Member on a claim
form acceptable to Oregon’s Health CO-OP that
can be processed without obtaining additional
information from the provider of services or from
a third party.
A clean claim does not include a claim from a
provider under investigation for fraud or abuse,
or a claim under review for Medical Necessity.
Claims Appeals
Contact Oregon’s Health CO-OP Customer
Service to appeal an action. An action includes
but is not limited to the denial, in whole or in
part, of payment for service.
Reconsideration for Payment
• Denied for missing information/
documentation not including
authorization related denials
• Duplicate claims
• Timely filing denials
Submit provider reconsideration/appeal
requests, in writing, by completing the
Provider Post Service Claim Reconsideration/
Appeal Form.
Include the reason for the dispute and any
relevant information and/or documentation
related to the dispute.
If the claim was denied because of authorization
issues, please send current medical
documentation with the appeal.
Mail or fax written claim appeals to:
Oregon’s Health CO-OP Claims Department
Reconsiderations/Claims Appeals
PO Box 40048
Portland, OR 97240
Attn: CO-OP Claims Appeals Coordinator
Or fax written claims appeals to Provider
Appeals Coordinator: 503-416-1301.
Oregon’s Health CO-OP resolves the appeal and
sends a notice of determination to the provider
no later than 45 calendar days after the day the
appeal is received.
Post Service Provider Claim Appeal
• Previously upheld reconsiderations
for payment
• Authorization related denials
• Contract rate
• Excluded benefits
IMPORTANT: Oregon’s Health CO-OP must
receive appeals no more than one year from
the original processing date of the claim.
Coordination of Benefits
If a member has health care coverage under
more than one health insurance plan, we will
coordinate benefits with the health insurance
plan to ensure the member receives the
maximum coverage allowable under Oregon law.
A set of rules governs coordination of benefits
(COB) in Oregon. The plan that pays first is called
the “primary plan.” The primary plan must pay
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OREGON’S HEALTH CO-OP
benefits in accordance with its policy terms
without regard to the possibility that another
plan may cover some expenses.
The plan that pays after the primary plan is
the “secondary plan.” The secondary plan may
reduce the benefits it pays so that payments
from all plans do not exceed one hundred
percent (100%) of the total allowable expense.
Clinical Editing
Oregon’s Health Co-OP uses the OptumTM Claims
Edit System® (iCES) to ensure the efficiency
and accuracy of our claims payments. Clinical
edits are based on OptumInsights’ Approved
Sources for Edit Development, such as American
Medical Association (AMA) Current Procedural
Terminology (CPT) guidelines, Centers for
Medicare & Medicaid (CMS) policies, National
Correct Coding Initiative (NCCI) coding edits and
specialty society recommendations, as well as
policies developed by Oregon’s Health CO-OP.
Actions of the clinical editing system include,
but are not limited to:
• Rebundling lab, X-ray, medicine, anesthesia
and surgical procedure codes.
• Denial warning message when surgery is
inconsistent with the diagnosis.
• Denial warning message on claims when a
patient’s age does not fall into the normal
age range for the procedure or diagnosis.
20
• Denial of a procedure considered integral to
another billed procedure.
• Denial of procedures not customarily billed
on the same day as a surgical procedure.
• Denial of services normally included as
follow-up care associated with a surgical
procedure.
Because valid exceptions to clinical editing
exist, Oregon’s Health CO-OP reviews records
for unusual or extraordinary circumstances that
may influence the benefit.
Hold Harmless
Network providers have agreed to accept our
allowable fee as payment in full for covered
services and supplies, whether paid by Oregon’s
Health CO-OP, the member or another payer.
As a network provider, this means you may
charge our members only for deductible,
coinsurance, copayments and non-covered
services. Providers must hold the member
harmless for any amounts identified below,
which will be considered contractual
adjustments. Please refer to your provider
agreement for further clarification.
• Charges above the maximum allowable fee
You must not bill a member for any amount
of your charge that is greater than the
maximum allowable fee per your provider
agreement.
PROVIDER MANUAL | 2014
• Charges denied due to Oregon’s
Health CO-OP
You must not bill a member for any amount
deemed a provider write-off based on
Oregon’s Health CO-OP policies, including
any services and supplies determined to be
not medically necessary.
• Charges related to associated claims
Claims for associated services rendered to
support any non-covered or not medically
necessary service will be denied and may
not be billed to a member. Services may
include, but are not limited to, anesthesia,
radiology, laboratory and hospital services.
