2014 Provider Resource GuideTable 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: www.familycareinc.org FamilyCare Navigation Services (customer service) FamilyCare Referrals and 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 Toll–free (888) 440-9912 • Capitol Dental: Toll–free (800) 525-6800 • Access Dental: (503) 445-9056 Toll–free (877) 213-0357 • Managed Dental: Toll–free (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) 345–5756 FamilyCare Credentialing Phone: (503) 471-2129 Fax: (503) 471-2156 E–mail:
[email protected] 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: Toll–free (800) 458-9518 • ODS/Moda: (503) 265-5680 Toll–free (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 www.familycareinc.org Benefit 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) 222–2880 Toll–free (800) 458–9518 (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. 4 www.familycareinc.org 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 Oregon’s 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 Toll–free (800) 458-9518 (TTY 711) Monday through Friday 9 a.m.–5 p.m. Call Oregon Health Plan customer service at 6 www.familycareinc.org (800) 699–9075 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 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 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 Mon–Fri: 9 a.m.–7:30 p.m. Sat & Sun: 9 a.m.–4 p.m. Mon–Fri: 8 a.m.–6 p.m. Sat: 9 a.m.–5 p.m. Closed on Sunday Mon–Fri: 9 a.m.–5 p.m. Children 16 years of age or older 7 days a week: 8 a.m.–8 p.m. Mon–Sun: : 8 a.m.–8 p.m. 7 days a week Mon–Fri: 9 a.m.–6 p.m. Sat: 9 a.m.–6 p.m. Mon–Fri: 9 a.m.–6 p.m. Sat: 9 a.m.–6 p.m. NAME/ ADDRESS PHONE/FAX HOURS Multnomah County U r g e n t C a r e C e n t e r s 8 www.familycareinc.org 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 Pacific 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 Mon–Fri: 8 a.m.–6 p.m. Sat: 9 a.m.–5 p.m. Closed on Sunday Sun–Sat: 8 a.m.–8 p.m. 7 days a week Mon–Fri: 8 a.m.–8 p.m. Sat & Sun: 9 a.m.–7 p.m. Mon–Fri: 9 a.m.–7 p.m. Sat & Sun: 10 a.m.–4 p.m. 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 Mon–Fri: 9 a.m.–7 p.m. Sat & Sun: 10 a.m.–4 p.m. Mon–Thu: 8:30 a.m.–4 p.m. Fri: 8:30 a.m.–1 p.m. Taking established members only Mon–Wed, Fri: 8 a.m.–5 p.m. Tue & Thu: 10:30 a.m.–7 p.m. Mon–Fri: 8 a.m.–8 p.m. Sat: 9 a.m.–5 p.m. Children 16 years of age or older Portland Clinic Urgent Care/SW Legacy Randall Children’s 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 Mon–Fri: 8 a.m.–8 p.m. Sat: 9 a.m.–5 p.m. Children 16 years of age or older Mon–Fri: 5 p.m–11 p.m. Sat–Sun: 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 Mon–Fri: 6 p.m.–9 p.m. Sat-Sun: 1 p.m.–9 p.m. Open most holidays Accepts newborns to age 21 Mon–Fri: 8 a.m.–6 p.m. Sat: 9 a.m.–5 p.m. Closed on Sunday Mon–Fri: 8 a.m.–8 p.m. Sat & Sun: 9 a.m.–7 p.m. U r g e n t C a r e C e n t e r s 10 www.familycareinc.org 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 Mon–Fri: 8 a.m.–8 p.m. Sat & Sun: 9 a.m.–5 p.m. Mon–Fri: 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, # L Wilsonville, OR 97070 861 W Main St. Molalla, OR 97038 (503) 685-9165 FAX: (503) 685-9163 (503) 829-7344 Mon–Fri: 9 a.m.–7 p.m. Sat & Sun: 10 a.m.–4 p.m. Mon–Fri: 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 Sun–Mon 8 a.m.–8 p.m. Open 7 days a week NAME/ ADDRESS PHONE/FAX HOURS U r g e n t C a r e C e n t e r s 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 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 Mon–Sat: 10 a.m.–7 p.m. Mon–Fri: 5 a.m.–9 p.m. Sat: 12 p.m.–8 p.m. Sun: 12 p.m.–6 p.m. Mon–Fri: 8 a.m.–8 p.m. Sat & Sun: 9 a.m.–7 p.m. Providence Medical Group Canby Immediate Care 200 S Hazel Dell Way Canby, OR 97013 (503) 215-9900 Mon–Fri: 8 a.m.–8 p.m. Sat & Sun: 9 a.m.–5 p.m. Providence Medical Group Sherwood Immediate Care 16770 SW Edy Road, Suite 102 Sherwood, OR 97140 (503) 215-9900 Mon–Fri: 8 a.m.–8 p.m. Sat & Sun: 9 a.m.–5 p.m. NAME/ ADDRESS PHONE/FAX HOURS Columbia County Legacy Urgent Care St Helens 500 N Columbia River Hwy., Suite 7 St. Helens, OR 97051 (503) 397-7119 Mon–Fri: 12 p.m–8:30 p.m. Weekends and holidays: 10:00 a.m.–5:00 p.m. 12 www.familycareinc.org 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 Mon–Fri: 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 D M E C o n t a c t s American Seating and Mobility www.asmrehab.com (503) 253–4655 Fax: (503) 253–4640 Apria Healthcare www.apria.com (503) 258–2200 Fax: (503) 255–5899 Byram Healthcare www.byramhealthcare.com (503) 233–2201 Fax: (503) 233–2257 DJO www.djoglobal.com (800) 336–6569 EMPI www.empi.com (800) 328–2536 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: 14 www.familycareinc.org Foothills Medical Supply www.foothillsmedsupply.com (800) 871–4083 Fax: (503) 874–1106 In Home Medical www.inhmed.com (541) 966–6293 Fax: (541) 278–3427 Keen Mobility www.keenhealthcare.com (503) 285–9090 Fax: (503) 223–9488 KCI www.kci.com (800) 275-4524 Norco (previously CareMedical) www.norco-inc.com (503) 288–8174 Fax: (503) 288–8817 Northwest Medical, Inc. www.nwmed.com (503) 234–6219 Fax: (503) 234–6521 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 • 