Policies and forms
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:
Behavioral health guidelines and forms
- Treatment Authorization Form - Applied Behavioral Analysis Services
- Behavioral Health Utilization Management Procedure Handbook
- Noncontracted MH and SUD fee schedule
- JCC Provider peer FAQ
- JCC Narrative Access Report
- Neurofeedback Frequently Asked Questions
Behavioral Health Delegated Credentialing
- Delegated Credentialing Provider Roster Template
- Credentialing Changes FAQ
- Delegated Credentialing Training Tool
Behavioral Health Documentation Requirements
- Behavioral Health Non COA Providers Documentation Standards
- Behavioral Health COA Providers Document Standards Checklist
- SUD Providers Documentation Standards Checklist
- Outpatient Behavioral Health Provider Requirements
Policies: General
Policies: Pharmacy
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
- Hepatitis C Prior Authorization Request form (OHP only)
- Nutritional Supplement Medication Request form
- Pharmacy Provider Reconsideration Request form
Policy updates and other forms: Pharmacy
- Authorization Policy-Injectables/Medications Administered Under the Medical Benefit (Updated 8/2024)
- Authorization Guidelines - Injectable Drugs for Bleeding and Clotting Disorders (Updated 3/2024)
- HepC DUR Provider Update
Electronic prior authorization Q&As
- Network provider ePA Q&A
- Surescripts ePA Assistance Guide
Treatment Pathways
- CareOregon Diabetes Treatment Pathway
- CareOregon Asthma Treatment Pathway - Pediatrics and Adults
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).
Diagnostic and treatment procedures: CPT code grid
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
- Care Coordination for Certified Community BH Clinics FAQ
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
- CareOregon Diabetes Resource Guide
- Policies and forms
- Language services
- Quality metrics toolkit
- Behavioral health providers FAQ
- Behavioral Health Qualified Directed Payments
- Strategic Healthcare Investment for Transformation (SHIFT)
- Spring Conference presenter bios
- Spring Conference session descriptions
- Policies and forms
- Language services
- Quality metrics toolkit
- Behavioral health providers FAQ
- Behavioral Health Qualified Directed Payments
- Strategic Healthcare Investment for Transformation (SHIFT)
- Spring Conference presenter bios
- Spring Conference session descriptions
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