Associated claim denials may occur at any
time: during pre- or post-payment reviews
and/or on appeal.
Overpayment Recovery
Oregon’s Health CO-OP will conduct
retrospective reviews of claims and
reimbursements to Providers. Except in the case
of fraud or abuse billing, any request for refund
of a payment previously made to Providers shall
be made in writing within 18 months — or, if
for reasons relating to coordination of benefits,
within 30 months — after payment was made,
and shall specify why Oregon’s Health CO-OP
believes the refund is owed.
payment of the claim. If a request for a refund is
not disputed in writing within 30 days after the
request is received, the request will be deemed
accepted, and Providers must pay the refund
within 30 days after the request is deemed
accepted.
Overpayments identified by Providers shall be
refunded within 60 days of identification of the
overpayment by Providers.
Notwithstanding the foregoing, Oregon’s Health
CO-OP may at any time request a refund of a
claim it has previously paid if liability is imposed
by law on a third party and we are unable to
recover from the third party because the third
party has paid or will pay Providers for the
services covered by the claim. If Providers fail to
refund an uncontested overpayment within the
time periods set forth in this section, Oregon’s
Health CO-OP may withhold any overpayment
amount from future payments for services
rendered by Providers.
If a refund is not timely received and we are
unable to withhold overpayments from future
payments, Oregon’s Health CO-OP may initiate
a collection or legal proceeding to recover
overpayment amounts; in a collection or legal
proceeding to recover overpayment, Oregon’s
Health CO-OP shall be entitled to recover its
reasonable attorneys’ fees and costs incurred in
such proceeding.
If the refund is requested for reasons relating
to coordination of benefits, Oregon’s Health
CO-OP will include in the written request the
name and mailing address of the other insurer
or entity that has primary responsibility for
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OREGON’S HEALTH CO-OP
Locum Tenens Claims
and Payments
Oregon’s Health CO-OP allows licensed providers
acting in a Locum Tenens capacity to temporarily
submit claims under another licensed provider’s
NPI number when that provider is on leave from
his/her practice. The Locum Tenens provider
must have the same billing type or specialty
as the provider on leave, e.g., a physician must
substitute for another physician.
Oregon’s Health CO-OP is not responsible
for compensation arrangements between
the provider on leave and the Locum Tenens
provider. Oregon’s Health CO-OP sends a
payment to the billing office of the provider
on leave. Per CMS guidelines, Oregon’s Health
CO-OP allows Locum Tenens to substitute for
another provider for 60 days. Providers serving
in a Locum Tenens capacity should bill with
Modifier Q6 to indicate the Locum Tenens
arrangement.
Interim Billing
Oregon’s Health CO-OP reimburses for the first
and subsequent interim billings for facilities
not reimbursed at Diagnosis Related Group
(DRG) rates. Interim claims must be submitted
in sequential order and in 30-day increments or
on a monthly basis. Each claim must include all
applicable diagnoses and procedures.
Facilities reimbursed based on DRG
methodology are paid when the patient is
discharged and the final billing is received.
All authorization guidelines apply.
Readmissions to Diagnosis Related Group
(DRG) Hospitals
The following readmissions within 15 days
of discharge are considered part of the initial
admission and are included in payment for the
initial admission:
• Additional surgery or follow-up care that
was planned at the time of discharge.
• Readmission for treatment of the same
condition.
22
PROVIDER MANUAL | 2014
7. QUALITY
IMPROVEMENT AND
CREDENTIALING
Program Goals
Our Quality Improvement Program focuses on
improvements that make health care:
• Safer
• More effective
• More patient-centered
• More timely
• More efficient
• More equitable
Program Objectives
Our Quality Improvement (QI) process is driven
by the Oregon’s Health CO-OP mission and
vision. Our objectives are to:
• Ensure that members receive maximal
health benefits from the resources available
to Oregon’s Health CO-OP.
• Monitor the health status of our members to
identify areas that most significantly impact
health status and/or quality of life.
• Ensure the optimal use of health strategies
known to be effective, including prevention,
risk reduction and evidence-based practices.
• Develop population-based health
improvement initiatives that can best be
implemented at a health plan level.
• Ensure quality and accountability through
measurement of performance and
utilization.
• Provide enhanced support for those with
special health care needs through:
›› Proactive identification of those at risk.
›› Case management and coordination of
fragmented services.
›› Promotion of improved chronic care
practices.
• Coordinate fragmented services by
supporting integrated models of mental
and physical health care services.