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) 325–9906 Fax: (503) 325–1437 Olson Medical www.olsonmedicalservices.com (503) 607–1170 Fax: (503) 607–1169 Walla Walla Home Medical www.wallawallahomemedical.com (509) 525–1066 Fax: (509) 522–2361 East Side Orthotics & Prosthetics www.surelimb.com (503) 257–6623 Fax: (503) 257–6624 DME Provider, Website, Contact Types of Supplies • Complex rehab • Hospital beds • 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 • 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 braces • Back braces Hanger Pros & Orthotics clinic locations www.hanger.com (877) 442-6437 • Orthotics and prosthetics • Leg braces • Back braces D M E C o n t a c t s 16 www.familycareinc.org DME Contacts Oregon Orthotic Services Inc. www.oregonorthoticservices.com (503) 242–9136 Fax: (503) 242–9139 Prosthetics & Orthotic Services www.prostheticorthoticservices.com (509) 525–8322 Fax: (509) 525–2982 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: 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. Definitions: 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 Toll–free: (877) 875-4657 (503) 265–8515 Toll-free: (800) 716–1777 Fax: (503) 954–1038 Hours: Mon–Fri: 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*) 18 www.familycareinc.org (503) 802–8700 Mon–Fri : 7 a.m.–6 p.m. Toll–free: (800) 889–8726 Oregon Relay Service: (503) 802–8058 (TTY: 711) M e d i c a l T r a n s p o r t a t i o n / I n t e r p r e t e r S e r v i c e s (503) 222-2779 MetroWest @ (503) 648–6656 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 e–mail:
[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 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) 584–2169 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) 584–2192 E–mail:
[email protected] 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 CIM’s main menu, go to “Member Search,” enter the patient data, which will bring up the patient’s 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 e–mail Regarding This Member.” Logins for CIM users A separate window or tab for an e–mail will appear, with the FamilyCare’s enrollment e–mail address auto-flled in the “Send to” feld:
[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 member’s as- signment to refect that your clinic is the member’s primary care clinic. Both our Provider-Network Services Department and our Enrollment Department can provide you with more detailed information regarding timeframes for assignments. C I M I n f o r m a t i o n a n d F A Q • 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. 20 www.familycareinc.org The Health Evidence Review Commission’s (HERC) Prioritized List of Health Services (Prioritized List) indicates what is funded under the Oregon Health Plan’s 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 line—on 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 List’s 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) C I M I n f o r m a t i o n a n d F A Q 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) DMAP’s 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) 336–6016. 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 DMAP’s Benefts and HSC Inquiry tool may provide useful to some users, FamilyCare recommends using CIM frst and foremost to conduct ICD-9 searches. 22 www.familycareinc.org 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 FamilyCare’s referral rules are refected within the CIM system, CIM will, in most cases, automatically approve the evaluation when only ONE visit is requested. FamilyCare’s 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) 345–5704 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 find a list of FamilyCare contracted specialists? C I M I n f o r m a t i o n a n d F A Q 24 www.familycareinc.org The Oregon Health Plan does not cover pain management visits for non- funded diagnoses. For funded diagnoses, FamilyCare’s 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 member’s 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 26 www.familycareinc.org 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 client’s 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 Benefit 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. Benefit plan(s) Only these codes are for medical benefits: 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 Beneficiary 4. Third-party liability (TPL) Information and coverage dates 5. Managed care Effective 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 benefit 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 benefits is exempt from copayment, this field 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 difficulty 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 member’s 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) 222–2880 or (800) 458–9518. 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
