2909 Daggett Ave, Suite 225 ⚫ Klamath Falls, OR 97601 ⚫ 541-883-2947 ⚫ Fax: 541-882-6914 Cascade Health Alliance Provider Manual Current as of 10/19
Mar 26, 2019 · 2909 Daggett Ave, Suite 225 ⚫ Klamath Falls, OR 97601 ⚫ 541-883-2947 ⚫ Fax: 541-882-6914 Cascade Health Alliance Provider Manual Current as of 10/19
Mar 26, 2019 — Provider Manual. Current as ... This manual provides critical information regarding the provider and plan responsibilities and ... (541) 723-2021.
Cascade Health Alliance Provider Manual
Current as of 10/19 2909 Daggett Ave, Suite 225 Klamath Falls, OR 97601 541-883-2947 Fax: 541-882-6914
Contact Information
Authorizations Utilization Management Department
Physical health Ph: 541-883-2947 Fx: 541-882-6914
Behavioral health Ph: 541-883-2947 Fx: 541-851-2069
Claims Department Ph: 541-883-2947 Fx: 541-273-0135
Compliance Department Email: compliance@cascadecomp.com
Customer & Member Services Primary Care Provider (PCP)/ Primary Care Dentist (PCD) assignments, authorization status
inquiry, and claim status inquiry Ph: 541-883-2947
Member Grievances, Appeals, & Hearings Compliance Department
Ph: 541-851-2078 Fx: (541) 882-6914 Member grievances and appeals can be submitted to CHA in person or by mail. A hearing request can be delivered in person or mailed to CHA or mailed/faxed directly to:
OHA-Medical Hearings 500 Summer St. NE E49 Salem, OR 97301-1077
Fx: 503-945-6035
Case Management Department Physical health
Ph: 541-883-2947 Fx: 541 882-6914 Behavioral health
Ph: 541-883-2947 Fx: 541-851-2069
Credentialing Quality Management Department
In-network providers Ph: 541-851-2092 Fx: 541-885-9858 Email: credentialing@cascadecomp.com
Contracting Ph: 541-883-2947 Fx: 541-885-9858
Dental Authorizations Claims Department
Ph: 541-883-2947 Fx: 541 882-6914
Member & Provider Complaints Compliance Department
www.cascadehealthalliance.com/contact/
Reconsiderations (Provider Appeals) Chief Medical Officer (CMO) and Compliance Department
Provider requesting appeal for a member denial Ph: 541-851-2078 Fx: (541) 882-6914
Pharmacy Services Department Prescription authorizations and signature programs (tobacco cessation, respiratory care management,
diabetes care management) Ph: 541-883-2947 Fx: 541-883-6104
Provider Enrollment Claims Department Out-of-network, out-of-area providers Ph: 541-883-2947 Fx: 541-273-0135
Provider Relations Ph: 541-883-2947 Fx: 541-885-9858
Quality Metrics Quality Management Department qualitymanagement@cascadecomp.com
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General Information
Cascade Health Alliance (CHA) 2909 Daggett Ave, Suite 225 Klamath Falls, OR 97601 Ph: 541-883-2947 Fx: 541-885-9858 www.cascadehealthalliance.com
CHA HIPAA Privacy Officer Ph: 541-883-2947
Oregon Department of Human Services (DHS) Service Delivery Area 11 (Klamath and Lakes Counties) Ph: 541-883-5570 http://www.oregon.gov/dhs/
Oregon Health Authority (OHA) Office of Information Services Ph: 877-398-9238 http://www.oregon.gov/oha
Oregon Health Plan (OHP) Ph: 1-800-699-9075 To learn more about OHP, go to OHA's website or follow the link below. http:/www.oregon.gov/oha/hsd/ohp
Oregon Medicaid Automated Voice Response Ph: 1-866-692-3864 For a description on how to use the Oregon Medicaid Automated Voice Response, go to OHA's Website.
Reporting Non-Compliance and Fraud, Waste, and Abuse (FWA)
CHA Compliance Officer: 541-883-2947
abuse@cascadecomp.com
Anonymous Online Reporting: (on the CHA website under "Contact Us") https://cascadehealthalliance.com/contact/
CHA maintains a strict Non-Intimidation and Non-Retaliation Policy.
Refer to Contact Information, Web Resources, Important Forms and Resources, and Klamath County Resource Guide for more details.
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CHA Web Resources
This page is a quick reference to a few items on the Cascade Health Alliance (CHA) website. Refer to Important Forms and Resources for more information.
Approved Drug List (Formulary)
Find CHA's Drug Formulary on CHA's website under Member Resources or follow the link below. https://cascadehealthalliance.com/wp-content/uploads/2018/06/2018-CHA-Formulary-Updated-6-20-18.pdf
Provider Portal
Access the Provider Portal at the link below. https://cascadehealthalliance.com/provider-portals/
Policies, Procedures, and Forms
Access CHA policies, procedures, and forms at the link below. https://cascadehealthalliance.com/policies-procedures-and-forms/
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OHA Web Resources
This page is a quick reference to a few Oregon Health Authority (OHA) websites. Refer to Clinical Practice Guidelines or Important Forms and Resources for more information.
