Find all the policies, forms and guidelines to deliver care to YCCO members.

Determine patient eligibility

Provider Handbook

YCCO Provider Handbook

Language Access

Language access is an important part of increasing health equity in our community. Refer the following for additional information related to language access:

Language Access Guidance

Language Access Toolkit

Lea más sobre el Acceso al Idioma para Miembros (Español)

Find A Health Care Interpreter

Access OHA Health Care Interpreter Registry Search: https://hciregistry.dhsoha.state.or.us/Search

Health Related Services  (HRS) Flex Funds

YCCO members may need special health related services to improve the overall quality of life which are not covered under the prioritized guidelines. If a YCCO member needs special services, providers can submit a flex funds request.

Flex Funds Request Form

The SDOH Metric requires all YCCO contracted providers to train staff who conduct SDoH screening with members. 

SDOH Training addresses the following:

1. Trauma Informed Care,

2. Motivational Interviewing,

3. Empathic Inquiry, and

4. Empathic Inquiry, Social Needs Screening Data & Clinical Workflows.

Complete the Social Determinants of Health (SDOH) Screening and Referral Metric Form Today

As YCCO contracted providers, you are responsible for ensuring that your staff, who conduct SDOH screenings, complete training in each category mentioned above. Once the training is completed, please submit the SDOH Training Attestation Form to providerrelations@yamhillcco.org as proof of completion.

The link below provides SDOH Screening Training Modules and Social Needs Training Resources Developed by the Oregon Rural Practice-based Research Network (ORPRN) and the Oregon Health Authority Transformation Center to support and meet the SDOH Screening and Referral Incentive Metric implementation.

Download Today!

SDOH Screening & Referral Metric Social Needs Training Resource

SDOH Training Attestation Form

Non-Emergent Medical Transportation (NEMT)

Members are eligible for non-emergency medical rides to physical health, dental and behavioral health appointments.

To assist a member in obtaining a ride or for more on this benefit call WellRide at 844-256-5720 Monday through Friday 7:30 a.m. until 6 p.m.

FamilyCore Program

FamilyCore is a community services network connecting parents with a broad support system to meet challenges head-on and to nurture strong families with children ages 0–5.

FamilyCore can receive referrals from providers or patients. Use the form to submit a Yamhill FamilyCore referral.

Prior Authorizations

Physical health

Find all the forms and information you need here for submitting prior authorizations for physical health services, including diagnostic and treatment procedure codes.

How to submit a prior authorization (PA)

Submit a prior authorization request for medical services electronically in the provider portal (CIM), or complete the Prior Authorization Request form that can be faxed to the UM Team.   Information about what services require preauthorization is located in CIM. Transplant services require a special PA Form below is the link to this form.

YCCO PA list (active and termed) as of 4.1.25

YCCO Physical Health (Medical) PA Request Form

Tips for submitting a PA Form

YCCO Transplant PA Request Form

YCCO TOC PA Form

Diagnostic and Treatment Procedures

For a complete list of diagnostic and treatment procedures (CPT code grid) please see the Provider Services tab in CIM. There are certain ancillary guideline notes that apply to services (e.g. tobacco cessation for elective procedures).

Radiology – Advanced Imaging & Cardiology Imaging – Cardiac Implantable

You must submit authorizations for some types of imaging via eviCore please use the link below for access and to submit a request.

https://www.evicore.com/

Effective 4/1/2025:

Please see the below changes to the prior authorization requirements for high cost imaging.

• Removal of prior authorization requirements for a select set of Echocardiography codes the PA List will indicate PA termination dates see the PA list here https://yamhillcco.org/providers/policies-and-forms/
• Implementation of a bundled authorization process for diagnostic imaging studies. This will occur at the point of first contact by a requesting provider when the provider attests that the radiology procedure is for restaging of cancer. This will create efficiencies in the submission process and reduce provider burden by eliminating the need for the provider to request multiple imaging authorizations throughout the surveillance of a patients chemotherapy. Please see attached for more details.
• Radiology authorization procedure codes, units, and timespans :
  • CPT Code
    • 70553 (MRI Brain with and without contrast)
    • 71260 (CT Chest with contrast)
    • 74160 (CT Abdomen with contrast)
    • 74177 (CT Abdomen and Pelvis with contrast)
  • Number of Units
    • 6 units are authorized and recommended to be used at a frequency of 1 unit every 2 cycles of chemotherapy
  • Timespan; Valid From and Valid Through
    • The standard approval time period is set for 365 days.

