Policies and forms in one place

Find all the policies, forms and guidelines you’ll need to deliver the best care possible to YCCO members.

Determine patient eligibility

Provider Handbook

Language Access

Language access is an important part to increasing health equity in our community. The materials below have been created with the purpose to support all types of health care providers in meeting the language needs for YCCO members.

Language Access Guidance

Language Access Toolkit

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

Sometimes a member needs special health related services to improve their overall quality of life which are not covered under the prioritized guidelines. If a YCCO member needs special services, providers can request consideration of additional support for the member.

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

COVID-19 Provider Materials

This guide acts as the single source for Oregon Medicaid provider guidance related to provision of services under Medicaid during the COVID-19 emergency declaration, as supported by:

• Oregon Administrative Rule (OAR) 410-120-0011 (Effect of COVID-19 Emergency Authorities on Administrative Rules) and
• Flexibilities approved by the Centers for Medicare & Medicaid Services (CMS), described on OHA’s page about Temporary Waivers and Flexibilities for Medicaid Programs during the COVID-19
  emergency.
• Click here to view the COVID-19 Medicaid Provider Guide.

Non-Emergent Medical Transportation (NEMT)

Members are eligible for non-emergency medical rides to their 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 Referrals

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

Providers can refer their patients to Yamhill FamilyCore or patients can refer themselves. The online form can be found here and is available in spanish. Providers can also download the FamilyCore program icon link for their desktops below.

FamilyCoreProgram

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 11152024

YCCO Physical Health PA Request Form

Tips for submitting a PA Form

YCCO Transplant PA Request Form

YCCO TOC PA Form

YCCO HRSN PA Form

YCCO Information Sharing Authorization 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/

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 are the same as all other medical management services.

• 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
  c)  Check prioritized line (providers can use the Line Search tool within CIM)
• If procedure code and diagnosis are funded and above the line, then 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), then 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), then submit PA request via CIM if services require a benefit exception review for medical necessity consideration

Behavioral Health & Wraparound Services

To submit prior authorizations for behavioral health, use the forms and information listed here. Behavioral health includes chemical dependency, mental health and wraparound services.

YCCO BH PA Grid

YCCO Overview of BH OP Levels of Care

The following fax forms must be used for behavioral health prior authorizations:

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. They include a planning process with a series of steps to help young people grow up in their homes. People from various parts of a family’s life are brought together. That could include a care coordinator or a family or youth support partner who understands the challenges the youth and family are facing.

Learn more

Downloadable PDFs:

Wrap Referral Form

• Use this form to request wraparound services for a member.

Barrier Submission Form

• Use this form to report any barriers families may be experiencing in receiving wraparound services. Reports will be reviewed by a practice workgroup who will work to identify solutions to barriers.

Barrier Resolution Process Diagram

• Learn more about the barrier resolution process.

Dental Health

Find all the forms and information you need here to submit prior authorizations for dental health services administered by Capitol Dental Care by going to the Capitol Dental Care website.

Visit Capitol Dental Care

Pharmacy/Medications

Some medications require prior authorization. Search for the medication in the formulary, it will indicate if the medication requires a prior authorization.

The formulary link provides all necessary forms and additional information related to pharmacy services as well as a printable formulary.

Pharmacy PA Form

Provider Retrospective Authorizations

YCCO UM is changing our process for accepting retrospective authorization requests.  

Effective 10/31/2024, we accept requests 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 request to be submitted as retro.  Thank you.

Provider Reconsiderations

If you do not agree with a claim or prior authorization decision you should work with the member to utilize their appeal rights. If you want to file an appeal on the member’s behalf they must give you permission.

Effective 12/1/2024: This information has been updated to clarify the content the Provider Reconsideration Form has been updated as well please read to ensure you have the most up to date information and form.

Reconsiderations are reviews on the initial decision you cannot submit additional documentation. All the information you need to know to submit for reconsideration is located below. Incomplete request will be closed as incomplete.

Claim Denials

Timely Filing:

• If due to a system issue (submitted electronically and there is documentation of the submission) contact the Claims Department. No reconsideration is required.
• If due to any other issue a reconsideration form with reason completely indicated as to why timely filing was not met. Submit to Provider Appeals appeals@yamhillcco.org or fax to 503.765.9675.

Pricing:

• Contact the Claims Department or Provider Relations providerrelations@yamhillcco.org
• No recon is accepted for this issue.

Corrected Claim:

• Contact Claims Department or resubmit a corrected claim.
• No recon is accepted for this issue.
• Prior Authorization: No reconsideration is accepted for claims denied for no prior authorization you must utilize the retrospective review process.

Prior Authorization Denials

Providers should encourage members to utilize the member appeal process for this type of denial. YCCO will only review the prior authorization information submitted in the original request NO NEW clinical information will be reviewed. If you have additional clinical information you must submit a new prior authorization.

 Reconsideration Request Submission Time Frames:

Claim Denials- Reconsideration must be received within 60 days from the date of the claim denial. YCCO will not do a reconsideration of a claim denied for no prior authorization.

Preauthorization Denials – Reconsideration must be received within 60 days from the date of the denial and we will not accept additional information this is a review of the information submitted in the authorization request. If there is new clinical information you should submit a new prior authorization request.

Reconsideration Review Time Frame:

YCCO has 60 days to process your request, you will receive a fax with the resolution of your provider appeal/reconsideration. Do not resend a request if you do not hear back after 60 days email  or call the Appeals Department.

Reconsiderations received outside of the time frame will not be accepted.

Form and Required Documentation

You must submit the YCCO Provider Reconsideration Form (located below) for your request to be accepted.

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.

Member Appeals:

Members have the right to appeal their denials they receive a form enclosed in their denial letter they received from YCCO. They only have 60 days from the date of their NOABD (denial letter) to request their appeal. The member, their representative, or provider with member’s written consent may file an appeal orally or in writing. There is more information on the member appeal process in the provider handbook here https://yamhillcco.org/wp-content/uploads/YCCO-Provider-Handbook.pdf or the member handbook here https://yamhillcco.org/members/member-handbook/.

Traditional Health Workers

If you are a THW provider and are interested in joining our provider network please email us at providerrelations@yamhillcco.org. 

Download the documents below to learn how to become a THW provider  with YCCO in your specific area of service.

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

Wellness Programs for Members

Persistent Pain Program: The PPP is an 8-week class combining pain management education and movement therapy.

PPP Program Materials: BrochurePersistent Pain Program Referral Form medical releaseSocial