FamilyCare Final 2014 Provider Resource Guide

2014 Provider Resource Guide
Table of Contents
Contact List 1
2
3
5
8
9
11
12
38
39
40
13
13
6
8
14
18
19
20
25
27
29
33
35
38
41
42
Coordinated Care Organization
Service Types
Oregon Health Plan
Community-Based Organizations/
Application Assisters
Enrollment/About FamilyCare
Claims FAQ
FAQ for Referrals
Member Search/
Determining Eligibility
Submitting Referrals
PH Tech Resource/Info Sheet
CIM Information and FAQ
Oregon Medicaid Provider
DME Contacts
Medical Transportation
Codes
Legacy
CDRC
Providence
Therapy Request Form
URL Reference Page
Urgent Care Centers
Multnomah County
Washington County
Clackamas County
Columbia County
Marion County
Walla Walla County
Our team empowers
members to
make informed
healthcare decisions
www.familycareinc.org
Coordinated Care
Organization
Service Types
FamilyCare, Inc. FamilyCare Health Plans
Contact List
OHP CCO Medical Card My Plan Medicare Advantage
Medical Card
Website:
FamilyCare Navigation Services
(customer service)
FamilyCare Referrals
and Authorizations
FamilyCare manages seven dental
plans; all of them have the same
benet. 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
Affordable,
high-quality
patient-centered
healthcare.
Phone: (503) 222-2880
Fax: (503) 345-5720
Fax for reconsiderations, ER records,
primary EOBs and corrected claims:
(503) 566-9801
FamilyCare Provider
Network Services
Phone: (503) 471-2149
Fax: (503) 734-3188
Phone: (503) 228-8228 ext. 2820
Fax: (503) 345-5770
FamilyCare
Care Management
Phone: (503) 222-2779
Maternity representative:
Zizi Rodriguez
Direct phone: (503) 3455756
FamilyCare Credentialing
Phone: (503) 471-2129
Fax: (503) 471-2156
Email:
Credentialing@familycareinc.org
FamilyCare
Pharmacy Department
Phone: (503) 471-2126
Fax: (503) 471-2176
FamilyCare
Addictions and Mental
Health Department
Phone: (503) 222-2880, ext. 5704
Fax: (503) 345-5754
PH Tech CIM
Technical Support
Phone: (503) 584-2169
Front Front
Back Back
CCOA: Medical, Mental Health and Dental
CCOB: Medical and Mental Health
CCOC: Medical and Dental
CCOE: Mental Health
CCOF: Dental
CCOG: Mental Health and Dental
Dental
Family Dental:
Tollfree (800) 458-9518
ODS/Moda:
(503) 265-5680
Tollfree (877) 277-7280
Willamette Dental:
(855) 433-6825
2 www.familycareinc.org
Oregon Health Plan

Last Updated: 11/15/2013
Page 2 of 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
treatment
Covered 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 care
Emergency 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 assistant
Covered Covered Covered
Medical equipment and supplies Limited Covered Covered
Medical transportation
Emergency
only
Covered 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 diagnoses
such as aphakia,
pseudoaphakia or
keratoconus
Services to improve
vision such as
frames, lenses and
contacts are covered
Benet Packages
FamilyCare and
the Oregon
Health Plan (OHP)
What makes us special?
FamilyCare was created more
than 30 years ago with one
primary focus to create a better
healthcare system to give
Oregonians on Medicaid access
to quality health care. Today, our
beliefs are the same. We remain
committed to treating people
with respect and breaking down
barriers to care.
Our providers have patient-
centered Primary Care Homes
where your care is coordinated
by a health care team with you in
the center. This team will ensure
you get the right care at the right
place. We have a large network
of providers who range from
corner family doctors to large
provider groups. Hospital
services, lab, X-rays, specialists,
and more are also part of our
network resources.
Our team provides services for adults,
children and families, whether they are
inpatient, outpatient, and home-based.
These services are delivered through
a broad network of community-based
contracted providers.
You are more than an ID card and
a number. As a member, you will get
a service coordinator who is part of
your healthcare team. The service
coordinator works one-on-one with
you and your primary care provider
to help you manage chronic diseases
or illnesses, even help with resources
outside of health to help live a better
life. Our service coordinators are just
like our customer service team; they
are local and ready to serve.
Located close to where they live or
work, our partners are: Access Dental,
Capitol Dental Care, Managed Dental
Care of Oregon, Willamette Dental
Group, and Family Dental Care.
We stand on the same
belief system.
We believe the relationship
between you and your primary
care provider is key.
A dedicated mental and
behavioral health team.
