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.
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.
Effective 1/1/17: Authorization is required for the following services:
- All Urgent/Emergent Inpatient Stays require notification within 24-hr of admission.
- All Elective (Planned) Inpatient Hospital Stays and IP Surgeries.
- All Skilled Nursing Facility and LTAC Stays: Initial Admit and Continued Stay.
- Some Prescription Drugs.
- Specific services on List of Services Requiring Authorization (Medicare Only) that include:
Durable Medical Equipment
Ortho Surgery: Hip, Knee, and Shoulder
Radiology: MRI, CT, PET, and SPECT scans
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.
- Specialist Referrals and Procedures, Injections and Infusion, Home Health, Hospice
- Outpatient Rehabilitation Therapy, Chiropractic, Acupuncture
- Synagis Therapy
- Skilled Nursing Facility Initial Admit
- Skilled Nursing Facility Continued Stay
Some authorizations may need extra documentation:
- A&D Residential Authorization
- CCC's Recuperative Care Program
- Children's Respite Request Form
- Mental Health & Chemical Dependency Authorization
- Psychological/Neuropsychological Testing
- Flexible Services Request Form
- Intensive Care Coordination and Wraparound Referral Packet
- Reconsideration/Review of a Claim
- Request an Interpreter
- Request a Drug Exception
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.