Policies and Forms

This page includes medical policies, forms and medical management guidelines for both physical and behavioral health. The physical health documents are provided by CareOregon, a partner of Yamhill Community Care Organization.

For best practices and current guidelines, please refer to this page at CareOregon.

Policies – General

• Criteria Used for Utilization Management Decisions
• Yamhill CCO Opiate Prescribing Guidelines

Policies – Pharmacy

• OHP Prior Authorization Use Criteria 

Forms – 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 Treatment Medication Request Form
• Nutritional Supplement Medication Request Form
• Synagis Medication Request Form
• OptumRx Mail Order Form
• Pharmacy Provider Reconsideration Request Form

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 (June 1, 2017)
• Authorization Policy - Injectable Drugs for Bleeding and Clotting Disorders (January 1, 2017)
• Pharmacy Payer Sheet - Medicaid 2013 (December 27, 2012)

Authorization Guidelines and Forms

Eligibility

Use the Provider Portal to verify a member’s eligibility with Yamhill Community Care Organization.

Authorization Guidelines 

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

Diagnostic and Treatment Procedures - CPT Code Grid

• Authorization guidelines by CPT code

DME - Authorization & Code Lists

• DME No Auth Required List
• DME Change of Vendor Request Form 

Frequently Asked Questions (FAQ's)

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

• Authorization Form for DME and Home Infusion
• Dental Restoration 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)

• Oregon Medicaid ID Application Form
• Referral Form - CareOregon Dental
• Referral Form - Early Intervention/Early Childhood Special Education (EI/ECSE)* Birth to Age 5
• 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)
• Community Health Hub Referral Form
• Adolescent Well Care Incentive Form

Behavioral Health Provider Forms

Chemical Dependency Forms

• CD authorization instructions: Instructions to request service authorization for Yamhill CCO members new to treatment (last updated 7/11/2016)
• OP, IOP, Residential, and MAT authorization request (last updated 7/11/2016)
• Funding extension for OP, IOP & residential, MAR: Instructions & form to request funding extension for Yamhill CCO members with existing service authorization (last updated 7/11/2016)
• Mental health & physical health authorization contacts for residential providers: For routine mental health & physical health services for Yamhill CCO members receiving residential treatment (last updated 7/11/2016)

Mental Health Forms

Mental Health Out of Panel Service Authorization: An authorization request form for outpatient behavioral health services performed by an out-of-panel provider (last updated 7/11/2016)

Yamhill County Family and Youth Wraparound Services

Wraparound is a planning process that follows a series of steps to support youth and their families accomplish the goals needed in order to reach their vision.

• Wraparound Flyer: The Wraparound process seeks to ensure children and youth grow up in their homes and communities. It is a planning team process that brings people together from various parts of the family’s life and includes support from a Care Coordinator and sometimes a Family and/or Youth Support Partners that are experienced with the challenges youth and families face. (last updated 6/28/16)
• Yamhill County System of Care Barrier and Community Need Form: Use this form to report any barriers that families may be experiencing in receiving the services they are needing from Wraparound.
• Barrier Resolution Approach Diagram for Systems of Care: This diagram shows the process of how the Barrier and Community Need Form is processed once submitted.