[email protected]. 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 file 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 file 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. C l a i m s F A Q 28 www.familycareinc.org 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 felds. In the center of the page body, just below the search criteria are instructions onwhat combination of criteria is required for the search. M e m b e r S e a r c h a n d D e t e r m i n i n g E l i g i b i l i t y 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 member’s 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 30 www.familycareinc.org Member Search and Determining Eligibility M e m b e r S e a r c h a n d D e t e r m i n i n g E l i g i b i l i t y On the multiple records Search Results page, a member’s 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 member’s 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 member’s PCP. From the full member record display, you will see many user tools and information links. 32 www.familycareinc.org 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: F A Q f o r R e f e r r a l s a n d A u t h o r i z a t i o n s 34 www.familycareinc.org For orthopedic specialist: Submitting Referrals S u b m i t t i n g R e f e r r a l s 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 member’s 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 day’s 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: The“Referring Prov” feld is auto-flled by default with the member’s PCP. 36 www.familycareinc.org 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 OHSU’s 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: Occupational Therapy evaluation: Speech Language Pathologist evaluation: Discipline CPT 99201 97003 92521 Craniofacial Disorders Clinic Physicians (two): Physical Therapy evaluation: Speech Language Pathologist evaluation: Discipline CPT 99201 97001 92521 NICU follow-up Clinic Physicians (two): Occupational Therapy evaluation OR: Physical Therapy evaluation: Discipline CPT 99201 97003 97001 Wheelchair Clinic Physicians (two): Occupational Therapy evaluation and/or: Physical Therapy evaluation: Discipline CPT 99201 97003 97001 Spasticity Clinic Physicians (two): Physical Therapy evaluation: Discipline CPT 99201 97001 Communication Disorders Clinic Physician: Speech Language Pathologist evaluation: Occupational Therapy evaluation: Psychology visit: Discipline CPT 99201 92521 97003 96125 96101 C o d e s 38 www.familycareinc.org 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, Legacy’s Feeding Clinic provides a speech therapy evaluation, where as CDRC’s Feeding Clinic provides a swallowing function evaluation. We’re 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: Speech Language Pathologist evaluation: Occupational Therapy evaluation: Psychological evaluation: Discipline CPT 99201 92521 97003 96101 Feeding Clinic Physician: Speech Language Pathologist evaluation: Occupational Therapy evaluation: Medical nutrition: Discipline CPT 99201 92521 97003 97802 School-Age Diagnostic Clinic Physician: Speech Language Pathologist evaluation: Occupational Therapy evaluation: Psychological evaluation: 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): Speech Language Pathologist evaluation: Discipline CPT 99201 92506 CDRC Genetics Clinic Physicians (multiple): Services as needed: Discipline CPT 99201 TBD Spina Bifida Clinic Physicians (multiple): Physical Therapy evaluation: Speech Language Pathologist evaluation (sometimes): Occupational Therapy evaluation (sometimes): Psychological testing (sometimes): Discipline CPT 99201 97001 92521 97003 96101 LEND Clinic Physician: Speech Language Pathologist evaluation: Psychological testing: Physical Therapy evaluation (sometimes): Occupational 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: Occupational Therapy evaluation: Speech Language Pathologist Physical Therapy evaluation: Discipline CPT 99201 97003 92521 97001 Healthy Lifestyles Clinic Physician: Physical Therapy evaluation: Psychological evaluation: Medical nutrition: Discipline CPT 99201 97001 96150 97802 Feeding Clinic Physician: Swallow function evaluation: Occupational Therapy evaluation: Medical nutrition: Discipline CPT 99201 92610 97003 97802 Child Development Clinic Physician: Speech Language Pathologist evaluation: Psychological testing: Physical Therapy evaluation (sometimes): Occupational Therapy evaluation (sometimes): Discipline CPT 99201 92521 96101 97001 97003 Rett Syndrome Clinic Physician: Occupational Therapy evaluation: Speech Language Pathologist evaluation: Physical Therapy evaluation: Occupational Therapy evaluation (sometimes): Discipline CPT 99201 97003 92521 97001 97003 Autism Clinic Physician: Occupational Therapy evaluation: Speech Language Pathologist evaluation: Psychological testing: Occupational Therapy evaluation (sometimes): Discipline CPT 99201 97003 92521 96101 97003 Neurodevelopment Clinic Physician: Occupational Therapy evaluation: Speech Language Pathologist evaluation: Physical Therapy evaluation: Occupational Therapy evaluation (sometimes): Discipline CPT 99201 97003 92521 97001 97003 C o d e s 40 www.familycareinc.org 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. ¹97110 —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 97110¹ 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
[email protected] www.oregon.gov/oha/healthplan/tools_prov/keys2success.pdf. 42 FamilyCare Health Plans Referral Department