FamilyCare Final 2014 Provider Resource Guide

7/22/2019 FamilyCare Final 2014 Provider Resource Guide

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2/23

Table of Contents

Contact List1

2

3

5

8

9

11

12

38

3940

13

13

6

8

1418

19

20

25

27

29

33

35

38

41

42

Coordinated Care OrganizService Types

Oregon Health Plan

Community-Based OrganApplication Assisters

Enrollment/About FamilyC

Claims FAQ

FAQ for Referrals

Member Search/Determining Eligibility

Submitting Referrals

PH Tech Resource/Info Sh

CIM Information and FA

Oregon Medicaid Provid

DME ContactsMedical Transportation

Codes

Legacy

CDRCProvidence

Therapy Request Form

URL Reference Page

Urgent Care Centers

Multnomah County

Washington County

Clackamas County

Columbia County

Marion County

Walla Walla County

www.familycareinc.org


3/23

Coordinated Care

Organization

Service Types

FamilyCare, Inc. FamilyCare Health Plans

Contact List

OHP CCO Medical Card My Plan Medicare AdvantageMedical Card

Website:www.familycareinc.org

FamilyCare Navigation Services(customer service)

FamilyCare Referralsand Authorizations

FamilyCare manages seven dental

plans; all of them have the same

benefit. The only difference is their

contracted dentists.

Care Oregon Dental

(503) 416-1444

Tollfree (888) 440-9912

Capitol Dental:

Tollfree (800) 525-6800

Access Dental:

(503) 445-9056

Tollfree (877) 213-0357

Managed Dental:

Tollfree (800) 538-9604

Phone: (503) 222-2880

Fax: (503) 345-5720

Fax for reconsiderations, ER records,

primary EOBs and corrected claims:

(503) 566-9801

FamilyCare ProviderNetwork Services

Phone: (503) 471-2149

Fax: (503) 734-3188

Phone: (503) 228-8228 ext. 2820

Fax: (503) 345-5770

FamilyCareCare Management

Phone: (503) 222-2779

Maternity representative:

Zizi Rodriguez

Direct phone: (503) 3455756

FamilyCare Credentialing

Phone: (503) 471-2129

Fax: (503) 471-2156

Email:

[email protected]

FamilyCare

Pharmacy Department

Phone: (503) 471-2126

Fax: (503) 471-2176

FamilyCareAddictions and Mental

Health Department

Phone: (503) 222-2880, ext. 5704

Fax: (503) 345-5754

PH Tech CIMTechnical Support

Phone: (503) 584-2169

Front Front

Back Back

CCOA:Medical, Mental Health and Dental

CCOB:Medical and Mental HealthCCOC:Medical and Dental

CCOE: Mental Health

CCOF: Dental

CCOG:Mental Health and Dental

Dental

Family Denta

Tollfree (80

ODS/Moda:

(503) 265-56

Tollfree (87

Willamette D

(855) 433-68



4/23

Oregon Health Plan

Last Updated: 11/15/2013

Page 2of 2

This chart shows what benefits are available under OHP Standard and what benefits are available under OHP

Plus. OHP Plus coverage varies depending on your age.

Health benefits

OHP Standard

(Ending

Dec. 31, 2013)

OHP Plus

Non-pregnant adults

(21 and older)

OHP Plus

Children/individuals

(age 0-20), and

pregnant adults

Acupuncture Limited Covered Covered

Chemical dependency Covered Covered Covered

Dental

Basic services including

cleaning, fillings and

extractions

Not covered Covered Covered

Urgent/immediate

treatmentCovered Covered Covered

Other services Not covered Limited Covered

Hearing aids and hearing aid exams Not covered Covered Covered

Home health; private duty nursing Not covered Covered Covered

Hospice care Covered Covered Covered

Hospital careEmergency treatment Covered Covered Covered

Inpatient/outpatient care Covered Covered Covered

Immunizations Covered Covered Covered

Labor and delivery Not covered Covered Covered

Laboratory and X-rays Covered Covered Covered

Medical care from a physician, nurse

practitioner or physician assistantCovered Covered Covered

Medical equipment and supplies Limited Covered Covered

Medical transportationEmergency

onlyCovered Covered

Mental health Covered Covered Covered

Physical, occupational and speech therapy Not covered Covered Covered

Prescription drugs Covered Covered Covered

Vision services

For medical care Covered Covered Covered

For eye health Not covered

Limited to specific

medical diagnosessuch as aphakia,

pseudoaphakia or

keratoconus

Services to improve

vision such as

frames, lenses and

contacts are covered

www.family

Benefit Packages

FamilyCare andthe OregonHealth Plan (OHP)

What makes us special

FamilyCare was created morethan 30 years ago with oneprimary focus to create a betterhealthcare system to giveOregonians on Medicaid accessto quality health care. Today, ourbeliefs are the same. We remaincommitted to treating peoplewith respect and breaking downbarriers to care.

Our providers have patient-centered Primary Care Homeswhere your care is coordinatedby a health care team with you inthe center. This team will ensureyou get the right care at the rightplace. We have a large networkof providers who range fromcorner family doctors to largeprovider groups. Hospitalservices, lab, X-rays, specialists,and more are also part of ournetwork resources.

Our team provides services for adults,children and families, whether they areinpatient, outpatient, and home-based.These services are delivered througha broad network of community-basedcontracted providers.

You are more than an ID card anda number. As a member, you will geta service coordinator who is part ofyour healthcare team. The servicecoordinator works one-on-one withyou and your primary care providerto help you manage chronic diseasesor illnesses, even help with resourcesoutside of health to help live a betterlife. Our service coordinators are justlike our customer service team; theyare local and ready to serve.

Located close to where they live orwork, our partners are: Access Dental,Capitol Dental Care, Managed DentalCare of Oregon, Willamette DentalGroup, and Family Dental Care.

We stand on the samebelief system.

We believe the relationshipbetween you and your primary

care provider is key.

A dedicated mental andbehavioral health team.

Real people, real service.We support individualized,Patient-centered care.

We have dental providers ready toserve all of our members.

Call us at (503) 2222880

Tollfree (800) 4589518 (TTY 711

Monday through Friday, 9a.m.5p

Navigation Services can answer

questions about the Oregon

Health Plan or FamilyCare.