• Participate in efforts that improve health
care for all Oregonians by:
›› Supporting community, state and
national health initiatives.
›› Building partnerships with other health
care organizations.
›› Pursuing research on new models of
health care design and delivery.
›› Seeking collaboration within the
community to identify and eliminate
health care disparities.
To meet these objectives, we have a process for
prioritizing QI projects that is consistent with our
mission, vision, care philosophy and values. The
process is based on the following parameters:
23
OREGON’S HEALTH CO-OP
• Improve our members’ satisfaction.
• Focus on high-volume, high-risk areas
that have a significant impact on
members’ health.
• Have measurable outcomes in terms
of quality of life and/or health resource
utilization.
• Involve programs or interventions that are
confirmed to improve outcomes, or that can
be evaluated to find out if outcomes will
improve.
• Align with efforts by provider groups,
community groups and other health
plans focused on improving the health of
Oregonians.
• Promote or improve models of care that can
be broadly generalized in the health care
system, such as the chronic care model or
the Patient Centered Primary Care Home
initiatives.
• Focus on areas that have a significant
impact on a population with exceptional
needs and those individuals with potential
for risk.
QI Program Committees
• Pharmacy and Therapeutics
Accountable for oversight of the Oregon’s
Health CO-OP pharmacy program, the
development and maintenance of the
Oregon’s Health CO-OP formulary and
programs that impact utilization.
24
• Medical Benefits Assurance
Accountable for oversight of the Oregon’s
Health CO-OP Medical Benefits Assurance Unit
and approval of medical policies and new
technology assessments.
• Quality Improvement
Advisory committee that provides oversight
and direction for Oregon’s Health CO-OP
initiatives that impact the quality of care for
our members.
• Peer Review
Accountable for monitoring and ensuring
the quality of care and service provided by
individual contracted providers.
• Service Quality
Accountable for identification of issues
impacting the satisfaction of our members
through the analysis and integration of
information from multiple sources.
•Credentialing
Accountable to ensure that Oregon’s Health
CO-OP offers a high quality panel of providers
to our members. It is also accountable for
delegation oversight.
PROVIDER MANUAL | 2014
Scope of Service and Issues Reviewed
Our Quality Improvement Program defines the
processes that we measure and monitor.
Major plan components include processes
involved with quality outcomes, patient safety
and service as they pertain to access, availability
and satisfaction. The scope of service also
includes any and all regulatory requirements.
Oregon’s Health CO-OP has determined that
areas in which our members receive care and
service should be monitored and evaluated for
opportunities for improvement.
These areas include:
• Hospitals
• Urgent care centers
• Primary care clinics
• Community health centers
• Consultation services
• Vision clinics
• Dialysis centers
• Hospices
• Skilled nursing facilities
• Drug and alcohol dependency facilities
• Health departments
The areas listed above encompass the care and
services delivered by our network providers.
Network providers of care to our members
are all primary care providers and specialists.
Behavioral health providers are included in the
Quality Improvement process. These providers
offer chemical dependency treatment, smoking
cessation and mental health services.
Issues reviewed by the Quality Improvement
Committee include, but may not be limited to:
• Selected Health Employer Data Information
Set (HEDIS) indicators
• Access to care
• Patient satisfaction
• Outcomes of care
• Patient safety
• Compliance with government regulations
Data sources may include claims data, medical
record data, patient complaints (grievances),
case management reports, pharmacy data,
satisfaction surveys and Quality Improvement
projects.
Research analysts, quality program staff and
Information System (IS) staff may use data
elements to develop a reporting format that
is reviewed and evaluated by the Quality
Improvement Committee.
The QI Committee uses data to recommend
interventions aimed towards improvement.
Any member-specific or provider-specific
data are considered confidential and treated
according to Oregon’s Health CO-OP policy. This
policy is fully congruent with HIPAA regulations.
The appropriate sources receive feedback with
findings, conclusions and recommendations.
The Quality Improvement Program staff prepares
a yearly evaluation of the program and presents
it to the QI Committee for review. The following
year’s program is built from this evaluation.
25
OREGON’S HEALTH CO-OP
Credentialing
Initial credentialing: The application for
provider status of a provider who is new to the
Oregon’s Health CO-OP panel, or a provider who
has terminated more than thirty (30) days prior
to applying and is requesting reinstatement.
Recredentialing: The process of periodically
re-evaluating current panel providers for
continuing competency to provide high quality
services to Oregon’s Health CO-OP members.