Oregon Health Evidence Review Commission (HERC)
The Health Evidence Review Commission (HERC) reviews medical evidence to prioritize health spending in the Oregon Health Plan (OHP) and to promote evidence-based medical practice statewide through comparative effectiveness reports, including coverage guidance's and multisector interventions, health technology assessments, and evidence-based practice guidelines. The commission uses a transparent public process to ensure its decisions are made in the best interest of patients and taxpayers while considering input from providers and members of the public, including those affected by the conditions discussed. To learn more about HERC, go to OHA's website or follow the link below. http://www.oregon.gov/oha/HPA/CSI-HERC/Pages/index.aspx
Prioritized List of Health Services
HERC ranks health care condition and treatment pairs in order of clinical effectiveness and cost-effectiveness. The Prioritized List of Health Services emphasizes prevention and patient education. In general:
· Treatments that help prevent illness are ranked higher than services that treat illness after it occurs. · OHP covers treatments that are ranked above a covered Prioritized List line for the client's reported
medical condition.
To learn more about the Prioritized List of Health Services, go to OHA's website or follow the link below. http://www.oregon.gov/oha/HSD/OHP/Pages/Prioritized-List.aspx
To search the prioritized list and to find a specific guide note, follow the link below. https://www.oregon.gov/OHA/HPA/CSI-HERC/Pages/Searchable-List.aspx
OHP Dental Services
OHP has a list of covered and non-covered dental services like the Prioritized List of Health Services. To learn more about dental services, view OHP's Dental Service Program on OHA's website or go to the following link. http://www.oregon.gov/oha/HSD/OHP/Pages/Policy-Dental.aspx
At the link above, review the most current Administrative rulebooks for Dental Oregon Administrative Rules (OARS).
Oregon Addictions and Mental Health Services
To learn more about OHP's behavioral health services, go to OHA's website or follow the link below. http://www.oregon.gov/OHA/amh/Pages/index.aspx
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Table of Contents
Contact Information ............................................................................................................................................... i General Information .............................................................................................................................................. ii CHA Web Resources ............................................................................................................................................. iii
Approved Drug List (Formulary) ..................................................................................................................................iii
Provider Portal ................................................................................................................................................................iii
Policies, Procedures, and Forms.....................................................................................................................................iii OHA Web Resources............................................................................................................................................. iv
Oregon Health Evidence Review Commission (HERC)............................................................................................... iv
Prioritized List of Health Services ..................................................................................................................................................iv
OHP Dental Services ....................................................................................................................................................... iv
Oregon Addictions and Mental Health Services ........................................................................................................... iv Provider Relations.................................................................................................................................................. 1 Introduction............................................................................................................................................................ 2
About CHA........................................................................................................................................................................ 2
CHA's Mission.................................................................................................................................................................................2 CHA's Vision ................................................................................................................................................................................... 2 Triple Aim ........................................................................................................................................................................................ 2 CHA's History..................................................................................................................................................................................3 Patient-Centered Primary Care Home (PCPCH) Program ............................................................................................................... 3
Member Rights and Responsibilities ..................................................................................................................... 4 Provider Requirements .......................................................................................................................................... 6
Credentialing..................................................................................................................................................................... 6
Application Review Process.............................................................................................................................................................6 Initial Credentialing..........................................................................................................................................................................7 Re-Credentialing .............................................................................................................................................................................. 8 Background History ......................................................................................................................................................................... 8 Facility/Organization Credentialing ................................................................................................................................................. 9
Annual Audits ................................................................................................................................................................. 10
Documentation ............................................................................................................................................................................... 10
Accessibility ..................................................................................................................................................................... 11
After Hours Access ........................................................................................................................................................................ 11 Hospital Services ............................................................................................................................................................................ 11 Urgent Care .................................................................................................................................................................................... 12 Emergency Care ............................................................................................................................................................................. 12 Appointments ................................................................................................................................................................................. 12 Access for Special Needs Members ............................................................................................................................................... 12 Non-Emergency Medical Transportation (NEMT) ........................................................................................................................ 13
Cultural and Linguistic Services ................................................................................................................................... 13
Interpretive Services....................................................................................................................................................................... 13
Non-Discrimination ........................................................................................................................................................ 14 CHA Benefit Plans............................................................................................................................................... 16
OHP Benefit Packages.................................................................................................................................................... 16 Benefits ................................................................................................................................................................. 17
Medical Benefits.............................................................................................................................................................. 17
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Dental Benefits ................................................................................................................................................................ 17
Behavioral Health Benefits ............................................................................................................................................ 18
Substance & Chemical Dependency Prevention & Treatment................................................................................... 18
Vision Benefits................................................................................................................................................................. 18
Other Benefits ................................................................................................................................................................. 18
Community Health Workers........................................................................................................................................................... 18
Services Not Covered by CHA....................................................................................................................................... 19 Compliance........................................................................................................................................................... 20
Provider and Clinic Responsibilities ............................................................................................................................. 20
Oregon State Laws.......................................................................................................................................................... 21
Protected Health Info (PHI) .......................................................................................................................................... 21
Conflict of Interest .......................................................................................................................................................... 22
Record-Keeping and Retention ..................................................................................................................................... 22
Record-Keeping ............................................................................................................................................................................. 22 Record Retention ............................................................................................................................................................................ 22