We are based right here in Portlan



5/23

Community-BasedOrganizations/

Application Assisters

African American

Health Coalition

Multnomah

2800 N Vancouver Ave.,

Ste. 100

Portland, OR 97227

(503) 413-1850

National Alliance

on Mental Illness

Oregon (NAMI)

Statewide

4701 SE 24th Ave.,

Ste. E

Portland, OR 97202

(800) 343-6264

Immigrant &

Refugee Community

Organization

Clackamas, Multnomah,

Washington

10301 NE Glisan St.

Portland, OR 97220

(503) 234 -1541

Asian Health &

Service Center

Clackamas, Multnomah,

Washington

3430 SE Powell Blvd.

Portland, OR 97202

(503) 872-8822

Urban League

of Portland

Multnomah

10 N Russell St.

Portland, OR 97227

(503) 280-2600

Oregon Latino

Health CoalitionMultiple Counties Statewide

240 N. Broadway

Ste. 215

Portland, OR 97227

Cascade AIDS

Project, Clackamas

Multnomah, Washington

and Statewide

208 SW 5th Ave.,

Ste. 800

Portland, OR 97204

(503) 223-5907

Central City Concern

Multnomah

232 NW 6th Ave.

Portland, OR 97209

(503) 294-1681

The Wallace

Medical Concern

Multnomah

Rockwood Building 124

NE 181st Ave.,

Ste. 103

Portland, OR 97230

(503) 489-1760

Outside In

Multnomah

1132 SW 13th Ave.

Portland, OR 97205

(503) 535-3800

Native American Youth

& Family Center

Multnomah

5135 NE Columbia Blvd.

Portland, OR 97218

(503) 288-8177

Enrollment

The Oregon Health Plan (OHP)is Oregons Medicaid program.The OHP provides high qualityhealthcare for adults, children,and families. Oregon is taking

full advantage of the nationalAffordable Care Act to include230,000 more Oregonians on theOHP. Now people who earn upto 138% of the Federal PovertyLevel will qualify. This means asingle person making $15,800 ayear and a family of four making$32,000 a year will now qualifyfor OHP. (source: www.oregon.gov)

Fast-track enrollment isavailable to adults whoreceive benefits through theSupplemental NutritionAssistance Program (SNAP) or

whose children get care fromthe Healthy Kids/Oregon HealthPlan. If adults meet the 2014income limits and have receiveda fast-track enrollment letter fromthe Oregon Health Authority,they can simply:

Great news about the

Oregon Health Plan

1

2

3

Fast-track enrollmentAs easy as 1-2-3

Fill out and sign the fast-track enrollment fo

Choose a Coordinated Care Organization (

Return the form to the Oregon Health Authoin the envelope provided

Individuals can callFamilyCare at (503) 222-2880Tollfree (800) 458-9518 (TTY 711)Monday through Friday9 a.m.5 p.m.

Call Oregon Health Plan

customer service at


(800) 6999075 for more

information.


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A Coordinated Care Organization(CCO) is a network of all types of

healthcare providers who have agreedto work together in their localcommunities for people who receivehealthcare coverage under the OregonHealth Plan. (source: www.oregon.gov)

People already on the OHP willcontinue to be covered. Fast-trackand Cover Oregon are there for thosewho are new to the OHP.

FamilyCare is a local health plan,founded to serve people on theOregon Health Plan. We are one of twocoordinated care organizations servingthe tri-county area (Clackamas,Multnomah, and Washington counties).For the last 30 years, our innovativeapproach to healthcare has createdsolutions for FamilyCare members toget comprehensive healthcare. Our purpose is to give individuals,one-on-one care so they can take chargeof their health. Everything

we do is for one simple reason to connect people to the care they

need. We are looking forward toserving more people with the same,coordinated, personalized healthcareFamilyCare has provided for 30 years.

What is a Coordinated Care

Organization (CCO)?

There are two ways tocheck for Oregon Health

Plan eligibility:

About FamilyCare

People can visit any OregonDepartment of Human Services officeand ask for an application. Go to

URL Reference 1.1 (www.ohp.oregon.gov)for a list of locations. There are alsoorganizations within the community withinformation and applications inseveral languages.

Individuals can go to URL Reference 1.2(www.coveroregon.com)to see if they qualifyfor the Oregon Health Plan or other types ofcoverage. There may be financial assistanceavailable for other health plans if they do notqualify for OHP.

In-person

Online

We were the first Medicaid health plan in

Oregon to integrate mental and physical

health coverage into one plan.

We became the first health plan

in the tri-county area (Clackamas,

Multnomah, and Washington counties)

certified by the Oregon Health Authority

as a Coordinated Care Organization (CCO).

We were the first CCO to add dental

care services.

We have a dedicated service

coordinator and health team assigned

to each individual who signs up for

FamilyCare. People can call one number

and get access to this health team.

Urgent

Care

Centers

Portland Adventist

Urgent Care

Rose City Urgent Care

& Family Clinic

The Portland Clinic

Urgent Care

Doctors Express

Doctors Express

Columbia Medical

Clinic Urgent Care:

Mall 205

Columbia

Medical Clinic

18750 SE StarkPortland, OR 97233

11155 NE Halsey St.Portland, OR 97220

800 SW 13th Ave.Portland, OR 97205

23 NW 23rd PlacePortland, OR 97210

7033 NE Sandy Blvd.Portland,OR 97213

9710 SE Washington St., Suite BPortland, OR 97216

8122 SE Tibbetts St.Portland, OR 97206

(503) 666-6717

FAX: (503) 666-6745

(503) 894-9005

FAX: (503) 719-4178

(503) 221-0161 x. 2000

FAX: (503) 274-1697

(503) 305-6262

(503) 305-6262

(503) 261-8000

FAX: (503) 777-8005

(503) 255-1111

FAX: (503) 777-8005

MonFri: 9 a.m.7:30 p.m.

Sat & Sun: 9 a.m.4 p.m.

MonFri: 8 a.m.6 p.m.

Sat: 9 a.m.5 p.m.

Closed on Sunday


Children 16 years of age or older

7 days a week: 8 a.m.8 p.m.

MonSun: : 8 a.m.8 p.m.

7 days a week


Sat: 9 a.m.6 p.m.


Sat: 9 a.m.6 p.m.

NAME/ ADDRESS PHONE/FAX HOURS

Multnomah

County



7/23

Rose City Urgent

Care & Family

Medicine Gresham

Tuality Urgent Care

Providence Medical

Group- Gateway

Immediate Care

Geneva Urgent Care

Forest Grove

2075 NE DivisionGresham OR 97030

7545 SE TV HighwayHillsboro, OR 97006

1321 NE 99th Ave., Suite 100Portland, OR 97220

3838 Pacific Ave.Forest Grove, OR 9 7116

(503) 894-9005

(503) 681-4223

FAX: (503) 5 91-9411

(503) 215-9900

(503) 992-0288

FAX: (503) 359-4724


Sat: 9 a.m.5 p.m.