PA Reminder:

• Check the service code against the YCCO PA list to determine considerations for submitting the code. If the code does not exist on the PA list, it does not mean that a PA is not required.
• No PA requirement for first and only request for a diagnostic service
  • Example: colonoscopy for those that meet cancer screening guidelines on prioritized list Colorectal cancer screening is included on Line 3 for average-risk adults aged 45 to 75, using one of the following screening programs:
    • Colonoscopy every 10 years
    • Flexible sigmoidoscopy every 5 years
    • Fecal immunochemical test (FIT) every year
    • Guaiac-based fecal occult blood test (gFOBT) every year
  • Subsequent requests for same diagnostic service (not in a series) and same diagnosis will require a PA to be submitted with YCCO
    • Example: second colonoscopy
  • First PA is required in a planned series of diagnostic studies, such as with a cancer diagnosis. The series of diagnostic studies will be authorized per the first PA, if medically necessary.

Medical Management Service Authorizations

Guidelines for requesting medical management service authorizations are outlined below. Initially, check current and active Prior Authorization list (located above) to see if procedure code is noted.

1. If procedure code is on the Prior Authorization list, then submit Prior Authorization request via CIM, fax, or email (forms located on this page).CIM – https://cim3.phtech.com/cim/login YCCO Utilization Management Fax: 503-850-9398 YCCO Utilization Management Email utilizationmanagement@yamhillcco.org
2. If procedure code is NOT on the Prior Authorization list, then 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 prior authorization 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 prior authorization 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 prior authorization request via CIM and note on the request “benefit exception review for medical necessity consideration”.

GO TO CIM

Durable Medical Equipment (DME)

For information on DME call Providence Home Services at 503.215.4663

Guidelines for DME:

Check current PA list within CIM or YCCO’s website

a) If procedure code is on the PA list, submit PA request via CIM

b) If procedure code is NOT on the PA list, check prioritized line

c) Check prioritized line (providers can use the Line Search tool within CIM)

If procedure code and diagnosis are funded and above the line, no PA is needed

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), PA is needed

If procedure code and diagnosis are not funded and fall below the line, or are not ranked (“no results found” in CIM), submit PA request via CIM

Behavioral Health & Wraparound Services

Behavioral health includes chemical dependency, mental health and wraparound services. Submit prior authorizations for behavioral health using the forms and information below:

YCCO BH PA Grid

YCCO Overview of BH OP Levels of Care

Behavioral health prior authorizations forms:

YCCO ABA PA Form

YCCO BH HLOC PA Fax Form

YCCO BH Outpatient PA Form

YCCO TMS PA Form

Behavioral Health Attestations Form of Compliance

2024 Provider Medicaid-Focused Attestation Form 

• 2024 Behavioral Health Direct Payment Guidance Document
• Behavioral Health Direct Payment FAQs

Wraparound services

Wraparound services help youth, and their families accomplish healthy lifestyle goals. Services include a care coordination planning process with a series of steps to help young people grow up in their homes and identify challenges faced.

Learn more about Wraparound services

 Downloadable PDFs:

Submit for to request wraparound services for a member.

Wrap Referral Form

Submit form to report any barriers families may be experiencing in receiving wraparound services. Reports are reviewed and discussed to identify solutions to barriers.

Barrier Submission Form

Learn more about the Barrier Resolution Process Diagram.

Dental Health

Forms and submission process for dental service prior authorizations administered by Capitol Dental Care can be found at:

Visit Capitol Dental Care

Pharmacy/Medications

Medication requiring a prior authorization will be indicated on the formulary.

The formulary link provides all necessary forms and additional information related to pharmacy services.

Provider Retrospective Authorizations

YCCO UM has changed the retrospective authorization process.