Fraud, Waste, and Abuse (FWA) .................................................................................................................................. 23
Criminal Health Care Fraud ........................................................................................................................................................... 23 Consequences of Committing Fraud, Waste, or Abuse .................................................................................................................. 23 Fraud, Waste, or Abuse Policies and Procedures ........................................................................................................................... 23
Cooperating with Internal Investigations..................................................................................................................... 24
Resolution, Communication, and Non-Retaliation ...................................................................................................... 24
Violations and Consequences......................................................................................................................................................... 24
Grievance System ................................................................................................................................................. 25
Complaints/Grievances .................................................................................................................................................. 25
Who can file a Grievance? ............................................................................................................................................................. 25 What does CHA do with a Grievance?........................................................................................................................................... 25
Appeals ............................................................................................................................................................................ 25
Who can request an Appeal? .......................................................................................................................................................... 25 When can an Appeal be filed?........................................................................................................................................................ 25 When does CHA respond to a submitted Appeal? ......................................................................................................................... 26 Expedited Appeals.......................................................................................................................................................................... 26 Appeals with Continuation of Benefits (COB)............................................................................................................................... 26 Appeal Decision ............................................................................................................................................................................. 26
Administrative Hearings ................................................................................................................................................ 26
Who can request a Hearing?........................................................................................................................................................... 26 When can a Hearing be requested?................................................................................................................................................. 26 Who attends the Hearing? .............................................................................................................................................................. 26 Where does the Hearing take place?............................................................................................................................................... 27 How is determination made? .......................................................................................................................................................... 27
Reconsiderations (Provider Appeal) ............................................................................................................................. 27
Denial ............................................................................................................................................................................... 27
Procedure Notice of Action ............................................................................................................................................ 28
NOABD Time Lines ...................................................................................................................................................................... 29 Member Dissatisfaction.................................................................................................................................................................. 29
Case Management................................................................................................................................................ 30
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CHA Case Managers ...................................................................................................................................................... 30
Coordination of Care...................................................................................................................................................... 30
Behavioral Health (BH) Case Management ................................................................................................................. 30
Prenatal Case Management ........................................................................................................................................... 31
High Risk Maternity Case Management ........................................................................................................................................ 31
Refer to Case Management............................................................................................................................................ 31
Case Management Signature Programs ....................................................................................................................... 32 Utilization Review ................................................................................................................................................ 33
Steps to verify a service is covered ................................................................................................................................ 33
Authorizations................................................................................................................................................................. 34
Provider Portal................................................................................................................................................................................ 34 Authorization Submission .............................................................................................................................................................. 34 Urgent Authorizations .................................................................................................................................................................... 35 Specialist Authorizations................................................................................................................................................................ 35 Authorizations NOT Required ....................................................................................................................................................... 36 CHA/MCR Duals ........................................................................................................................................................................... 36 Surgery Smoking Cessation ........................................................................................................................................................ 36
Second Opinions ............................................................................................................................................................. 37
Second Opinion Process Primary Care Provider ......................................................................................................................... 37 Second Opinion Process Specialist.............................................................................................................................................. 37
CHA Durable Medical Equipment................................................................................................................................ 38
Incontinence Supply Selection Process .......................................................................................................................................... 38 Insulin Pump Selection Process...................................................................................................................................................... 38
Clinical Practice Guidelines........................................................................................................................................... 39
Health Evidence Review Commission (HERC) ............................................................................................................................. 39 Gold Initiative for Obstructive Lung Disease (GOLD) .................................................................................................................. 39 American Diabetes Association ..................................................................................................................................................... 39 National Comprehensive Cancer Network (NCCN) ...................................................................................................................... 39 Centers for Disease Control and Prevention (CDC) ....................................................................................................................... 39
Dental Services ..................................................................................................................................................... 40
Dental Authorizations .................................................................................................................................................... 40
Dental Benefits ................................................................................................................................................................ 40
Special Care Members ................................................................................................................................................... 40 Pharmacy Services ............................................................................................................................................... 41
Approved Drug List (Formulary) ................................................................................................................................. 41
Pharmacy Signature Programs ..................................................................................................................................... 41
Respiratory Supplies (Respiratory Care Management) .................................................................................................................. 41 Diabetes Care & Education (Diabetes Care Management) ............................................................................................................ 42 Hepatitis C Treatment .................................................................................................................................................................... 42 Wellness Program (Sky Lakes Live Young Weight Management) ................................................................................................ 43 Smoking Cessation ......................................................................................................................................................................... 43
Claims ................................................................................................................................................................... 44