Closed on Sunday

SunSat: 8 a.m.8 p.m.7 days a week





NAME/ ADDRESS

NAME/ ADDRESS

NAME/ ADDRESSPHONE/FAX

PHONE/FAX

PHONE/FAXHOURS

HOURS

HOURS

Washington

County

Geneva Urgent Care

Beaverton

Hillsboro Urgent Care

Virginia Garcia

Urgent Care

Portland Clinic Urgent

Care/Tigard

4180 SW 110th Ave.Portland, OR 97005

434 1st Ave., Suite 300Hillsboro, OR 97123

226 SE 8th Ave.Hillsboro, OR 97123

9250 SW Hall Blvd.Tigard, OR 97223

(503) 642-7429

FAX: (503) 642-7487

(503) 648-8210

FAX: (503) 648-8283

(503) 601-7400

(503) 293-0161 x. 4000

FAX: (503) 452-3200



MonThu: 8:30 a.m.4 p.m.

Fri: 8:30 a.m.1 p.m.

Taking established members only

MonWed, Fri: 8 a.m.5 p.m.

Tue & Thu: 10:30 a.m.7 p.m.


Sat: 9 a.m.5 p.m.


Portland Clinic Urgent

Care/SW

Legacy Randall

Childrens

Urgent Care

6640 SW Redwood LanePortland, OR 97224

1960 NW 167th Place,Suite 103Beaverton, OR 97006

(503) 293-0161 x. 4000

FAX: (503) 452-3200

(503) 672-6050


Sat: 9 a.m.5 p.m.


MonFri: 5 p.m11 p.m.

SatSun: 12 p.m.8 p.m.

Pediatric Urgent Care

United Medical Urgent Care &

Family Medicine

Providence Medical Group

Scholls Immediate Care

11790 SW Barnes Road, #140Portland, OR 97225

9975 SW Frewing St., Suite 110Tigard, OR 97233

12442 SW Scholls Ferry Road,

Suite 100Tigard, OR 97233

(503) 597-5437

FAX: (503) 643-7300

(503) 765-5400

(503) 215-9900

MonFri: 6 p.m.9 p.m.

Sat-Sun: 1 p.m.9 p.m.

Open most holidays

Accepts newborns to age 21


Sat: 9 a.m.5 p.m.

Closed on Sunday





8/23

NAME/ ADDRESS

NAME/ ADDRESS

PHONE/FAX

PHONE/FAX

HOURS

HOURS

Providence Bridgeport

Health Center

Immediate Care

Providence TanasbourneHealth Center

Immediate Care

18040 SW Lower Boones Ferry Road,Suite 100Tigard, OR 97224

18610 NW Cornell Road, Suite 101Hillsboro, OR 97124

(503) 215-9900

(503) 215-9900



MonFri: 7 a.m.11 p.m.Sat & Sun: 7 a.m.11 p.m.

Clackamas

County

Geneva Urgent Care

Wilsonville

Molalla Urgent Care

29756 SW Town Center Loop West, # LWilsonville, OR 97070

861 W Main St.Molalla, OR 97038

(503) 685-9165

FAX: (503) 685-9163

(503) 829-7344



MonFri: 5 p.m.9 p.m.

Sat: 12 p.m.8 p.m.

Sun: 12 p.m.6 p.m.

Doctors Express

17437 Boones Ferry Road.Lake Oswego, OR 97035

(503) 305-6262 SunMon 8 a.m.8 p.m.

Open 7 days a week


Milwaukie Urgent Care

Rodney E. Orr, MD, PC

DBA- Family Medical

Group of Molalla

Providence Medical Group

Happy Valley

Immediate Care

2403 SE Monroe St., Suite AMilwaukie, OR 9722

861 West Main St.Molalla, OR 97038

16180 SE Sunnyside Road,Suite 102Happy Valley, OR 97015

(503) 659-4444

(503) 829-7374

(503) 215-9900

MonSat: 10 a.m.7 p.m.


Sat: 12 p.m.8 p.m.

Sun: 12 p.m.6 p.m.



Providence Medical

Group Canby

Immediate Care

200 S Hazel Dell WayCanby, OR 97013

(503) 215-9900 MonFri: 8 a.m.8 p.m.


Providence Medical GroupSherwood Immediate Care

16770 SW Edy Road, Suite 102Sherwood, OR 97140

(503) 215-9900 MonFri: 8 a.m.8 p.m.



Columbia

County

Legacy Urgent Care

St Helens

500 N Columbia River Hwy., Suite 7

St. Helens, OR 97051

(503) 397-7119 MonFri: 12 p.m8:30 p.m.

Weekends and holidays:

10:00 a.m.5:00 p.m.



9/23

Marion

County

Walla Walla

County

NAME/ ADDRESS

NAME/ ADDRESS

PHONE/FAX

PHONE/FAX

HOURS

HOURS

Rodney E. Orr, MD, PC

DBA-Family Medical

Group of Silverton

335 Fairview St.Silverton, OR 97381

(503) 873-8686 MonFri: 5 a.m.9 p.m.

Sat: 12 p.m.8 p.m.

Sun: 12 p.m.6 p.m.

Walla Walla Clinic

Walk-in Urgent Care

Kadlec ClinicUrgent Care

55 W Tietan St.Walla Walla, WA 99362

4804 Clearwater Ave.Kennewick, WA 99336

(509) 525-3720

FAX: (509) 522-1577

(509) 942-2355

FAX: (509) 222-2355

N/A

N/A

DME Contacts

American Seating and Mobil ity

www.asmrehab.com(503) 2534655Fax: (503) 2534640

Apria Healthcare

www.apria.com(503) 2582200Fax: (503) 2555899

Byram Healthcare

www.byramhealthcare.com(503) 2332201Fax: (503) 2332257

DJO

www.djoglobal.com(800) 3366569

EMPI

www.empi.com(800) 3282536www.djoglobal.com

Arch Fitters

N/A

DME Provider,

Website, Contact Types of Supplies

Complex rehab-power WC Standard manual wheelchairs Scooters Complex rehab-power WC Standard

manual wheelchairs Scooters

Oxygen C-pap RAD Standard wheelchair Apnea monitor Walker Nebulizer Hospital bed Bath bench Commo Items in a capped rental

CPAPs BiPAPs

Prefer for diabetic Incontinence Surgical Enteral Stocking Bath

Osteogenesis stimulators

Diabetic shoes Foot inserts

Tens units

Repairs:

Repairs:



10/23

Foothills Medical Supply

www.foothillsmedsupply.com(800) 8714083Fax: (503) 8741106

In Home Medical

www.inhmed.com(541) 9666293Fax: (541) 2783427

Keen Mobility

www.keenhealthcare.com(503) 2859090Fax: (503) 2239488

KCI

www.kci.com(800) 275-4524

Norco (previously CareMedical)

www.norco-inc.com(503) 2888174

Fax: (503) 2888817

Northwest Medical, Inc.

www.nwmed.com(503) 2346219Fax: (503) 2346521

DME Provider,Website, Contact Types of Supplies

Canes Crutches Walkers Manualwheelchairs CPAP Oxygen Hospital bed s

Scooters WC accessories Photo therapy lights Items provided by Foothills Medical Supply Hospital beds made by Invacare or Midline

