Transitioning to CareOregon Advantage
We want to make sure your transition to our health plan or your start to a new plan year is as smooth as possible.
If you are currently receiving treatment covered by Medicare, or if treatment was planned prior to you becoming a CareOregon Advantage member, we will cover your treatment during the first 90 days you are on our plan. This is known as “continuity of care.” After 90 days, we will require prior authorization and/or require you to receive your treatment from an in-network provider if it is being provided by a provider that is not in our network.
Medicare Part C organization determinations and appeals
Organization determinations
If you, your representative or your health care provider want to request an organization determination or prior authorization for medical services or drugs administered in the physician’s office, here are a few different ways you can make the request.
- Call: 503-416-4279, toll-free 888-712-3258 or TTY 711
- Fax:
Part B Drugs: 503-416-4722
Medical Services: 503-416-3671 - Mail: CareOregon Advantage
Attn: Clinical Operations
315 SW Fifth Ave
Portland, OR 97204
Appeals
There are several ways you, your representative or your doctor can request an appeal:
- Call: 503-416-4279, toll-free 888-712-3258 or TTY 711
- You can write out your request and fax or mail it to us
Fax:
Part B Drugs: 503-416-1428
Medical Services: 503-416-8118
Mail: CareOregon Advantage
Attn: Clinical Operations
315 SW Fifth Ave
Portland, OR 97204
Coverage policies
CareOregon Advantage makes coverage decisions based on National Coverage Determinations, Local Coverage Determinations or other CMS published guidance. If guidelines are absent or vague, CareOregon Advantage may develop and maintain our own clinical policies.
Covered medical services, limitations, and exclusions can be found in the CareOregon Advantage Evidence of Coverage and Summary of Benefits.
Continuous glucose monitors prior authorization criteria
- Continuous Glucose Monitoring Prior Authorization Criteria (obtained at the pharmacy)
Medical services and Part B drugs that require prior authorization
- OHP Auth required list: Injectable and Oncology Medications Administered by Provider
- Auth Policy for Injectables- Bleeding Clotting-Disorders