Real people, real service.
We support individualized,
Patient-centered care.
We have dental providers ready to
serve all of our members.
Call us at (503) 2222880
Tollfree (800) 4589518 (TTY 711)
Monday through Friday, 9 a.m.5 p.m.
Navigation Services can answer
questions about the Oregon
Health Plan or FamilyCare.
We are based right here in Portland.
Community-Based
Organizations/
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 Coalition
Multiple 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 quality
healthcare for adults, children,
and families. Oregon is taking
full advantage of the national
Affordable Care Act to include
230,000 more Oregonians on the
OHP. Now people who earn up
to 138% of the Federal Poverty
Level will qualify. This means a
single person making $15,800 a
year and a family of four making
$32,000 a year will now qualify
for OHP. (source: www.oregon.gov)
Fast-track enrollment is
available to adults who
receive benefts through the
Supplemental Nutrition
Assistance Program (SNAP) or
whose children get care from
the Healthy Kids/Oregon Health
Plan. If adults meet the 2014
income limits and have received
a fast-track enrollment letter from
the Oregon Health Authority,
they can simply:
Great news about the
Oregon Health Plan
1
2
3
Fast-track enrollment
As easy as 1-2-3
Fill out and sign the fast-track enrollment form
Choose a Coordinated Care Organization (CCO)
Return the form to the Oregon Health Authority
in the envelope provided
Individuals can call
FamilyCare at (503) 222-2880
Tollfree (800) 458-9518 (TTY 711)
Monday through Friday
9 a.m.5 p.m.
Call Oregon Health Plan
customer service at
(800) 6999075 for more
information.
A Coordinated Care Organization
(CCO) is a network of all types of
healthcare providers who have agreed
to work together in their local
communities for people who receive
healthcare coverage under the Oregon
Health Plan. (source: www.oregon.gov)
People already on the OHP will
continue to be covered. Fast-track
and Cover Oregon are there for those
who are new to the OHP.
FamilyCare is a local health plan,
founded to serve people on the
Oregon Health Plan. We are one of two
coordinated care organizations serving
the tri-county area (Clackamas,
Multnomah, and Washington counties).
For the last 30 years, our innovative
approach to healthcare has created
solutions for FamilyCare members to
get comprehensive healthcare.
Our purpose is to give individuals,
one-on-one care so they can take charge
of their health. Everything
we do is for one simple reason
to connect people to the care they
need. We are looking forward to
serving more people with the same,
coordinated, personalized healthcare
FamilyCare has provided for 30 years.
What is a Coordinated Care
Organization (CCO)?
There are two ways to
check for Oregon Health
Plan eligibility:
About FamilyCare
People can visit any Oregon
Department of Human Services offce
and ask for an application. Go to
URL Reference 1.1 (www.ohp.oregon.gov)
for a list of locations. There are also
organizations within the community with
information and applications in
several languages.
Individuals can go to URL Reference 1.2
(www.coveroregon.com) to see if they qualify
for the Oregon Health Plan or other types of
coverage. There may be fnancial assistance
available for other health plans if they do not
qualify for OHP.
In-person
Online
We were the rst Medicaid health plan in
Oregon to integrate mental and physical
health coverage into one plan.
We became the rst health plan
in the tri-county area (Clackamas,
Multnomah, and Washington counties)
certied by the Oregon Health Authority
as a Coordinated Care Organization (CCO).