Complex rehab Hospital beds Incontinence supplies CPAP Oxygen Hospital beds Complex rehab CPAPs/BiPAPs Items in a capped rental

Complex rehab-power WC Bath safety Pressure mattress Hospital beds Oxygen Standing frames Items provided by Keen Mobility Hospital beds Complex rehab Standard wheelchairs

Wound vac

CPAP Nebulizer Breast pumps

Hospital beds Incontinence supplies CPAP Oxygen Hoyers Bath chairs Breast pumps Items in a capped rental CPAPs

BiPAPs

Repairs:

Repairs:

Repairs:

Repairs:

Repairs:

Repairs:

DME Contacts

North Coast Medical Supply

www.nchc.net(503) 3259906

Fax: (503) 3251437

Olson Medical

www.olsonmedicalservices.com(503) 6071170Fax: (503) 6071169

Walla Walla Home Medical

www.wallawallahomemedical.com(509) 5251066

Fax: (509) 5222361

East Side Orthotics& Prosthetics

www.surelimb.com(503) 2576623Fax: (503) 2576624

DME Provider,

Website, Contact Types of Supplies

Complex rehab Hospital beds Incontinence supplies CPAP Oxygen Bath

Complex rehab items providedby NCHC Items in a capped rental,

provided by NCHC Manual wheelchairs Scooters

Walkers Manual wheelchairs Bath equipment Enteral Hospital beds

Complex rehab Hospital beds Incontinence supplies CPAP Oxygen Bath

Hospital beds Complex rehab Standard wheelchairs Items provided by Walla Walla Home Medical Items in a capped rental

Orthotics and prosthetics Leg brace Back braces

Hanger Pros & Orthotics

clinic locations

www.hanger.com(877) 442-6437

Orthotics and prosthetics Leg brace Back braces



11/23

DME Contacts

Oregon Orthotic Services Inc.

www.oregonorthoticservices.com(503) 2429136Fax: (503) 2429139

Prosthetics & Orthotic Services

www.prostheticorthoticservices.com(509) 5258322Fax: (509) 5252982

DME Provider,Website, Contact Types of Supplies

Orthotics and prosthetics Leg braces Back braces

Orthotics and prosthetics Leg braces Back braces

Complex rehab:

power wheelchairs with special features,

tilt-n-space, power recline, custom

seating system

Standard wheelchairs:

manual self-propelling wheelchairs

Power operated vehicles:

scooters

Bath equipment:

grab bars, transfer bench, tub bench,

commodes

Orthotics:

braces for lower or upper

extremities, backs

Prosthetics:

artificial limbs

Ostogenesis stimulators:

bone growth stimulators

Capped rental:

Medicaidthere is currently an

authorization in place allowing a

rental; the equipment is not currently

owned by the member.

Medicare the member is currently

renting the equipment; there may or

may not be an authorization on file

depending if the code for the

equipment requires authorization or

not; the equipment is not

member owned during this time.

Definitions:

MedicalTransportation/Interpreter Services

Please note the following resources

are available for medical appointments

only. This is not to be used for personal

travel needs.

Tri-County

Eastern Oregon(Currently serving only

dual members Medicare + Medicaid)

Linguava

Interpreter Services

We provide language services through

Linguava for onsite and telephonic

interpretation, which enables our clients to

be connected promptly and directly with

the language specialist of their choice.

Linguava strives to meet diverse interpreting

needs by prioritizing customer service and

top-quality interpretation.

Clatsop County(Currently serving onlydual members Medicare + Medicaid)

Urgent transportationneeds

Tollfree: (877) 875-4657

(503) 2658515Toll-free: (800) 7161777

Fax: (503) 9541038

Hours: MonFri: 7 a.m.7 p.m.

Sat: 8 a.m.5 p.m.

Toll-free: (866) 811-1001

(Sunset Empire)

(Multnomah, Washington

and Clackamas counties)

*The Service Coordinator needs

to document the approved

transportation. Please

include travel date and place

at the time of scheduling.

(Must be scheduled by

FamilyCare Service

Coordinator*)


(503) 8028700

MonFri : 7 a.m.6 p.m.

Tollfree: (800) 8898726

Oregon Relay Service:

(503) 8028058 (TTY: 711)

(503) 222-2779

MetroWest @ (503) 6486656


12/23

PH TechResource/Info Sheet

FamilyCare CIMWeb link:URL Reference 1.3

FamilyCare CIMYouTube training video:

URL Reference 1.4

CIM support (error messages, etc.) New user access and/or access

troubleshooting

EDI information

(or email: [email protected])

PH Tech Payer ID: 93121

Group ID: H3818 (Medicare)

Group ID: 218751 (Medicaid CCO)

Group ID: 122577 (Medicaid

older group ID before CCO; will

still be accepted, but not p referred)

Update for Optuminsight

EDI Submitters:

Starting June 30, please use

the new PH Tech payer ID

established for:

PH Tech CIMTechnical Support

(503) 5842169

Update for Emdeon

EDI Submitters:

EDI payer ID informationeffective 07/01/2013

Starting June 30, please use the

new PH Tech payer ID with Group ID.

NOTE: Your claim will not be

accepted if the Group ID is not

present upon claim submission.

Payer ID: PHR01 (New ID for

2013 DOS Medicare claims)

Payer ID: FCR01 (continue for

only 2012 DOS Medicare claims)

Payer ID: PHD01 (continue for

Tri-County Medicaid claims)

Please submit paperclaims to:

FamilyCare Medicare

PO Box 5308

Salem, OR 97304

PH Tech

FamilyCare Account Representative

(503) 5842192

Email: [email protected]

www2.phtech.com

CIMInformationand FAQWhen working in CIM, clinic staff may

find it helpful to reference the

CIM Provider Manual

login to CIM>>Provider

Services >>CIM Provider

Manual. PH Tech provides this

help function for CIM users.

In CIM, logins are created by the

assigned clinic administrator. To

create new users, use the Register

User link. The access type for

individuals is as follows:

Logins for CIM users

In CIMs main menu, go to

Member Search, enter the patient

data, which will bring up the patients

eligibility information (i.e., the OHP

recipient ID number or their name

(first and last) and date of birth), and

click the link titled Send email

Regarding This Member.

Logins for CIM users

A separate window or tab for an

email will appear, with the FamilyCares

enrollment email address

auto-filled in the Send to field:

[email protected].

The message can be as simple as

Member sees Dr. Smith at our clinic

as PCP. Please assign. Our enrollment

department will update the members as-

signment to reflect that your clinic is the

members primary care clinic.

Both our Provider-Network Services

Department and our Enrollment

Department can provide you with

more detailed information regarding

timeframes for assignments.

