Policies and Forms

Most of the policies and forms are in the provider portal CIM under Provider Services. (Last Updated 12/10/2020)

*ATTENTION*: New PCP Assignment Policy active January 1st, 2021: PCP Assignment FAQ

Policies – Pharmacy

Forms – Pharmacy

Please fax PBM auth requests to 503-574-8646 or toll-free 800-249-7714.

Practice Guidelines

Medical – Providence Health Plan Practice Guidelines

Dental  – Capitol Dental Practice Guidelines

Mental Health – Levels of Care

Pharmacy – Yamhill Opioid Guidelines

Vaccines – Community Vaccination Guidelines


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.

Tips for Submitting a PA

Authorization and Referral FAQ

Medical Authorization Request Forms

You can also find this information on the Provider Services tab in CIM.  Provider Portal

YCCO PA list – active codes – as of 12022020
YCCO PA list – terminated codes – as of 12022020

Medical Services PA Request
Transplant PA Request

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 503-376-7436.
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 Worker Hub Referral Form

UM Policies

Behavioral Health Provider Forms

Chemical Dependency Forms chemical dependency out of panel service authorization

Mental Health Forms

Yamhill County Family and Youth Wraparound Services

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