Claims Submission.......................................................................................................................................................... 44
Timely Filing.................................................................................................................................................................................. 44 Timely Payment ............................................................................................................................................................................. 44 DMAP ID Number ......................................................................................................................................................................... 45 Locum Tenens Claims and Procedures .......................................................................................................................................... 45
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Interim Billing ................................................................................................................................................................................ 45
Claims Reconsideration or Disputes ............................................................................................................................. 46
Claims Appeals .............................................................................................................................................................................. 46
Clinical Review of Claims and Services Procedure ..................................................................................................... 46
Readmissions to Diagnosis Related Groups (DRG) Hospitals ....................................................................................................... 46
Adjustment-Overpayment Process ............................................................................................................................... 47 Billing Members.............................................................................................................................................................. 47
Billing for non-covered services .................................................................................................................................................... 47 Billing for members with other insurance ...................................................................................................................................... 47
Low and Zero Dollar Claims ......................................................................................................................................... 48 Procedure Specific Claims ............................................................................................................................................. 48
Hysterectomy and Sterilization ...................................................................................................................................................... 48 Vaccines for Children (VFC) Billing ............................................................................................................................................. 49 Newborn Claims............................................................................................................................................................................. 49 Labs ................................................................................................................................................................................................ 49
Quality Management............................................................................................................................................ 50 Quality Metrics ............................................................................................................................................................... 50 Performance Improvement Projects ............................................................................................................................. 51
Important Forms & Resources ............................................................................................................................ 52 Appeals & Grievance Forms & Resources ................................................................................................................... 52 Authorization Forms & Resources................................................................................................................................ 52 Case Management Forms & Resources ........................................................................................................................ 53 Claims Forms & Resources............................................................................................................................................ 53 Pharmacy Forms & Resources ...................................................................................................................................... 53
Community Health Partnerships......................................................................................................................... 54 Mental Health Emergency ............................................................................................................................................. 54 Behavioral Health Services ............................................................................................................................................ 54
Klamath Basin Behavioral Health .................................................................................................................................................. 54 Klamath County Community Corrections ...................................................................................................................................... 55
Substance Use Disorder Services................................................................................................................................... 56
BestCare Treatment Services ......................................................................................................................................................... 56 Lutheran Community Services Northwest ..................................................................................................................................... 57 Transformations Wellness Center .................................................................................................................................................. 57
Other Resources.............................................................................................................................................................. 58
Life Recovery Network .................................................................................................................................................................. 58 Oregon Vocational Rehabilitation Services Department................................................................................................................ 59 Veterans Enrichment Center........................................................................................................................................................... 59
Klamath County Resource Guide ........................................................................................................................ 60
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Provider Relations
Cascade Health Alliance (CHA) believes quality relationships among members, providers, and staff are based on commitment, trust, respect, and communication. CHA's integrated network of clinical professionals delivers health care at the right time and the right place while controlling costs for both members and taxpayers. The basis of CHA's works involves the foundational ideas of Care, Coverage, and Compassion with a range of signature plans designed to meet the state's diverse communities and their health needs. CHA is a locally owned coordinated care organization (CCO) with highly engaged provider partners. Innovative medical services, which reduce costs and increase practice efficiency, enable CHA to provide the highest quality health care for members. With a commitment to create and maintain a positive working relationship with provider offices, CHA intends to:
· Lead, strive, and innovate to be the most accessible user-friendly coordinated care organization. · Deliver first rate Provider network management, relations, and solutions. · Be accessible, prompt, and considerate in meeting requests. · Furnish contracted providers with useful, accurate, and eligible metrics and data. · Provide timely and useful financial and utilization reports to the appropriate provider management
personnel. · Maintain a strong communication link through updates, web access, office visits, and community
workshops. As committed partners in delivering optimum health care, CHA anticipates providers will:
· Maintain contractual obligations with CHA. · Collaborate with CHA in providing efficient accessible health care. · Proactively communicate to CHA when goals appear to not be met.
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Introduction
The Cascade Health Alliance Provider Manual is developed for contracted providers as a reference tool to provide important information concerning the role of the provider and office staff in the delivery of health care to members. This manual provides critical information regarding the provider and plan responsibilities and should be used in conjunction with the provider's contract with Cascade Health Alliance (CHA). Refer to CHA's website to locate additional reference tools such as the provider directory, formularies, and other plan materials.
CHA hopes this manual and the website is found helpful in caring for members. Please inform CHA about any questions or suggestions regarding how CHA can improve this document or the website. This document will be reviewed and updated annually.
About CHA
CHA is a provider-owned coordinated care organization (CCO) based in Klamath Falls, Oregon. A CCO is a network of all types of health care providers (physical health, dental, and behavioral health, and pharmaceutical) who work together in their local communities to serve people who receive health care coverage under the Oregon Health Plan (OHP), Oregon's Medicaid insurance. CCOs focus on prevention and helping people manage chronic conditions, like diabetes and asthma. This helps reduce unnecessary emergency room visits and gives people support to be healthy. CCOs help providers talk to each other and share important health information.
CHA serves more than 17,000 people with Medicaid coverage under the Oregon Health Plan (OHP) in Klamath County. Cascade Comprehensive Care (CCC), CHA's parent company, also serves more than 3,000 Medicare members through their partner ATRIO Health Plans. CHA works hard to create and manage quality health care services in the community.
CHA's Mission
We endeavor to improve the health of our members by joining with our community partners to advocate for reliable, accessible, and high-quality health care that empowers the people who live in our community to improve their health and wellbeing.
CHA's Vision
To build a healthy community for the population we serve.
Triple Aim
CHA strives to achieve the triple aim: better health, better care, and lower costs.
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CHA's History
Three Klamath County primary care physicians founded Klamath Comprehensive Care in 1992 to serve Medicaid enrollees under Oregon's new managed care initiative, the Oregon Health Plan (OHP). The company became CCC in 1995 and later created CHA as a subsidiary in 2012. CHA began operating as a CCO in 2013. Because CHA is a local company, CHA can better serve members by meeting more of their needs. Members receive case management for a wide range of physical health, dental, behavioral health, and pharmaceutical services. To stay connected with the community, CHA receives guidance regarding immediate community needs from the Community Advisory Council (CAC), composed of at least 51% of individuals who are either members or their caretakers. CCC is proud of its deep connections to the Klamath Falls community and its organizations. The company has invested significant funds and staff time to community partner organizations for projects to positively impact the social determinants of health.