FamilyCare Medicaid/CCO

PO Box 5930

Salem, OR 97304

Courtney Bailey

CIM Provider Manual:

Eligibility only: view eligibility only Claims: view claims and eligibility

Authorizations: view claims,

eligibility and authorizations

Remember to register your

employees for all the FamilyCare

options (FamilyCare CCO Metro, MH,

Inc., MEDICARE, FHP and PCO).

Choosing all options allows your

employees to view the full range of

coverage FamilyCare offers.



13/23

The Health Evidence Review

Commissions (HERC) Prioritized List

of Health Services (Prioritized List)indicates what is funded under the

Oregon Health Plans Medicaid

coverage. It is located at URL

Reference 1.5. The Prioritized List

lists ICD-9s, HCPCs and CPTs that

have been reviewed by the HERC.

They have used a weighted system

to determine where conditions and

services fall on this list. There are

692 lines of coverage, and each line

lists conditions and services;

however, only the first 498 line items

are funded. An ICD-9 falling on line

137 receives funding, whereas an

ICD-9 falling on line 531 does not.

Conditions and services may fall

on multiple lines, and there are some

conditions and services that do not

appear on the Prioritized List. An

explanation of coverage for these

items appears in the June 2011

Biennial Report, on pages 36

and 56 URL Reference 1.6.

CIM has a tool for users that

indicates if items pair together

or appear on the same lineon the

Prioritized List. This tool also allowsusers to determine where an ICD-9

item falls on the Prioritized List. To

access this tool, follow the path login

to CIM>>Provider Services>>

DMAP Line Search.

Below is an example of a search

result, using ICD-9 327.23 (OSA).How do I know if a diagnosiscode is funded and if there are

guidelines for it? The search result displays the current funding

line (498), the line on which the ICD-9 falls

(Line 210 funded), the associated Guideline Notes

(which are viewable on the Prioritized List), anda Detail option.

The detail option will display the Prioritized Lists

information regarding that line, including all the

codes present on that line (I CD-9s, CPTs and

HCPCs). Clinics rarely require access to notes in

the Detail option, but Detail notes are

available if needed.

Below are examples of how diagnosis codes will appear in

the DMAP Line Search tool for all potential line placements:

ABOVE THE LINE

ICD-9 327.23(obstructive sleep apnea)

BELOW THE LINE

ICD-9 784.0 (headache)

ABOVE and BELOW THE LINE

ICD-9 784.0 ICD-9 850.9(unspecified concussion)

NOT RANKEDICD-9 719.46(pain in joint, lower leg)

DMAPs MMIS provider portal isanother tool with capabilities ofconducting ICD-9 line searches, viathe Benefits and HSC Inquiry tool.For MMIS access and registration,contact the Oregon Health Authority(OHA) at URL Reference 1.7,or calltoll-free (800) 3366016.An excellent resource for Medicaidproviders, Keys to Successcan be found at URL Reference 1.8.

Please note that the Benefits andHSC Inquiry tool in MMIS may beconfusing to users, as informationgenerated can provide misleadingresults. Therefore, while DMAPsBenefits and HSC Inquiry toolmay provide useful to some users,FamilyCare recommends usingCIM first and foremost to conductICD-9 searches.



14/23

FamilyCare strives for a 4-hour

TAT on routine referral requests.

Use of the CIM system to request

initial referrals can, at times, result in

automatic and instantaneous

approval of your referral requests. A Referral in the CIM system is

used only when making the initial

referral request to a specialist and

only covers office visits. Referral

should not be used to request visits

for members who are already

established with a provider. Requests

from specialists should be entered

into CIM as Pre-Authorizations.

Please note that referrals are required

on file for all ages and specialty

types except OB/GYN providers

for family planning purposes (like

contraceptive management andsterilization), pregnancy and routine

well woman checks (the

yearly exams).

When requesting a referral from

FamilyCare the most commonly

requested service request only

the initial visit. Since FamilyCares

referral rules are reflected within the

CIM system, CIM will, in most cases,

automatically approve the evaluation

when only ONE visit is requested.

FamilyCares referral rule, as it

relates to specialist referrals, will

allow for an initial visit to a specialist

for above the line, below the line,

and unranked diagnoses.

Referrals and pre-authorization

turnaround times (TAT)

Requesting referrals

Requests to specialists for

diagnoses that fall below the line, or

for diagnoses not ranked, will result

in a Received status in CIM.

Please note that requests

resulting in a Received status

require manual processing by

FamilyCare, which will delay the

request. Additionally, note that some

diagnoses fall both above and below

the line; these conditions will only

receive automatic approval for

the evaluation.

FamilyCare can approve up to six

(6) visits to a specialist within a six (6)

month timeframe, for referrals of

diagnoses that fall above the line.

The DMAP Line Search tool

should, therefore, be used to

identify the lines on which diagnoses

fall. Consistent use of this tool will

allow clinic staff to effectively identifyconditions that are readily approved

for single or multiple visits.

Which referral or

pre-authorization types

require prior authorization

and/or review?

FamilyCare does not require

prior authorization for in-office

services rendered by members

PCPs. However, pre-authorization

and medical review is required for

genetic testing and spinal MRI and

PET scans.

Additionally, FamilyCare requires

prior medical review for referrals to

pain management specialists.

Only behavioral health services

allow for self-referral of members.

Examples include mental health

or chemical dependency services.

Please contact FamilyCare

Behavioral Health at (503) 3455704

for additional information regarding

FamilyCare Behavioral Health referral

and authorization policies.

FamilyCare believes that family

physicians are the foundation

for building a caring, efficient

healthcare system in cooperationwith specialists and other providers.

To that end, patient care should be

managed through our members

primary care physician offices.

What types of specialties

allow for self-referrals?

What do I need to know

about MyPlan and

PremierCare members?

(MyPlans C, A, R, E, S and S+Rx)

members. However, we do require

that these members receive prior

authorization for inpatient stays,

skilled nursing facility stays and

durable medical equipment (DME).

Plan information for Medicare

Advantage Plan members is

available on our website at

www.familycareinc.org.

FamilyCare does not require

referrals or prior authorization for

outpatient services received by

Medicare Advantage Plan

FamilyCare does have a currenta list of contracted specialists for

our Medicaid plan available on our

website. If you are unable to refer

a member to a particular

specialist, or to inquire about

available specialists, please

contact Navigation Services at

(503) 345-5701.Please note that

our Medicare and Medicaid

contracted specialty lists are

located on our website at

www.familycareinc.org.

Where can I find a list of

FamilyCare contracted specialists?


The Oregon Health Plan does not

cover pain management visits for

non- funded diagnoses.

For funded diagnoses,

FamilyCares expects specialists

to create, approve, enact and

enforce a comprehensive pain

management regimen for patients.Pain management referrals, in which

the specialist is intended to assume

management control of the members

pain issues, will not be approved.