General Guidelines
Most providers must complete a credentialing
application when contracting with Oregon’s
Health CO-OP. Providers who are subject to the
credentialing process include:
• Certified Nurse Midwife
• Doctor of Medicine
• Doctor of Naturopathy
• Doctor of Osteopathy
• Doctor of Podiatric Medicine
• Nurse Practitioner
• Physician Assistant
• Occupational Therapist
• Speech Therapist
• Physical Therapist
On an ongoing basis, we review providers’
practice utilization data, member complaints,
quality of care assessments and any changes in
application status.
Oregon’s Health CO-OP credentialing process
maintains a “professional misconduct” policy to
ensure the safety of our members.
This policy guides the Credentialing Committee
in the decision-making process when incidents
of inappropriate sexual behavior are identified.
During the credentialing process, our
Credentialing Committee may deny, suspend
or terminate a provider’s participation with
the plan.
The revised Fair Hearing Policy outlines the
process for providers to appeal and/or challenge
an adverse action. Fair hearing is offered to both
initial and recredentialed providers.
If you have questions, please contact your
Network Relations Associate.
Initial Credentialing
Providers interested in joining the network
serving Oregon’s Health CO-OP members must
submit a signed and dated Oregon Practitioner
Credentialing Application, along with the
following information:
• Audiologist
• Signed and dated attestation questions.
• Behavioral Health/Chemical Dependency
Specialist
• Attachment A, referring to the attestation
questions answered “yes.”
• Licensed Acupuncturist
• Signed and dated Authorization and
Release of Information form.
26
PROVIDER MANUAL | 2014
• Evidence of current licensure by State of
Oregon (copy of wallet-sized license is
sufficient).
• Evidence of current DEA certification or
prescriptive privileges, if applicable.
• Evidence of current professional liability
insurance coverage in the amount of no less
than $1 million per incident and $3 million
aggregate, or equivalent protection.
• Copies of specialty board certificate(s),
if applicable.
• Copy of current curriculum vitae.
Recredentialing
All credentialed providers are recredentialed at
least once every three years. Ninety days before
the provider’s recredentialing date, Oregon’s
Health CO-OP sends a recredentialing packet to
the provider.
The following information is needed to complete
the recredentialing process:
• Copy of state license.
• Current DEA registration and proof of
prescriptive privileges, if applicable.
IMPORTANT: The applicant must inform
Oregon’s Health CO-OP within 30 days if changes
occur to any statements on the application.
• Current professional liability insurance
coverage in the amount of $1 million per
incident and $3 million in aggregate, or
equivalent protection.
Oregon’s Health CO-OP’s Credentialing
Committee reviews the initial application
documents, including the provider’s application,
attached documents, verification of state
licensure, National Practitioner Data Bank
report, closed claim reports, license action
report, Medicare Opt-Out Report, any patient
complaints about the provider and site visit
reviews (for primary care providers only).
• The Oregon Practitioner Recredentialing
Application, including:
Education, work history and call coverage are
also elements of the review process.
The Credentialing Committee may request
additional informationif necessary.
The Credentialing Committee recommends
acceptance or rejection of the application. The
Oregon’s Health CO-OP Network and Quality
Committee (a subcommittee of the board) grants
final approval.
›› Signed and dated attestation questions
›› Attachment A, referring to attestation
questions answered “yes”
›› Signed and dated Authorization and
Release of Information form
Our Credentialing Committee considers this
information along with the National Practitioner
Data Bank inquiry results, closed claim reports,
license action report, Medicare Opt-Out Report
and member complaints.
Failure to provide recredentialing information in
a timely manner may be brought to the attention
of the Oregon’s Health CO-OP Credentialing
Committee. Noncompliance may result in a
recommendation to send the provider a notice
of termination.
27
OREGON’S HEALTH CO-OP
Providers’ Rights: Policy
and Procedures
Background
Oregon’s Health CO-OP considers it essential
to maintain a provider panel that has the legal
authority, relevant training and experience
to provide care for our members. Provider
rights ensure that all participants in the
credentialing process are aware of their rights
during the credentialing process. We advocate
for provider rights to be readily accessible and
understandable to all providers.
Policy
The Oregon’s Health CO-OP Credentialing Unit
adheres to the following provider rights and
notifies each provider of these rights during
initial credentialing and at the beginning of each
recredentialing cycle.
This policy applies to all records maintained on
behalf of the Oregon’s Health CO-OP provider
panel and is limited to the credentials and
performance improvement files of individual
practitioners.