Patient-Centered Primary Care Home (PCPCH) Program
The Patient-Centered Primary Care Home (PCPCH) Program is part of Oregon's efforts to fulfill a vision of better health, better care, and lower costs for all Oregonians. By recognizing clinics who offer high-quality, patient-centered care, CHA can begin breaking down the barriers standing between patients and good health. The PCPCH Program is housed in the Oregon Health Authority's Transformation Center. The PCPCH Program administers the application, recognition, and verification process for practices applying to become PatientCentered Primary Care Homes. The goals of the program are to develop strategies to identify and measure what a primary care home does, promote their development, and encourage Oregonians to seek care through recognized Patient-Centered Primary Care Homes. PCPCHs are governed by OAR 409-055-0000 to 409-055-0090.
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Member Rights and Responsibilities
As a provider, having knowledge of Member Rights and Responsibilities is important. Refer to the next two pages for an excerpt from the CHA Member Handbook.
Members have the right to get provider names, locations, phone numbers, non-English languages spoken, and providers accepting new patients. This information is in the Provider Directory located online at https://cascadehealthalliance.com/find-a-provider/. Members may request a copy of the CHA Provider Directory at any time by calling Member Services at 541-883-2947 or Relay 711.
As an Oregon Health Plan (OHP) client, you have the right: · To be treated with dignity and respect the same as
any other patients; · To have a language interpreter or a sign language
interpreter available free of charge if requested; · To get covered substance abuse treatment and
family planning services without a referral; · To have a friend, family member, or advocate with
you during appointments and at other times as needed within clinical guidelines; · To be actively involved in the development of your treatment plan; · To receive information about your condition and covered and non-covered services, to allow an informed decision about proposed treatment(s); · To consent to treatment or refuse services (except for court-ordered services) and be told the consequences of that decision; · To receive written materials describing rights, responsibilities, benefits available, how to access services, and what to do in an emergency; · To receive written materials translated in a language that you can understand · To receive written materials explained in a manner that is understandable to you; · To receive necessary and reasonable services to diagnose the presenting condition; · To receive covered services under OHP which meet generally accepted standards of practice and are medically appropriate; · To obtain covered preventive services; · To receive a referral to specialty providers for medically appropriate, covered services; · To have a clinical record which documents conditions, services received and referrals made; · To have access to your own clinical record, unless restricted by statute;
· To have your medical records corrected; · To transfer a copy of your clinical record to another
provider; · To give a friend, family member or advocate
permission to access your clinical records; · To a statement of wishes (Advance Directive) and a
power of attorney for health care; · To receive written notice before a denial of, or change
in, a service level or benefit is made, unless such notice is not required by federal or state regulations; · To know how to make a complaint, grievance or appeal with CHA and receive response; · To request an administrative hearing with the Dept. of Human Services or Oregon Health Authority; · To show your medical record or other evidence during the appeal and fair hearing process; · To receive a notice of an appointment cancellation in a timely manner; · To receive adequate notice of DHS/OHA privacy practices; · To choose your provider; · To have CHA's written materials explained in a manner that is understandable; · To make complaints and get a response without a bad reaction from CHA or your provider; · To receive care when you need it, 24 hours a day, seven days a week; · To be able to limit who can see your health records; · To help make decisions about your health care, including refusing treatment; · To not be held down, kept away from other people or forced to do something you don't want to do; · To ask the Oregon Health Authority Ombudsperson for help with problems at 503-947-2346 or Toll Free 877642-0450.
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As an OHP client, your responsibilities are: · To treat all providers and personnel with respect; · To be on time for appointments made with
providers; · To request an interpreter at least 1 day before the
appointment; · To call in advance if you are going to be late or have
to cancel your appointment; · To seek periodic health exams, check-ups, and
preventive services from your medical, dental or mental health providers; · To use your Primary Care Provider (PCP) or clinic for diagnostic and other care, except in an emergency; · To obtain a referral to a specialist from your PCP or clinic before seeking care from a specialist, unless self-referral is allowed; · To use emergency and urgent care services appropriately; · To give accurate information for inclusion in the clinical record; · To help the provider or clinic obtain clinical records from other providers. This may include signing a release of information form; · To ask questions about conditions, treatments and other issues related to your care that you don't understand; · To use information to make informed decisions about treatment before it is given;
· To help in the creation of a treatment plan with your provider;
· To follow prescribed, agreed-upon treatment plans; · To tell your provider you have OHP coverage and to
show your Oregon Health ID when asked; · To call OHP Customer Service at 1-800-699-9075 to
report: o A change of address or telephone number; o If someone in the family becomes pregnant; o The birth of a child; o If any family members move in or out of the household;
· If there is any other insurance available and to report any changes in insurance in a timely manner.
· To pay for non-covered services you receive if you signed a Client Agreement to Pay waiver (OHP 3165);
· To assist OHP to find any other insurance to which you are entitled and to pay OHP the amount of benefits you received as a result of an accident or injury;
· To notify OHP or CHA of issues, complaints or grievances;
· To sign a release so that DHS/OHA and CHA can get information they need to respond to an administrative hearing request in an effective and efficient manner.
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Provider Requirements
Providers and organizations who elect to participate with Cascade Health Alliance (CHA) must ensure the requirements detailed in this document are met.