Services rendered that are not

office visits (E&M codes) such as

physical, occupational, and speech

therapies, as well as medical nutrition

counseling must be entered as

pre-authorizations, listing the

service-specific code.

Oregon Medicaid Provider Web Portal Eligibility Verification Request Screen


15/23

If all attempts have been madeand your office is still unable to place

the member with an appropriate

specialist, please faxthe following

information to: Orthopedic

Coordinator (503) 345-5901.

This information may also be

faxed directly to Authorizations at

(503) 345-5770. Attention: Orthopedic

Coordinator FamilyCare cannot

provide an immediate response, as

it may take several weeks or more to

place a member, but every attempt

will be made to place a member with

an appropriate specialist.

Medical records relating to the

need for a referral

Imaging reports related to the

need for the referral

A list of conservative treatments

already attempted, such as

physical therapy, joint injections,

past surgical treatments and

medication management

A list of all current medications

that the member is taking


AA#####A

12/09/1910

######### JOHN DOE

######### JOHN DOE

######### JOHANNA DOE

######### JOE DOE

DOE

JANE A

1234567890 NPI YE OLDE PILL SHOP

Oregon Medicaid Provider Web Portal Eligibility Verification Request Screen

How to verify client eligibility and copayment responsibility at https://www.or-medicaid.gov

At the main menu, click Eligibility.Enter the clients 8-digit ID number, plus name or date of

birth, then click search.

For date of service, enter a From date no more t han 13 months before the

date of inquiry, and To date no later than the da te of inquiry.

For service limitations, also enter a procedure code.

The following information will appear. To view copayment information, click on

BMD, BMH. BMM or BMP in the Benefit Plan section of the screen.

1. Client information

Last EPSDT : Not u

Last Dental Visit: D(blank if none)

Phone Number: Of

2. Benefit plan(s)

Only these codes are forbenefits:

BMD, BMM: OHP

DrugBMH: OHP Plus

BMP : OHP Plus Sup

KIT: OHP Standard

CWX: OHP Plus covCAWEM Prenatal p

CWM: CAWEM

MED: Medicare Ben

4. Third-party liability (TPL)

Information and coverage date

5. Managed care

Effective dates of managed carCare Manager (PCM) enrollm

CCOA: Coordinated care o(CCO) for physical, dental

health care

CCOB: CCO for physical

health care

CCOE: CCO for mental hDCO: Dental Care Organ

FCHP: Fully Capitated He

MHO: Mental Health Org

PCO: Physician Care Orga

CCOG: CCO for mental aonly

6. Lockin

Assigned pharmacy for Pharmacy Management Program clients (notused).

7. Service limitation

The next available date of service for the procedure entered.

HEALTH CAR

Division of M

3. Service Type Coverage and Copay

This screen shows the services covered by thselected, grouped by service type (e.g., MedPharmacy). Non-covered services will not

Coverage: Active or Limited

Copay: The amount to pay ($0, $1, or $with BMD, BMM, or BMH benefits is ecopayment, this field will read $0.00 for

Questions? Call DMAP Provider Services at 800-336-6016.

1. 6.

2.

3.

4.

5.

6.

7.

I am having difficulty referringa FamilyCare Medicaid

member for orthopedic needs.

What do I do?

The orthopedic shortage for

Medicaid members is a long standing

issue in this community. FamilyCare

is aware of the problem and, in order

to better assist our providers, will

work with local orthopedic p roviders

to identify an office where the

members referral may be placed.

FamilyCare will then notify your office

when the member is accepted to anoffice. Please do not request that

FamilyCare coordinate orthopedic

referrals first, before your office has

first made every attempt to place the

member. Oftentimes, if a member

was previously seen by an on-call

orthopedic physician at a facility for

an acute event, the member may

receive a follow-up visit at that facility

by the same orthopedic physician

(if the facility originally referred

the physician).

While acquiring referrals for

Medicaid members may be difficult,the provider should make every

attempt to refer the member to

an orthopedic specialist before


16/23

Claims FAQ

If you are a contracted provider,

you can use our Provider Portal

known as the Clinical Integration

Manager (CIM). If you are a

contracted provider with

FamilyCare and need CIM access,

please call our Provider Navigation

Services at (503) 2222880 or

(800) 4589518.

You can file a reconsideration or

review of a claim by choosing the

appropriate link on the p rovider

portal. You will need to fill out the

Claim Review Request form and

fax it to the number listed on the

form. Provide documentation to

support coverage and/or

explanation for reconsideration.

Oregon Medicaid requires that all

providers who provide services to

Medicaid members have an active

and valid Oregon Medicaid

number. If you practice within

Oregon, you may contact DMAP

Provider Enrollment on your own

at (800) 422-5047 or

[email protected].

For Medicare claims with

dates of service on or after

January 1, 2010, timely filing

is one year from the date of

service. For Medicare claims

with dates of service before

January 1, 2010 see the CMS

News Release addressing

For Medicaid claims, timely

filing for non contracted

providers is 120 days from the

date of services. Contractedproviders, please see

your contract.

Q: How can I check the

status of a claim which I

have submitted?

Q: How would I file a

reconsideration/review

for a claim?

Q: My claim was rejected forNo Medicaid/Medicare

number, what do I need to

do to get my claim processed?

Q: How long do I have tofile a claim?

Regardless of location, you

can have FamilyCare apply for

an Oregon Medicaid number on

your behalf. To do so, please fill

out the Oregon Medicaid

Application Information Form for

all NPIs which need an Oregon

Medicaid number. The form can

be faxed to Provider Services

at (503) 734-3188.

Likewise, Medicare requires

that all providers are enrolled

in Medicare and have an activeMedicare/PTAN number. If the

provider in question is enrolled

in Medicare, please Fax proof of

Medicare enrollment to Provider

Services at(503) 734-3188.



17/23

Member Search and

Determining Eligibility

The Member Search tool

provides access to member-centric

information and related tools. Select

the Member Search link on the

Main Menu to access the Member

Search page.

Once the Member Search link

is selected, the Member Search page

appears. At the top of the Member

Search page is the search section. In

it are Member Search criteria fields.

In the center of the page b ody, just

below the search criteria are

instructions onwhat combination of

criteria is required for the search.

After the required data is entered,

click on the Search button to the right

of the input fields.

The search results are displayed

on the Member Search page. If

nothing is found, the message

0 record(s) found matching that

criteria is displayed.

If a search yielded unexpected

results, first verify that a

drop-down option from the

Insurance Carrier field has been

properly selected. If Click to

Select Carrier is selected as the

Search criteria, the search will

yield no results.

If a search yielded unexpected

results, next verify that the

Eligibility Date field has been

entered. If it is blank, then it is

probably not the issue. If there is

an eligibility date entered, it must

be within the eligibility and

termination dates of one of the

members records. Typically, one

record is found when the date is

correctly entered. More might be

found if there are eligibility records

with overlapping eligibility dates.

