Referrals and Authorizations
Assigning members to a Primary Care Provider
All members are assigned to a primary care provider (PCP) shortly after their enrollment to FamilyCare Health. We currently offer members and PCPs a 120-day transition period, during which new patients can meet with the PCP of their choice, even if they’re not the assigned PCP. This gives us a chance to help members find a new plan or a new PCP.
If you agree to see a FamilyCare Health member for a non-emergency regular office visit outside of this transition period and you aren’t the assigned PCP, the claim will be denied. If you call Provider Navigation Services prior to the appointment, we can assist in getting the member assigned to you so the claim for the care is approved. If you have any questions or concerns, please call our Provider Education Services at 503-222-2880 or 800-458-9518.
Clinical Practice Guidelines
FamilyCare Health adopts practice guidelines, specified in 42 CFR 438.236 (b), (c) and (d), that are based on valid and reliable clinical evidence or a consensus of healthcare professionals and that consider the needs of Members in consultation with Participating Providers and reviews and updates them periodically as appropriate. FamilyCare Health recommends the following clinical practice guidelines to help practitioners and members make decisions about appropriate health care for specific clinical circumstances. See our Clinical Guidelines.
Not all services require authorization. Please refer to the links below to see if you need to submit a request. FamilyCare Health has a no retro authorization policy. Claims for services requiring prior authorization will be denied if rendered prior to receiving authorization.
Please note: You now have two ways to submit referrals and authorizations to FamilyCare Health:
- Electronically, via PH Tech’s Community Integration Manager, or CIM
- Via fax, after downloading and filling in by hand one of the forms below
- Specialist Referrals and Procedures, Injections and Infusion, Home Health, Hospice
- Outpatient Rehabilitation Therapy, Chiropractic, Acupuncture
- Durable Medical Equipment (DME)/Prosthetic Orthotic Services (POS)
- Skilled Nursing Facility Initial Admit
- Skilled Nursing Facility Continued Stay
- Recuperative Care Program
Behavioral Health Services
- Mental Health & Chemical Dependency Authorization
- Substance Use Disorder Residential Treatment
- Youth Respite Request Form
- Psychological/Neuropsychological Testing
- Referral to Applied Behavioral Analysis (ABA)
- Applied Behavioral Analysis (ABA) Authorization
- Flexible Services Request Form
- Intensive Care Coordination and Wraparound Referral Packet
- Reconsideration/Review Claim Reconsideration Request Form
- Request an Interpreter