Credentialing
CHA credentials licensed providers and facilities who provide services to members. Credentialing is the process CHA verifies a provider's ability and competency to provide care to members. Both the initial credentialing and re-credentialing processes follow predetermined standards and criteria, which are detailed below. All providers must have a Department of Medical Assistance Programs (DMAP) Identification number for billing purposes.
CHA is committed to ensuring no person is excluded or denied credentialing on the basis of race, color, ethnicity, religion, National Origin, sex, sexual orientation, gender, gender identity, age, physical or mental disability, citizenship, or veteran status. CHA expects providers to uphold these standards during interactions with members.
Application Review Process
All applications are reviewed and approved by CHA's Quality Management Committee at regularly scheduled meetings. Files can either be approved, denied, or suspended. Denied files are maintained for three years and will contain specific reasons for the denial. This information is protected under ORS 41.675.
Incomplete applications will be returned to the provider or facility for completion and will not be processed until all information has been received by CHA.
The provider or clinic has the responsibility to notify CHA of any changes in the available rendering provider's status and to submit appropriate credentialing documentation within 30 days of the change. Failure to do so may impact reimbursement for services provided.
CHA refers to the following rules and regulations during the credentialing process. These include Code of
Federal Regulations (CFRs), Oregon Administrative Rules (OARs), and Oregon Revised Statues (ORSs).
42 CFR § 438.12
42 CFR § 455.400-455.470 (excluding 455.460)
42 CFR § 438.214
OAR 409-045-0035
OAR 410-120-1395
OAR 410-130-0610
OAR 410-141-3120
OAR 410-141-3269
ORS 41.675
Oregon Health Plan, Health Plan Services Contract #143110-11
Patient Protection and Affordable Care Act Section 6402
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Initial Credentialing
Prospective providers intending to contract with CHA or provide services to members must submit a signed and dated Oregon Practitioner Credentialing Application (OPCA) in addition to the following information:
· Signed and dated attestation questionnaire · Attachment A, referring to the attestation questions which were answered "yes" · Signed and dated Authorization and Release of Information · Evidence of current licensure by the State of Oregon · Evidence of current Drug Enforcement Administration (DEA) certification or prescriptive privileges, if
applicable · Evidence of current professional liability insurance coverage in the amount of no less than $1 million
per incident, $3 million aggregate, or equivalent protection · Copies of specialty board certifications, if applicable · Copy of current curriculum vitae · Clinic restraint and seclusion policy or a statement on letterhead attesting the practice is prohibited · Clinic non-discrimination policy · Clinic policy regarding the provision of culturally and linguistically appropriate services · Background check
The following providers are subject to the credentialing process:
Audiologist
Behavior Analyst Technician
Board Certified Behavioral Analyst
Chiropractors
Behavior Interventionist Clinical Pharmacist
Behavioral Health Specialist (LCSW, LMFT, LPC, PhD, PsyD)
Certified Nurse Midwife
Denturist
Doctor of Dental Surgery
Doctor of Medical Dentistry
Doctor of Medicine
Doctor of Osteopathy
Doctor of Osteopathy
Doctor of Podiatric Medicine
Expanded Practice Dental Practitioners
Licensed Acupuncturist
Licensed Assistant Behavior Analyst
Licensed Assistant Behavior Analyst
Licensed Electrologist
Locum Tenens (tenure longer than 60 days)
Nurse Practitioners
Oral Surgeons
Independent Peer Support Specialist
Registered Behavior Technician Speech Therapist
Licensed Massage Therapists Occupational Therapist Physician Assistant Physical Therapist
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Abbreviations used: Licensed Social Worker (LCSW), Licensed Marriage and Family Therapist (LMFT, Licensed Professional Counselor (LPC), Doctor of Philosophy (PhD), and Doctor of Psychology (PsyD)
Re-Credentialing
Credentialed providers are recredentialed every three years. CHA will notify providers 90 days prior to the expiration date of the current credential. CHA contacts providers when key documents such as licenses, DEA certification, and insurance are due to expire. The following information is required to complete the recredentialing process:
· Signed and dated Oregon Practitioner Recredentialing Application (OPRA), including o Signed and dated attestation questionnaire o Attachment A, referring to attestation questions answered "yes" o Signed and dated Authorization and Release of Information form
· Copy of current state license · Copy of current DEA registration and proof of prescriptive privileges, if applicable · Current professional liability insurance coverage in the amount of $1 million per incident, $3 million
aggregate, or equivalent protection · Restraint and Seclusion logs for the previous 36 months, if applicable · Background Check
Background History
A background check will be performed for each provider applying for initial credentialing or re-credentialing. Additionally, CHA's contract with Oregon Health Authority (OHA) and federal regulations prohibit employing, contracting, or paying sanctioned individuals. CHA checks the following verification websites monthly to monitor Providers:
Office of Inspector General (OIG)
System for Award Management (SAM)
ALERT!
· The Credentialing Specialist will immediately notify the Director of Quality Management, Medical Director, and Compliance Officer upon discovery of a provider who has been convicted of a felony or misdemeanor related to a crime or violation of federal or state laws under Medicare, Medicaid, or Title XIX (including pleas- of "nolo contendere" or "no contest").
· The Compliance Officer will immediately notify OHA's Provider Services Unit.