We were the rst 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 Stark
Portland, OR 97233
11155 NE Halsey St.
Portland, OR 97220
800 SW 13th Ave.
Portland, OR 97205
23 NW 23rd Place
Portland, OR 97210
7033 NE Sandy Blvd.
Portland,OR 97213
9710 SE Washington St., Suite B
Portland, 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
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Rose City Urgent
Care & Family
Medicine Gresham
Tuality Urgent Care
Providence Medical
Group- Gateway
Immediate Care
Geneva Urgent Care
Forest Grove
2075 NE Division
Gresham OR 97030
7545 SE TV Highway
Hillsboro, OR 97006
1321 NE 99th Ave., Suite 100
Portland, OR 97220
3838 Pacic Ave.
Forest Grove, OR 97116
(503) 894-9005
(503) 681-4223
FAX: (503) 591-9411
(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/ ADDRESS PHONE/FAX
PHONE/FAX
PHONE/FAX HOURS
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 300
Hillsboro, 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 Lane
Portland, OR 97224
1960 NW 167th Place,
Suite 103
Beaverton, 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, #140
Portland, OR 97225
9975 SW Frewing St., Suite 110
Tigard, OR 97233
12442 SW Scholls Ferry Road,
Suite 100
Tigard, 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
U
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NAME/ ADDRESS
NAME/ ADDRESS
PHONE/FAX
PHONE/FAX
HOURS
HOURS
Providence Bridgeport
Health Center
Immediate Care
Providence Tanasbourne
Health Center
Immediate Care
18040 SW Lower Boones Ferry Road,
Suite 100
Tigard, OR 97224
18610 NW Cornell Road, Suite 101
Hillsboro, OR 97124
(503) 215-9900
(503) 215-9900
Clackamas
County
Geneva Urgent Care
Wilsonville
Molalla Urgent Care
29756 SW Town Center Loop West, # L
Wilsonville, 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
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Milwaukie Urgent Care
Rodney E. Orr, MD, PC
DBA- Family Medical
Group of Molalla
Happy Valley
Immediate Care
2403 SE Monroe St., Suite A
Milwaukie, OR 9722
861 West Main St.
Molalla, OR 97038
16180 SE Sunnyside Road,
Suite 102
Happy 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 Way
Canby, OR 97013
(503) 215-9900 MonFri: 8 a.m.8 p.m.
Sherwood Immediate Care
16770 SW Edy Road, Suite 102
Sherwood, 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.
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 Clinic
Urgent 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
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American Seating and Mobility
www.asmrehab.com
(503) 2534655
Fax: (503) 2534640
Apria Healthcare
www.apria.com
(503) 2582200
Fax: (503) 2555899
Byram Healthcare
www.byramhealthcare.com
(503) 2332201
Fax: (503) 2332257
DJO
www.djoglobal.com
(800) 3366569
EMPI
www.empi.com
(800) 3282536
www.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 Commode
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:
Foothills Medical Supply
www.foothillsmedsupply.com
(800) 8714083
Fax: (503) 8741106
In Home Medical
www.inhmed.com
(541) 9666293
Fax: (541) 2783427
Keen Mobility
www.keenhealthcare.com
(503) 2859090
Fax: (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) 2346219
Fax: (503) 2346521
DME Provider,
Website, Contact
Types of Supplies
Canes Crutches Walkers Manual
wheelchairs CPAP Oxygen Hospital beds
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
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) 6071170
Fax: (503) 6071169
Walla Walla Home Medical
www.wallawallahomemedical.com
(509) 5251066
Fax: (509) 5222361
East Side Orthotics
& Prosthetics
www.surelimb.com
(503) 2576623
Fax: (503) 2576624
DME Provider,
Website, Contact
Types of Supplies
Incontinence supplies CPAP
Oxygen Bath
Complex rehab items provided
by NCHC
Items in a capped rental,
provided by NCHC
Manual wheelchairs Scooters
Walkers Manual wheelchairs
Bath equipment Enteral
Hospital beds
Incontinence supplies CPAP
Oxygen Bath
Standard wheelchairs
Items provided by Walla
Walla Home Medical
Items in a capped rental
Orthotics and prosthetics Leg braces
Back braces
Hanger Pros & Orthotics
clinic locations
www.hanger.com
(877) 442-6437
Back braces
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DME Contacts
Oregon Orthotic Services Inc.
www.oregonorthoticservices.com
(503) 2429136
Fax: (503) 2429139
Prosthetics & Orthotic Services
www.prostheticorthoticservices.com
(509) 5258322
Fax: (509) 5252982
DME Provider,
Website, Contact
Types of Supplies
Back 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:
artifcial limbs
Ostogenesis stimulators:
bone growth stimulators
Capped rental:
Medicaid there 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 fle
depending if the code for the
equipment requires authorization or
not; the equipment is not
member owned during this time.
Denitions:
Medical
Transportation/
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 only
dual members Medicare + Medicaid)
Urgent transportation
needs
Tollfree: (877) 875-4657
(503) 2658515
Toll-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)
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S
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(503) 222-2779
MetroWest @ (503) 6486656
PH Tech
Resource/Info Sheet
FamilyCare CIM
Web link: URL Reference 1.3
FamilyCare CIM
YouTube training video:
URL Reference 1.4
CIM support (error messages, etc.)
New user access and/or access
troubleshooting
EDI information
(or email: edi.support@phtech.com)
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 preferred)
Update for Optuminsight
EDI Submitters:
Starting June 30, please use
the new PH Tech payer ID
established for:
PH Tech CIM
Technical Support
(503) 5842169
Update for Emdeon
EDI Submitters:
EDI payer ID information
effective 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 paper
claims to:
FamilyCare Medicare
PO Box 5308
Salem, OR 97304
PH Tech
FamilyCare Account Representative
(503) 5842192
Email: courtney.bailey@phtech.com
www2.phtech.com
CIM
Information
and FAQ
When working in CIM, clinic staff may
fnd 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
(frst 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-flled in the Send to feld:
FCIEnrollment@familycareinc.org.
