Policies and Forms
Just a Friendly Reminder:
Please make sure you have submitted all of your claims, appeals and authorizations for any dates of service prior to January 1, 2019 by March 31, 2019. If you require any additional assistance or have questions call Customer Service at 503.488.2800, select prompt 2 and then prompt 3 and you will then be transferred for further assistance. Thank you.
This site is under development as we transition to Providence Plan Providers for physical health services. Most of the policies and forms are in the provider portal CIM under Provider Services.
This page includes medical policies, forms and medical management guidelines for both physical and behavioral health.
Policies – General
Policies – Pharmacy
Forms – Pharmacy
Please fax PBM auth requests to 503-574-8646 or toll-free 800-249-7714.
- Pharmacy Prior Authorization Form
- Medical Drug PA Request
- Pharmacy Managed Prior Authroization Criteria
- Pharmacy Step Therapy Criteria
Use the Provider Portal to verify a member’s eligibility with Yamhill Community Care.
Authorization Guidelines and Forms-Medical
To submit a prior authorization request for medical services you can either use the electronic system (CIM), or you can download a from to fax your request to the UM Team. The link is below in the authorization request forms.
Medical Authorization Request Forms
You can also find this information on the Provider Services tab in CIM. Provider Portal
Diagnostic and Treatment Procedures – CPT Code Grid
- For a complete list, please see Provider Services tab in CIM.
DME – Authorization & Code Lists
Guidelines for DME are the same as all other medical management services.
1) Check current and active PA list within CIM or YCCO’s website
a) If procedure code is on the PA list, then submit PA request via CIM
b) If procedure code is NOT on the PA list, then check prioritized line
i) Check prioritized line (providers can use the Line Search tool within CIM)
(1) If procedure code and diagnosis are funded and above the line, then no PA is needed
(2) If procedure code and diagnosis are funded and above the line, but guideline notes indicate medical criteria must be met to provide services (e.g. Tobacco cessation for elective procedures), then PA is needed
(3) If procedure code and diagnosis are not funded and fall below the line, or are not ranked (“no results found” in CIM), then submit PA request via CIM if services require a benefit exception review for medical necessity consideration
Miscellaneous Policies and Forms
There are certain circumstances when a member needs health related services to improve the overall their quality of life. Sometimes these services are not covered under the prioritized guidelines. If you feel you have a YCCO member that needs such services, please read the attached policy and complete the request form for consideration of additional support. Please fax completed forms to 503-376-7524.
Flex Funds Request
At Yamhill Community Care, we strive to make our community a great place to live in. We know that a healthy lifestyle isn’t just about seeing your doctor occasionally. There are many other different ways to improve the way you live. YCCO’s Community Health Hub is a group of people focused on finding our members the services they need.
Community Health Hub referral form
- Please see Provider Services tab in CIM. Provider Portal
Behavioral Health Provider Forms
Chemical Dependency Forms
- Chemical Dependency Out of Panel Service Authorizations: Instructions to request service authorization for Yamhill CCO members new to treatment (last updated 12/18/2017)
- Chemical Dependency Authorization instructions: Instructions to request service authorization for Yamhill CCO members new to treatment (last updated 12/18/2017)
- 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 12/18/2017)
Mental Health Forms
- Mental Health Out of Panel Service Authorization Request Form and Level of Care Model: Request form for authorization of MH services to Yamhill CCO members and Level of Care criteria (last updated 12/18/2017)
- Mental Health Authorization instructions: Instructions to request service authorization for Yamhill CCO members new to treatment (last updated 12/18/2017)
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)
Click here to download the Wraparound referral form.
- 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.