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Facility/Organization Credentialing
The following information is required to credential facilities/organizations:
· The facility/organization must be accredited by at least one of the following accrediting bodies. Please submit a copy of the accreditation certificate and the most current survey report: o The Joint Commission on Accreditation of Health Care Organizations o American Osteopathic Association o Det Norske Vertis (DNV) o Council on Accreditation o Commission on Accreditation of Rehabilitation Facilities o Accreditation Association for Ambulatory Health Care, Inc. o Community Health Accreditation Program o American Association for Accreditation of Ambulatory Surgery Facilities. o Other accreditations may be accepted pending review by the Quality Management Committee o If the facility is not accredited, an updated current Medicare Survey Audit, Medicaid Audit, or DHS Certification Survey must be submitted for review.
· Non-discrimination policy and restraint and seclusion policy o Each policy must be verified that it meets the standards of the OARs under which the facility is certified, and includes provisions to ensure that members are not discriminated against when accessing services due to their race, color, National Origin, ethnicity, citizenship, age, physical or mental disability, religion, sex, sexual orientation, gender, gender identity, or veteran status.
· Complete staff list including full name, educational credentials (including verification of education), Qualified Mental Health Associate (QMHA) or Qualified Mental Health Professional (QMHP) designation, certifications and/or licenses, and position within the facility
· Current organization chart including direct lines of supervision
Delegated Credentialing
For Behavioral Health and Substance Use Disorder Clinics, CHA may exercise its right to delegate its credentialing authority of non-licensed providers to the facility. All licensed providers will continue to be credentialed by CHA, including the facility itself. Should CHA delegate authority to the facility, a delegation agreement must be in place. CHA audits delegated entities on an annual basis to ensure compliance with CHA Credentialing Policies.
Delegated organizations must ensure verification has occurred monthly on their providers through OIG and SAM to ensure no provider has been sanctioned.
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Annual Audits
As part of CHA's contract with OHA and the provider's and/or clinic's contract with CHA, the CHA Compliance Department is obligated to perform routine clinic and chart audits to assure quality of care is provided to members. Clinical audits are completed to meet contractual requirements, as well as provide technical assistance to providers to improve coordination of care, quality of care, and patient satisfaction. These audits help ensure members receive optimal health care from all providers.
Audits are performed annually for each clinic on 1% of charts or five charts, whichever is greater, and may include a site visit and/or a remote desk audit. CHA uses a standardized tool for audits; this template is available upon request. A notification letter will be sent to providers and clinics 90 days prior to the audit. This letter requests provider/clinic contact CHA to schedule a reasonable time to conduct the audit. Within 45 days of audit completion, a review of findings (ROF) will be sent to the provider and clinic. Clinics and providers will be rated as either substantially compliant, partially compliant, or non-compliant. High risk findings result when the safety of a member has been placed in jeopardy or when there was noted potential to place the member at high risk for further complications or an adverse outcome.
· Substantially Compliant overall score greater than 90% and no high-risk findings · Partially Compliant overall score between 75% - 90% or overall score greater than 90% with high risk
findings · Non-Compliant overall score less than 75%
Clinics and/or providers who are found to be Substantially or Partially Compliant will undergo routine annual audit of 5% or 10 charts, whichever is greater. Non-Compliant clinics and/or providers will be placed on a Plan of Correction and will undergo a more intensive audit process to ensure compliance and patient safety. Clinics and/or providers placed on a Plan of Correction are expected to comply with all actions pursuant to the findings and make the required corrections as stipulated in the Plan within 120 days of receiving the audit report and Plan of Correction. Clinics and/or providers who demonstrate no action toward compliance will be at risk of risk termination of contract with CHA.
Documentation
Protected health information (PHI) used or disclosed for purposes of treatment, payment, or health care operations is permitted by HIPAA Privacy Rules (45 CFR 164.506). Use or disclosure for these purposes does not require the consent or authorization from the member. For persons other than providers who are participating in the Healthcare Effectiveness Data and Information Set (HEDIS) activities, such as third-party vendors and/or medical record review staff, an assigned HIPAA-compliant Business Associate Agreement with CHA is required prior to accessing any PHI.
CHA expects providers to: · Maintain well-documented medical records in a manner that is current, detailed, accurate, organized,
complete, and readily accessible to permit effective and confidential patient care, quality review of patient interactions, and accurate billing for services provided. · Provide CHA access to medical records for purposes of review. · Send requested documentation to CHA in a timely manner. · Participate with CHA's quality improvement initiatives to improve quality ratings.
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Accessibility
CHA's intent is to provide members access to health care services 24 hours a day, seven days a week. Only appropriately trained medical staff should triage phone calls. When a provider is unavailable to provide services, he or she must ensure another provider could provide coverage. Contact the CHA Customer Service Department if the accessibility standards cannot be met at any time. A member should call 911 if the member has a serious health crisis, emergency, or accident.
Providers shall meet OHP standards for timely access to care services and should consider the urgency of the need of services as specified in OAR 410-141-3220 and 410-141-3160:
Emergency Care Seen immediately or referred to an emergency department depending on the member's condition.