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 refect 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.
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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.
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 frst 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 allows
users 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 diagnosis
code 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), and
a Detail option.
The detail option will display the Prioritized Lists
information regarding that line, including all the
codes present on that line (ICD-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)
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BELOW THE LINE
ICD-9 784.0 (headache)
ABOVE and BELOW THE LINE
ICD-9 784.0 ICD-9 850.9
(unspecifed concussion)
NOT RANKED
ICD-9 719.46
(pain in joint, lower leg)
DMAPs MMIS provider portal is
another tool with capabilities of
conducting ICD-9 line searches, via
the Benefts and HSC Inquiry tool.
For MMIS access and registration,
contact the Oregon Health Authority
(OHA) at URL Reference 1.7, or call
toll-free (800) 3366016.
An excellent resource for Medicaid
providers, Keys to Success
can be found at URL Reference 1.8.
Please note that the Benefts and
HSC Inquiry tool in MMIS may be
confusing to users, as information
generated can provide misleading
results. Therefore, while DMAPs
Benefts and HSC Inquiry tool
may provide useful to some users,
FamilyCare recommends using
CIM frst and foremost to conduct
ICD-9 searches.
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 offce 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 fle for all ages and specialty
types except OB/GYN providers
for family planning purposes (like
contraceptive management and
sterilization), 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 refected 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 identify
conditions 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-offce
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, effcient
healthcare system in cooperation
with specialists and other providers.
To that end, patient care should be
managed through our members
primary care physician offces.
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 current
a 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 nd a list of
FamilyCare contracted specialists?
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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
offce 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-specifc code.
If all attempts have been made
and your offce is still unable to place
the member with an appropriate
specialist, please fax the 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 Verication 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 than 13 months before the
date of inquiry, and To date no later than the date 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 Benet Plan section of the screen.
1. Client information
Last EPSDT : Not used.
Last Dental Visit: Date of the visit
(blank if none)
Phone Number: Of DHS branch.
2. Benet plan(s)
Only these codes are for medical
benets:
BMD, BMM: OHP with Limited
Drug
BMH: OHP Plus
BMP : OHP Plus Supplemental
KIT: OHP Standard
CWX: OHP Plus coverage for
CAWEM Prenatal program clients
CWM: CAWEM
MED: Medicare Beneciary
4. Third-party liability (TPL)
Information and coverage dates
5. Managed care
Eective dates of managed care or Primary
Care Manager (PCM) enrollment. Plan types:
CCOA: Coordinated care organization
(CCO) for physical, dental and mental
health care
CCOB: CCO for physical and mental
health care
CCOE: CCO for mental health care only
DCO: Dental Care Organization
FCHP: Fully Capitated Health Plan
MHO: Mental Health Organization
PCO: Physician Care Organization
CCOG: CCO for mental and dental health
only
6. Lockin
Assigned pharmacy for Pharmacy Management Program clients (not
used).
7. Service limitation
The next available date of service for the procedure entered.
DMAP 3161 (08/13)
HEALTH CARE PROGRAMS
Division of Medical Assistance Programs
3. Service Type Coverage and Copay
This screen shows the services covered by the benet plan
selected, grouped by service type (e.g., Medical Care or
Pharmacy). Non-covered services will not display here.
Coverage: Active or Limited
Copay: The amount to pay ($0, $1, or $3). If a client
with BMD, BMM, or BMH benets is exempt from
copayment, this eld will read $0.00 for all services.
Questions? Call DMAP Provider Services at 800-336-6016.
1. 6.
2.
3.
4.
5.
6.
7.
I am having difculty referring
a 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 providers
to identify an offce where the
members referral may be placed.
FamilyCare will then notify your offce
when the member is accepted to an
offce. Please do not request that
FamilyCare coordinate orthopedic
referrals frst, before your offce has
frst 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 diffcult,
the provider should make every
attempt to refer the member to
an orthopedic specialist before
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 fle a reconsideration or
review of a claim by choosing the
appropriate link on the provider
portal. You will need to fll 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
provider.enrollment@state.or.us.
For Medicare claims with
dates of service on or after
January 1, 2010, timely fling
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
fling for non contracted
providers is 120 days from the
date of services. Contracted
providers, please see
your contract.
Q: How can I check the
status of a claim which I
have submitted?
Q: How would I le a
reconsideration/review
for a claim?