NOTE: References from peers and other
recommendations are protected information
that is excluded from this list of rights.
Oregon’s Health CO-OP has adopted the
following statement of provider rights that
applies to all contracted medical professional
providers. Providers are notified of these
rights in two ways:
28
• The Provider Rights document is
included with the Initial /Recredentialing
applications.
• Provider rights are documented in the
Provider Manual.
Providers in the credentialing/recredentialing
process have the following rights:
• To be free from discrimination in terms of
participation or indemnification solely on
the basis of licensure, as long as providers
are acting within the lawful scope of
licensure/certification.
• To be notified in writing of any decision that
denies participation on the Oregon’s Health
CO-OP panel.
• To be aware of applicable credentialing/
recredentialing policies and procedures.
• To review information submitted by the
applicant to support the credentialing
application.
• To correct erroneous information submitted
by third parties that does not fall under the
Oregon Peer Review Statute protections
(Section 41.675).
• To be informed of the status of their
credentialing or recredentialing application
on request, and to have that request granted
within a reasonable period of time.
• To be notified of these rights.
Source: NCQA Standard CR 1, Element B; 42 CFR
422.202(a) and (c)
PROVIDER MANUAL | 2014
Procedures
Responsibility
Actions
Provider
A provider has the right to examine his or her credentialing folder.
Request to review your credentialing file by asking (written, electronic or
telephone) the Oregon’s Health CO-OP Quality Improvement Manager/Chief
Medical Officer to schedule a review time. Make this request at least 24
hours in advance of your preferred review time. You must present a driver’s
license or other photo identification before reviewing the file.
Staff from the Quality Management Department/ Credentialing Unit must
supervise a provider during the examination/review.
Sufficient time must be allowed for providers to review their credentialing
file. Review time must be mutually agreed upon by the provider and
credentialing specialist. Records may not be removed or copied
unless expressly permitted by the chief medical officer or a designated
representative.
You have the right to receive a copy of any document (s) in your
credentialing folder that you submitted or that were addressed or copied
to you.
If you file an appeal, you are entitled to full access to your credentialing/
recredentialing and Quality Improvement (QI) folder(s).
After you review your file according to this policy and procedure, you
may submit a written request to the chief medical officer that asks for
corrections or deletions of information in the file. The request must include
a statement of the basis for the action requested.
Chief Medical
Officer
Review a provider’s requests for correction or deletion of information
within thirty (30) days and recommend to the Credentialing Committee
whether or not to honor the request(s).
29
OREGON’S HEALTH CO-OP
Responsibility
Actions
Credentialing
Committee
Notify the provider in writing within two (2) weeks of the committee’s
decision. The decision of the Credentialing Committee is final.
Provider
You may clarify discrepancies by providing documentation such as a
license, malpractice claims history or board certification decisions. You
must submit this information in writing (electronic or hard copy) within
two weeks of receiving the request.
Information obtained from you becomes part of the credentialing
application.
Credentialing
Specialists
Send a copy of the document to the provider if he or she does not have it.
Review new information with the provider by phone.
Write a summary memo based on the provider’s own words. Note the
review date on the memo and initial the date.
If the provider does not provide information that clarifies discrepancies
within the two-week time frame, process the application. Assess extensions
on a case-by-case basis.
Inform the Quality Improvement (QI) manager of any delinquencies related
to providers and information discrepancies.
Organizational Credentialing
Oregon’s Health CO-OP credentials institutional
providers or suppliers such as hospitals,
skilled nursing facilities, home care agencies,
behavioral health services, clinical laboratories,
outpatient speech and physical therapists,
ambulatory surgery centers, end-stage renal
30
disease services, outpatient diabetes selfmanagement training, portable X-ray providers,
rural health centers and Federally Qualified
Health Centers. A standardized application is
used for this process.
PROVIDER MANUAL | 2014
8. PHARMACY PROGRAM
• Drugs used for non-medically accepted
indications.
Oregon’s Health CO-OP Formularies
• Drugs used to promote fertility or to treat
sexual dysfunction or disorder in either men
or women.
The Oregon’s Health CO-OP Formulary is a
list of covered drugs selected by a pharmacy
and therapeutics committee to treat medical
conditions that are covered by Oregon’s Health
CO-OP.
General Formulary Information
Formulary decisions are based on critical review
of the available scientific evidence for efficacy,
safety, outcomes, cost-effectiveness and value.
