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 4/7/17List 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:

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. 

This change is happening for two reasons: The Adobe software used to create and update these is now unavailable, and most FamilyCare Health providers already use one of the two available methods. We recommend using CIM for the fastest turnaround time. To learn more about CIM, including how to register for or use the system, see All About Claims.

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. 

Note: Forms have been updated for ICD-10.

Request for:


Some authorizations may need extra documentation:

Other Requests:

Clinical Practice Guidelines
FamilyCare 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 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. 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 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.   

Upcoming Events

Popular Links