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.
and an additional provider manual or handbook.
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.
Health Related Services (HRS)
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.
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
- 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 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.
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.
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.
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.
- 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 firstname.lastname@example.org
- If procedure code is NOT on the Prior Authorization list, then 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 prior authorization 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 prior authorization 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 prior authorization request via CIM and note on the request “benefit exception review for medical necessity consideration”.
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.
The following fax forms must be used for behavioral health prior authorizations:
Behavioral Health Attestations Form of Compliance
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.
- Use this form to request wraparound services for a member.
- 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.
- Learn more about the barrier resolution process.
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.
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.
You can ask YCCO for a reconsideration of your prior authorization request or claim denial. A reconsideration is also called a provider appeal. All the information you need to know to submit for reconsideration is located below.
Form and Required Documentation
You must submit the YCCO Provider Appeal/Reconsideration Form (located below) and submit it with the required documentation for your request. Chart notes are required for all prior authorization denials and for claims that are denied for no prior authorization.
You submit your form and documentation one of the following ways:
YCCO Appeal and Grievance Department:
Email: email@example.com (Remember to send your request with Secure in the subject line to protect member HIPAA.)
You can reach the YCCO Appeal and Grievance Department via phone at 971.345.5933.
A provider appeal 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. You can do your provider appeal or reconsideration without member authorization.
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 firstname.lastname@example.org.
Download the documents below to learn how to become a THW provider with YCCO in your specific area of service.
THW Integration 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 release
POLICIES AND FORMS IN ONE PLACE
-Health Related Services
-Non-Emergent Medical Transportation (NEMT)
-Diagnostic Treatments & Pocedures
WELLNESS PROGRAMS FOR MEMBERS
-Persistent Pain Program