When a search yields successful

results, those results are displayed

in the body of the Member Search

page. In the example below, a

single record result is displayed in

the member record format. If multiple records are found,

those results are displayed in a

table, in a summary format

NOTE: Some information is missing.

Search terms are not case sensitive

The correct insurance carrier

must be selected from

the Insurance



18/23

Member Search and

Determining Eligibility

On the multiple records SearchResults page, a members eligibility

may be determined from the

Effective Date and Term Date

columns in the table.

There are two linked items in a

table row. In the first column, a link

may be selected by clicking the

ellipsis button. In the second column,

a link may be selected by clicking

the members name.

When either link from the first or second column

is selected, the full member record for that summary

row is displayed. Record in Member Search:

To identify the Plan Type, look a the

Plan row in the right column of the

record. The plan name contains the plan

type identifier.

PCP History:

This link allows the user to view provid-

ers that have been the members PCP.

From the full member record display, you will

see many user tools and information links.



19/23

FAQ for Referralsand Authorizations

With the exception of routine

OBGYN care and diagnoses

listed on the NO AUTH list,

all office visits require authorization.

Informatively, most diagnostics,

including CTs and X-rays, are on

the NO AUTH list.

Routine obstetric care, yearly Pap

tests, etc. do not need authorization.

Please be advised that office

visits for routine prenatal care,

pregnancy-related conditions,

sterilization, or family planning do

not require referrals or prior

authorizations from FamilyCare. My

Plan/Medicare members do not

need authorization for office visits.

However, authorization is required

for members receiving inpatient

surgery.

When referring a member for a

new specialist visit, FamilyCare will

automatically approve one (1) visit.

Please request only one (1) visit

for auto approval.

Enter a pre-authorization for

therapy. Only the initial evaluation is

needed, when a PCP is requesting

these services for members. The

therapy office is responsible for

requesting any follow-up services,

once the evaluation is complete. Thetherapy office will supply FamilyCare

with the evaluation records,

indicating the developed treatment

plan for the member.

Physical therapy evaluation:

CPT 97001 Occupational therapy evaluation:

97003 Speech therapy evaluation:

CPT 92521

Nutrition, MRIs, therapy

and surgeries always need

medical review and, therefore,

require submission of chart

notes. These services should

be entered as Prior Auth, not

Referral,and should list the

CPT for the requested service.

New Referral to Specialist

Referrals for therapy services:

Authorizations for

Therapy Services

Submitting

a ReferralQ: Do I need an authorization?

Q: Do I need to send

chart notes?

1. Confirm PCP (provider) made

attempt to find an orthopedic

provider (list of names)

2. Fax authorizations and

referrals to (503) 345-5770: Chart notes

Imaging reports

List of conservative treatments

that have been tried

List of current medications

Within the Referral Authorizationpage, complete (at minimum) therequired information (denoted byred field labels). The Member,Start Date and Referring Provfields are auto-filled, when thepage first displays.

A:

A:


For orthopedic specialist:


20/23

Submitting

Referrals

Verify the Request Auth from PCP(I am the specialist) checkbox is

correctly selected or de-selected.

The default is unchecked, indicating

that the authorization request is from

the PCP who is not the specialist.

However, check the box if the

authorization request is from the

specialist office.

If the Request Auth from PCP

(I am the specialist) box is checked,

a pop-up warning message appears.

Follow the instructions indicated

within the pop-up, if needed. Then

click OK to continue.

Member:

The Member field is auto-filled by

default with the members data: plan

name, member name, date of birth

and eligibility time span

(start/end date).

Start Date:

The Start Date field is auto-filled

with the current days date. If the

auto-filled start date isincorrect, type in the correct date.

Defaulted Fields

The start date must be within the eligibility timespanlisted in the Member field.

If the start date is NOT within the eligibility

timespan listed in the Member field, search for

the correct eligibility time span using the ellipsis

button at the end of the Member textbox.

NOTE: If a correct eligibility time span

cannot be found, the referral cannot besubmitted. Exit the page.

Referring Prov:

TheReferring Prov field is

auto-filled by default with the members PCP.



21/23

In order to streamline the process for requesting pediatric team evaluations,

we are enclosing a reference sheet that you can use when requesting these team

evaluations. This quick reference lists the CPT codes to use when requesting

authorizations for team evaluations at OHSUs Child Development and Rehabilitation

Center (CDRC), Legacy Pediatric Development and Rehabilitation, and ProvidenceNeurodevelopmental Center for Children. Multidisciplinary team evaluations must be

entered as Pre-Authorizations. All of the services provided in the team evaluation will

be listed in one Pre-Authorization request.

April 4, 2013

When requesting an authorization

for a team evaluation for pediatric

patients, please:

Enter the request as a

pre-authorization

Include the clinic name in the

Comments/Notes section of

the request form

Include the appropriate CPT

codes. All are entered on asingle pre-authorization

CPTs forTeam Evaluation

Authorizations

Notes:

Codes

Legacy

Feeding Clinic

Physician:

Occupational Therapy evaluation:

Speech Language Pathologist evaluation:

Discipline CPT

99201

97003

92521

Rett Syndrome Clinic

Physician:



Discipline CPT

99201

97003

92521

Craniofacial Disorders Clinic

Physicians (two):

Physical Therapy evaluation:


Discipline CPT

99201

97001

92521

NICU follow-up Clinic

Physicians (two):

Occupational Therapy evaluation OR:


Discipline CPT

99201

97003

97001

Wheelchair Clinic

Physicians (two):

Occupational Therapy evaluation and/or:


Discipline CPT

99201

97003

97001

Spasticity Clinic

Physicians (two):


Discipline CPT

99201

97001

Communication Disorders Clinic

Physician:



Psychology visit:

Discipline CPT 99201

92521

97003

96125

96101


Use these CPT codes for pre-authorization request for team evaluations. If the

member will not be seen for a team evaluation, please coordinate with the office

where the member will be seen in order to determine which services should be

specified in your pre-authorization or referral request.

If your office has a request for one of these clinics, refer to this list to determine

which CPTs to use. We will use this tool to confirm that the appropriate codes have

been entered.

Remember, these services require preauthorization, not a referral. (In CIM,

the term referral is used only to refer a member out for specialist office visits

and office visits only.)

This reference sheet also shows which services are offered at each facility. For

example, Legacys Feeding Clinic provides a speech therapy evaluation, where as

CDRCs Feeding Clinic provides a swallowing function evaluation.

Were pleased to inform you that we have updated Clinical Information Manager

(CIM) to let you specify where you want your patients to be evaluated. Simply select

the clinic using the Auth Types field.

Dear Provider,

If you have any questions, please call.

