Policies and forms

Click here to learn more about BH Qualified Directed Payments (BH QDP)

This section includes medical policies, forms and medical management guidelines for physical and behavioral health. Some documents are provided by CareOregon, the health insurance provider that works with Jackson Care Connect. For dental health information, visit the provider page of the appropriate plan:

• Advantage Dental
• Capitol Dental
• ODS

Behavioral health guidelines and forms

• Treatment Authorization Form - Applied Behavioral Analysis Services 
• Behavioral Health Documentation Standards
• Behavioral Health Outpatient Provider Requirements
• Behavioral Health Utilization Management Procedure Handbook
• Noncontracted MH and SUD fee schedule
• JCC Provider peer FAQ
• JCC Narrative Access Report

Behavioral Health Delegated Credentialing

• Delegated Credentialing Provider Roster Template
• Credentialing Changes FAQ
• Delegated Credentialing Training Tool

Policies: General

• Criteria used for utilization management decisions

Policies: Pharmacy

• OHP Prior Authorization Use criteria

Forms: Pharmacy

• Home Infusion Prior Authorization 
• Prior Authorization and Formulary Exception Request form (OHP only)
• Injectable Medication Administered by Provider Authorization form
• Hospice Prior Authorization form
• Chemotherapy Prior Authorization and Formulary Exception Request form (OHP)
• Hepatitis C Prior Authorization Request form (OHP only)
• Hepatitis C Case Management Request form
• Hepatitis C Case Management Member Opt-Out form
• Nutritional Supplement Medication Request form
• Synagis Medication Request form
• Opioid Prior Authorization form Dynamic PA (OHP only)
• Pharmacy Provider Reconsideration Request form

Policy updates and other forms: Pharmacy

• Authorization Policy-Injectables/Medications Administered Under the Medical Benefit (Updated 6/2023)
• Authorization Guidelines - Injectable Drugs for Bleeding and Clotting Disorders (Updated 4/2022)

Authorization guidelines and forms

Eligibility

Use the Provider Portal to verify a member’s eligibility with Jackson Care Connect.

Authorization guidelines 

Changes are posted on the 15th day of the calendar month (or the next business day).

• CareOregon Utilization Management Procedure Handbook

Diagnostic and treatment procedures: CPT code grid

• Authorization guidelines by CPT code

DME: Authorization and code lists

• DME No Auth Required List (OHP and Medicare)
• DME Change of Vendor Request form (OHP and Medicare)

Frequently asked questions (FAQs)

• Comorbid conditions FAQ
• DME and supplies FAQ
• National Drug Code (NDC) requirements FAQ
• Surgical Procedure Anatomical Modifier Rule

Authorization request forms

• Enteral/Parenteral Prior Authorization form
• DME Prior Authorization form
• HOME INFUSION Prior Authorization
• Dental Hospitalization Authorization form (OHP and Medicare)
• Inpatient Authorization form (OHP and Medicare)
• Retro Facility Authorization form (OHP and Medicare)
• Retro Office Clinic Authorization form (OHP and Medicare)
• Limb Prosthetic Prior Authorization form (OHP and Medicare)
• Safe Opioid Use Tapering Plan Prior Authorization form
• SNF-IPR-LTAC Authorization Request form (OHP and Medicare)
• RCP Authorization Request form (OHP)

Miscellaneous policies and forms

• Oregon Medicaid Practitioner Application form
• Oregon Medicaid Organization Application form
• Referral Form: Early Intervention/Early Childhood Special Education (EIECSE) Birth to Age 5
• Complex Care Case Management Referral
• Provider Claim Appeal form
• Member Request to Review Claim Records form
• Client Agreement to Pay for Health Services form: Medicaid (OHP)
• Oregon Health Authority Primary Care Provider Attestation
• PCP Re-Assignment Request form (OHP and Medicare)
• Health-Related (Flex) Services Policy
• Health-Related (Flex) Services request form
• Health-Related Services: K Plan Letter request
• Health-Related Services: Hotel Liability form
• Health-Related Services: Hotel request checklist
• Health-Related Services: Budget worksheet
• Health-Related Services: States of Emergency Request form instructions
• Health-Related Services: States of Emergency Request form
• Hospital-based Credentialing Notification form
• Member Incentive form
• Member incentives frequently asked questions
• Traditional Health Worker Provider Enrollment form
• Traditional Health Workers Claims Submission Guide
• Doula Enrollment form
• Model of care training: Presentation (PPTX) | Attestation (DOCX)
• JCC Member phone request policy and procedure