Q: My claim was rejected for
No Medicaid/Medicare
number, what do I need to
do to get my claim processed?
Q: How long do I have to
le a claim?
Regardless of location, you
can have FamilyCare apply for
an Oregon Medicaid number on
your behalf. To do so, please fll
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 active
Medicare/PTAN number. If the
provider in question is enrolled
in Medicare, please Fax proof of
Medicare enrollment to Provider
Services at (503) 734-3188.
FamilyCare Health
Plans is dedicated
to creating healthy
individuals and
healthy families.
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Member Search and
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 felds.
In the center of the page body, just
below the search criteria are
instructions onwhat combination of
criteria is required for the search.
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After the required data is entered,
click on the Search button to the right
of the input felds.
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, frst verify that a
drop-down option from the
Insurance Carrier feld 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 feld 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
Member Search and
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On the multiple records Search
Results 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 frst 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 frst 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 identifer.
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.
FAQ for Referrals
and Authorizations
With the exception of routine
OBGYN care and diagnoses
listed on the NO AUTH list,
all offce 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 offce
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 offce 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 offce is responsible for
requesting any follow-up services,
once the evaluation is complete. The
therapy offce 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 Referral
Q: Do I need an authorization?
Q: Do I need to send
chart notes?
1. Confrm PCP (provider) made
attempt to fnd 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 Authorization
page, complete (at minimum) the
required information (denoted by
red feld labels). The Member,
Start Date and Referring Prov
felds are auto-flled, when the
page frst displays.
A:
A:
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For orthopedic specialist:
Submitting
Referrals
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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 offce.
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 feld is auto-flled 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 feld is auto-flled
with the current days date. If the
auto-flled start date is
incorrect, type in the correct date.
Defaulted Fields
The start date must be within the eligibility timespan
listed in the Member feld.
If the start date is NOT within the eligibility
timespan listed in the Member feld, 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 be
submitted. Exit the page.
Referring Prov:
TheReferring Prov feld is
auto-flled by default with the members PCP.
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 Providence
Neurodevelopmental 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 a
single pre-authorization
CPTs for
Team 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
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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 offce
where the member will be seen in order to determine which services should be
specifed in your pre-authorization or referral request.
If your offce has a request for one of these clinics, refer to this list to determine
which CPTs to use. We will use this tool to confrm 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 offce visits
and offce 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 feld.
Dear Provider,
If you have any questions, please call.
Sincerely,
Galen Sinnock, Team Lead
Referrals and Authorizations
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 Bida 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
97003
Autism Clinic
Physician:
Discipline CPT
99201
97003
92521
96101
97003
Neurodevelopment Clinic
Physician:
Discipline CPT
99201
97003
92521
97001
97003
C
o
d
e
s
Codes
Codes

FAMI LYCARE I NCORPORATED 825 NE MULTNOMAH, SUI TE 300 PORTLAND, OR 97232
503-222-2880 800-458-9518 TTY/TTD: 711 WWW. FAMI LYCAREHEALTHPLANS. ORG
FamilyCare Health Plans Referal Department
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: ______________ Urgent Request: (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
2
92521 Will be listed on auth allowing for any one of the following codes: 92521 92524
Attention Requested 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 a
No 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 list 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 15min
modalities/visit) 97003 Occupational Therapy Eval
SPEECH
92521
2
Speech Eval E2511 Speech software for personal computer
92610 Swallow Eval E2512 Accessory for Speech Device- Mounting
92507 Tx of Speech followup E2599 Accessory for Device
92508 Group Speech L7510 Repair of Device, Minor
92526 Tx swallowfollowup L7520 Repair of Device, labor per 15 min
92611 Fluoroscopic Eval L8500 Artificial Larynx, any type
S9152 ST Re-Eval L8501 Trach Speaking valve
A4649 St Supplies L8507 Tracheo-Esophageal voice prosthesis, patient
E2500 Speech Device < or = 8 min L8509 Tracheo-Esophageal voice prosthesis, provider
E2502 Speech Device > 8 or < 20 min L8510 Voice amplifier
E2506 Speech Device > 20 or < 40 min L8515 Gelatin capsule, application
E2508 Speech Device message formulation L9900 O&P supply of another HCPC
E2510 Speech Device Multiple Methods V5336 Repair/Modify Device
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
www.team.provider-access@state.or.us
www.oregon.gov/oha/healthplan/tools_prov/keys2success.pdf.
42
FamilyCare Health Plans Referral Department

FamilyCare Final 2014 Provider Resource Guide

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2014 Provider Resource Guide

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