Sincerely,

Galen Sinnock, Team Lead

Referrals and Authorizations


22/23

Providence

Autism Clinic

Physician:



Psychological evaluation:

Discipline CPT

99201

92521

97003

96101

Feeding Clinic

Physician:



Medical nutrition:

Discipline CPT

99201

92521

97003

97802

School-Age Diagnostic Clinic

Physician:




Discipline CPT

99201

92521

97003

96101

Central Auditory Function, initial 60 min

(Not covered by OHP):

Central Auditory Function, each additional 15min

(4-5 units) (Not covered by OHP):

92620

92621

Auditory Processing Evaluation

Discipline CPT

Craniofacial Disorders Clinic

Physicians (multiple):


Discipline CPT

99201

92506

CDRC

Genetics Clinic


Services as needed:

Discipline CPT

99201

TBD

Spina Bifida Clinic



Speech Language Pathologist evaluation (sometimes):

Occupational Therapy evaluation (sometimes):

Psychological testing (sometimes):

Discipline CPT

99201

97001

92521

97003

96101

LEND Clinic

Physician:


Psychological testing:

Physical Therapy evaluation (sometimes):


Discipline CPT

99201

92521

96101

97001

97003

NICU Follow-Up Clinic

Physician:

Alternate clinician (Psych, SLP, PT, or special ed):

Discipline CPT

99201

96111

Down Syndrome Clinic

Physician:


Speech Language Pathologist


Discipline CPT

99201

97003

92521

97001

Healthy Lifestyles Clinic

Physician:



Medical nutrition:

Discipline CPT

99201

97001

96150

97802

Feeding Clinic

Physician:

Swallow function evaluation:


Medical nutrition:

Discipline CPT

99201

92610

97003

97802

Child Development Clinic

Physician:



Physical Therapy evaluation (sometimes):


Discipline CPT

99201

92521

96101

97001

97003

Rett Syndrome Clinic

Physician:





Discipline CPT

99201

97003

92521

97001

97003Autism Clinic

Physician:





Discipline CPT

99201

97003

92521

96101

97003

Neurodevelopment Clinic

Physician:





Discipline CPT

99201

97003

92521

97001

97003www.familycareinc.org

CodesCodes

FamilyCare Health Plans Referal Department825 NE Multnomah Suite 300 Portland OR 97232

FamilyCare Health Plans Referral Department


23/23

FAMILYCARE INCORPORATED 825 NE MULTNOMAH, SUITE 300 PORTLAND, OR 97232

503-222-2880 800-458-9518 TTY/TTD: 711 WWW. FAMILYCAREHEAL THPLANS.O RG

825 NE Multnomah, Suite 300, Portland, OR 97232

Phone: 503-228-8228 or toll-free 800-684-3799

Fax: 503-345-5770 or toll-free 800-270-7737

THERAPY REQUEST FORM

IMPORTANT: Valid referral must be on file from the referring Provider, prior to reviewing for additional services.

Physical Occupational Speech Wound Care

Date: ______________ UrgentRequest: (contact referral and auth dept if unclear if request meets urgent criteria)

Person completing this form: _____________________________________Phone: ___________ Fax: __________

Working at: PCP Specialist Therapy Office

Member name: ________________________________________________________________________________DOB: _____________________________________ Recipient ID: ______________________________________

Ordering Physician: ____________________________________________________________________________Phone:_____________________________________ Fax: _____________________________________________

Rendering Therapist: ___________________________________________________________________________

Phone:_____________________________________ Fax: _____________________________________________

Primary ICD-9 Code: _________________________ Secondary ICD-9 Code:______________________________Date of Evaluation:___________________________

INSTRUCTIONS: Please list the number of units in the box to the left of the service requested.

97110 Will be listed on auth allowing for 4 units per DOS for any combination of the following codes:

97012 97014, 97022, 97032, 97036, 97112 97113, 97124, 97140, 97760, 97761, 97762, 97353,97530, 95831 98534, 95851, 95852, 97755

292521 Will be listed on auth allowing for any one of the following codes: 92521 92524

AttentionRequested Specialist/Facility: Payment is contingent upon eligibility, authorization requirements, exclusions and limitations of contract.

Extensions for ongoing requests need to be requested before initial authorization expires. FamilyCare has aNo Retro Authorization policy. Any services completed without prior authorization will need to be submitted

using our Claim Reconsideration Request Form.

Please visit our website to see our Medicaid l ist of services not requiring an authorization:http://www.familycareinc.org/

FCI_FRM_00060_2014

PHYSICAL OR OCCUPATIONAL VISITS

QTY CODE DESCRIPTION QTY CODE DESCRIPTION

97001 Physical Therapy Eval 97110 Therapeutic visits (up to 4 15minmodalities/visit)97003 Occupational Therapy Eval

SPEECH

925212 Speech Eval E2511 Speech softwarefor personalcomputer

92610 SwallowEval E2512 AccessoryforSpeechDevice- Mounting

92507 Tx of Speech follow up E2599 Accessory for Device

92508 Group Speech L7510 Repair of Device, Minor

92526 Tx swallow follow up L7520 Repair of Device, labor per 15 min

92611 Fluoroscopic Eval L8500 Artificial Larynx, any typeS9152 ST Re-Eval L8501 Trach Speaking valve

A4649 St Supplies L8507 Tracheo-Esophageal voice prosthesis, patient

E2 500 Spe ec h De vice < o r= 8 m in L8509 Tracheo-Esophageal voice prosthesis, provider

E2502 Speech Device > 8 or < 20 min L8510 Voice amplifier

E2506 Speech Device > 20 o r < 4 0 mi n L8515 Gel ati n capsule, a pplicati on

E2508 Speech Device message formulation L9900 O&Psupplyofano therHCPC

E2 510 Spe ec h De vice M ul ti pl e Metho ds V 533 6 R ep ai r/Mod ify Dev ice

WOUND CARE OTHER SERVICES

97542 WC Managment 97542 WC Managment

92597 Oral Device Eval 92597 Oral Device Eval

92607 Eval For Rx Aug Device 92607 Eval For Rx Aug Device

92608 Addl 30 Min Eval

92609 Device Prog/Modify

URL Reference Page

www.ohp.oregon.gov

URL Reference 1.2

URL Reference 1.3 URL Reference 1.4

URL Reference 1.5

URL Reference 1.6

URL Reference 1.7

URL Reference 1.8

URL Reference 1.1

http://www.youtube.com/

watch?v=CV-EgCon-B4

www.oregon.gov/oha/OHPR/pages/herc/

current-prioritized-list.aspx.

www.oregon.gov/oha/OHPR/HERC/docs/R/2011br.pdf

www.coveroregon.com

https://cim6.phtech.com

[email protected]

www.oregon.gov/oha/healthplan/tools_prov/keys2success.pdf.

Documents

FamilyCare Final 2014 Provider Resource Guide