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Referrals and Authorizations

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.

Reminder to contracted providers: Requirement for timely filing of claims is 120 days from date of service.

Medicaid

Effective 4/7/17: List of Services Not Requiring Authorization (Medicaid only) 

When providing services specified on the “List of Services Not Requiring Authorization”:

  • Member must have active coverage at time of service. 
  • The service must be a Covered Service pursuant to HERC Prioritized List and/or applicable OAR guidelines. HERC Website **Claims will be denied for services rendered that do not meet guidelines specified on the HERC Prioritized List and/or applicable OAR.**
  • Services rendered by non-contracted providers are reimbursed at DMAP rates as payment in full. Members cannot be billed for balance.

Request to Add Code to Medicaid No Authorizations List Request Form (Medicaid only)

Medicare

Effective 1/1/17: Authorization is required for the following services:

          Cardiac Services

           Durable Medical Equipment

           Medical Drugs 

           Ortho Surgery: Hip, Knee, and Shoulder 

           Radiology: MRI, CT, PET, and SPECT scans 

           Sleep Studies 

           Spinal Surgery Procedures and Epidural Injection

           Other Surgeries: Hammertoe, Bunionectomy, Carpal Tunnel, Sinus Surgery        

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

NOTE: You can no longer electronically complete an authorization form on the FamilyCare Health website then submit it via fax. 

For questions, to check on a coverage decision, a Part D exception request, or an appeal, call Navigation Services at 503-222-2880 or 800-458-9518. 

Request for:

Some authorizations may need extra documentation:

Other Requests:

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.

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.   


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