Effective 10/31/2024, requests are accepted up to 90 days retro to the date of service.  Request submitted beyond the 90 day timeframe, will receive contact from YCCO and the request will be withdrawn.  YCCO will consider rendering a UM review depending on the circumstances that caused the retro submission.

YCCO encourages providers to utilize the member appeal process. More information on this process is below and also included in the denial letter (NOABD).

Provider Reconsiderations

Effective 5/1/2025: Any provider request for reconsideration of a denial, which could include submission of a new PA request will be handled in a manner consistent with the member appeal process. Providers receive a copy of the member appeal form (OHP 3302) with a copy of the denial letter (NOABD).

More about how to submit an appeal on behalf of a member is below.

If no PA was ever completed you can utilize the prior authorization process more information on this process is located on our Policies and Forms webpage.

The YCCO Provider Reconsideration Form has been updated please use the current form.

Prior Authorization Denials

• Providers must work with members to utilize the member appeal process for this type of denial.  A provider appeal or reconsideration is not the same as a member appeal, appeals on behalf of the member must have written authorization from the member.

Claim Denials

Timely Filing:

• If due to a system issue (submitted electronically and there is documentation of the submission) contact the Claims Department. Providers can use the reconsideration form and supporting documentation these should be sent directly to Claims: Fax: (503) 315-4135 or Email: yamhillclaims@ayin.com
• EOB Related: Documentation can be attached to the claim in CIM *You MUST email yamhillclaims@ayin.com through the claim in order to alert claims to the attachment.*
• If the claims department upholds your timely filing denial you can then fill out a provider reconsideration form and attach all documentation from the claim department reviews with your supporting documentation pertaining to your request. A provider reconsideration will not be accepted prior to a claim department review.

Pricing:

• Contact the Claims Department via Customer Service or email yamhillclaims@ayin.com. If you need additional assistance after the claim department review contact YCCO Provider Relations at providerrelations@yamhillcco.org.
• No reconsideration is accepted for this type of review.

Corrected Claim:

• Contact Claims Department or resubmit a corrected claim.
• No recon is accepted for this issue.

Claim Denied for no Prior Authorization:

• Providers must work with members to utilize the member appeal process for this type of denial.  Appeals on behalf of the member must have written authorization from the member.

Submitting an Appeal on Behalf of a Member

The member appeal form is located here

• OHA 3302 Appeal and Hearing Request

Member appeals must be submitted within 60 days from the date of the denial.

You can mail, fax or email your appeal:

Fax: 503-765-9675

Email: appeals@yamhillcco.org

Mail: Yamhill Community Care

Attn: Appeals & Grievance Specialist

PO Box 5490

Salem, OR 97304

Submitting a Reconsideration

Submit the completed form one of the following ways:

YCCO Appeal and Grievance Department:

Fax: 503.765.9675

Email: provider.appeals@yamhillcco.org (Remember to send your request with Secure in the subject line to protect member HIPAA.)

• YCCO Provider Reconsideration Form

You can reach the YCCO Appeal and Grievance Department via phone at 971.345.5933, please use the provider prompt

A provider appeal or reconsideration is not the same as a member appeal, to appeal on behalf of the member you must have written authorization from the member to submit an appeal on their behalf.

Reconsiderations must be submitted within 60 days of the date of the denial.

Members have the right to appeal denials members receive a form accompanying the YCCO denial letter. Member appeals must be submitted within 60 days from the date of their NOABD (denial letter). The member, their representative, or provider with member’s written consent may file an appeal orally or in writing. More information on the member appeal process can be found in the Provider handbook or Member handbook.

*DO NOT USE the provider reconsideration form to submit a member appeal *

Traditional Health Workers (THW)

THW providers interested in joining our provider network please email providerrelations@yamhillcco.org

Download the documents below to learn how to become a THW specialized provider with YCCO.

CHW Billing Guidance_FINAL 2021 

Doula Billing Guidance_YCCOFINAL_2021 

PSS Billing Guidance_FINAL 2021 

PWS Billing Guidance_Final 2021 

THW Integration Toolkit 

Tip Sheet for Support and Supervision of THWs 

Traditional Health Worker Toolkit