In general, the following are not covered:
• Brand name drugs for which FDA approved
and equivalent generic drugs are available,
except select “narrow therapeutic index”
drugs.
• Experimental or investigational drugs, or
drugs used in a research study or in another
similar investigational environment.
• Over-the-counter (OTC) drugs or
medications or vitamins that may be
purchased without a prescription, or
prescribed drugs that are available in an
OTC therapeutically similar form.
• Drugs not listed in the formulary.
• Drugs removed from the formulary
throughout the year by the pharmacy
and therapeutics committee. The drug
names are then posted on our website
at (link coming soon).
• Drugs used for cosmetic purposes or hair
growth.
• Drugs used for treatment of obesity or
weight loss.
• Drugs used as a preventive measure against
the hazards of travel.
• Growth hormone except to treat
documented growth hormone deficiencies.
• Other drugs specifically excluded from
coverage, such as drugs not approved by the
FDA, including compound drugs from bulk
powder, and DESI drugs.
The formularies apply only to drugs provided by
a pharmacy and do not apply to drugs used in an
inpatient setting or furnished by a provider.
The drugs listed in the CO-OP formulary might
have copays or coinsurance that may change
from year to year. For more information, visit the
Provider Portal or contact Customer Service at
503-488-2833 or toll-free, 1-855-722-8207.
Drugs that require prior authorization or step
therapy, or that carry age restrictions or quantity
limits, are designated as PA, ST, AR and Qty
Limit, respectively.
Drugs labeled PA or PA required require prior
authorization before a member can fill the
prescription at a network pharmacy.
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OREGON’S HEALTH CO-OP
Drugs labeled ST or Step Therapy are limited
to coverage only when certain conditions have
been met—for example, the member has an
approved claim for a formulary alternative in
his or her prescription profile. The member or
provider must submit a Formulary Exception
form if ST criteria are not met and the member
does not have claims history of the prerequisite
drug.
Drugs labeled AR or Age Restriction require
the member to be younger than or older than
a specific age. For example, a drug may be
restricted to those under age 6 or over age
16. The member or provider must submit a
Formulary Exception form if member does
not meet age criteria.
Drugs labeled QTY, QL or QTY Limit are restricted
to specific quantities. If a provider or member
wants to exceed the limit, a Formulary Exception
form must be submitted.
To obtain prior authorization or request a
formulary exception, fax a completed Prior
Authorization or Formulary Exception form,
available at (link coming soon). Providers will
receive a faxed response which may include
an approval, denial or request for additional
information in support of medical necessity no
later than 72 hours of receipt.
The formula and formulary updates are on our
website at (link coming soon). Note: We’ll post
formulary updates by the 15th of each month.
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Please contact Oregon’s Health CO-OP
Customer Service at 503-488-2833 or
toll-free at 1-855-722-8207 if:
• You would like a paper copy or additional
copies of the formulary book.
• You want formulary updates.
• You have questions or concerns about the
pharmacy benefit or formulary.
• You have suggestions for formulary changes
or have questions related to pharmacy
claims.
Office Administered Injectables
Requiring Prior Authorization
Some drugs require prior authorization when
furnished by and administered incident-to a
physician’s service in a clinic or facility.
For more information, please refer to the
Injectables/Medications Administered Under
the Medical Benefit Authorization Policy web
link here. To request prior authorization, please
complete the appropriate Injectables Billed to
the Medical Benefit Form available here add web
link here, attach medical record information
in support of medical necessity (including
diagnosis, co-morbidities and treatment
history), and fax all documents to Oregon’s
Health CO-OP at 503-416-1308.
PROVIDER MANUAL | 2014
Drug Denials, Appeals and Retro
Authorizations
Oregon’s Health CO-OP pharmacist and Medical
Director are available to discuss drug denial
decisions. The benefit provisions, guidelines
or criteria on which the denial decision was
based are available upon request by contacting
Customer Service at 503-488-2833 or toll-free
at 1-855-722-8207. Oregon’s Health CO-OP will
request medical records for a thorough review
of the appeal.
Retro authorizations are accepted. For
more information, please refer to Section
5 of this Manual, Prior Authorizations or
Preauthorizations.
Oregon’s Health CO-OP looks forward to being partners
in improving the health and well being of Oregonians.
12.09.13
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OREGON’S HEALTH CO-OP
www.ohcoop.org
facebook.com/oregonshealthcoop
twitter.com/orhealthco_op
OHC-PR-Provider Manual-103-11.13
12.10.13
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