Urgent Care Seen within 72 hours or as indicated in initial screening in accordance with OAR 410-141-0140
Well Care Seen within 60 days or within the established community standard in accordance with OAR 410-141-0220
Emergency Dental Care Seen or treated within 24 hours
Urgent Dental Care Seen within one to two weeks or as indicated in the initial screening in accordance with OAR 410-123-1060
Routine Dental Care Seen for routine care within an average of eight weeks and within 12 weeks or community standard, whichever is less, unless there is a documented special clinical reason which would make access longer than
12 weeks appropriate Non-urgent behavioral health treatment Seen for intake assessment within two weeks from the date of request
After Hours Access
Providers must have after hours availability for members.
Hospital Services
Non-emergent inpatient admissions require a prior authorization while emergent admissions do not require a prior authorization. Refer to the CHA Medical Authorization Grid for a detailed list of services that require or do not require a prior authorization.
To ensure members are receiving appropriate care and discharge planning, CHA case managers work with admitting providers and hospitalists. CHA case managers can provide assistance during the discharge process. They can help with coordination of all necessary services and required follow-up with a Primary Care Provider (PCP), Primary Care Dentists (PCD), or behavioral health (BH) provider.
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Urgent Care
Urgent problems include, but are not limited to, severe infection, sprains, and strong pain. Members are instructed to call their PCP office first regarding any health problems. PCPs should be available to members day, night, weekends, and holidays to schedule an appointment, give medical advice, or direct the member to the right place to receive care.
CHA believes in PCP centered care and does not contract with urgent care centers. Contracted providers must offer same day appointments.
Emergency Care
Emergency services do not require a prior authorization.
Emergency services require immediate medical attention, the absence of which many result in the following:
Serious jeopardy to health of Serious impairment of bodily Serious dysfunction of bodily
the individual
functions
organs or parts
Including self-inflicted harm
Appointments
CHA's intent is to ensure members have access to a PCP, PCD, BH provider, and, when appropriate, a specialty care provider.
Scheduling
Providers and office staff are responsible for scheduling members. CHA may assist a member if the member has difficulty scheduling a appointment.
Missed Appointments and Behavioral Issues
Providers have the right to be respected. If a clinic must fire or terminate the care of a member, based on either member or provider request, the clinic should contact CHA. CHA will also need to receive a copy of the termination notice. All fired members must be able to continue seeing the clinic for urgent and emergent care for 30 days following termination.
If members have behavioral concerns, contact CHA.
Access for Special Needs Members
Providers and office staff must be aware of and comply with the Americans with Disabilities Act (ADA).
The availability of the following types of facility support is required:
Corridor railings
Ramp or street-level access
Wheelchair access Including access to elevators, restrooms, and exam rooms
Providers and office staff need to be prepared to meet the needs of members who do not speak English as well as members who suffer from visual or hearing impairments.
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Non-Emergency Medical Transportation (NEMT)
Members can receive free medical transportation. To help a member schedule a ride, call TransLink.
Translink Contact Information
Phone
TTY
541-842-2060 541-734-9292
Toll Free
1-888-518-8160
Rides must be scheduled at least 72 hours in advance.
Hours
Monday Friday 7:00am 7:00pm
Cultural and Linguistic Services
Providers and office staff need to be prepared to meet the needs of members who do not speak English and who suffer from visual or hearing impairments. CHA will provide assistance when needed. There is no fee to the member or provider for translation services.
Interpretive Services
CHA will provide member handbooks and all other printed information intended for widespread distribution to members in the primary language of each substantial population of non-English speaking members. These member materials include satisfaction surveys, grievances, and appeals. CHA defines substantial as 30 nonEnglish speaking households which share the same primary language.
CHA's online Provider Directory lists all bilingual PCP offices with bilingual capacity. The language(s) spoken can be obtained from CHA.
During normal business hours, CHA can make arrangements to provide qualified interpreters who can interpret in the primary language of each substantial population of non-English speaking members. The interpreters shall be capable of communication in English and the primary language of the member as well as be able to translate medical information effectively.
PCP offices shall have signs in the primary language of each substantial population of non-English speaking member in their practice.
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AT&T Interpreter Line
All CHA contracted clinics and providers have access to CHA's interpreter line. How to use interpreter line: Organization Name: Cascade Comprehensive Care, Inc. When receiving call: 1. Use conference Hold to place the limited English speaker on hold 2. Pick up new line 3. Dial: 1 (800) 774-4344 4. Provide the representative/line: o 6-digit Client ID: 242053 o Personal code (DMAP number): 135843 Press 1 for Spanish Press 2 for all other Languages · Speak the name of the language when prompted, and an interpreter will be connected to the line. 5. Hit Conference line button TWICE and all parties should be connected. 6. Brief the interpreter. Summarize what needs to be accomplished and give any instructions. When placing a call to a limited English Speaker, begin at step 2.
Non-Discrimination
CHA is committed to ensuring no person is excluded or denied benefits of services on the basis of race, color, ethnicity, religion, National Origin, sex, sexual orientation, gender, gender identity, age, physical or mental disability, citizenship, or veteran status. CHA expects providers to uphold these standards during interactions with members. CHA will not discriminate against providers who serve high-risk populations or specialize in conditions that require costly treatment.
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CHA Benefit Plans
Every member receives a Member ID card from Oregon Health Plan (OHP) and Cascade Health Alliance (CHA). If an ID card is lost, a member can call CHA Member Services 541-883-2947 or OHP Customer Services at 1-800-699-9075. Example of a CHA Member ID card:
OHP Benefit Packages
OHP offers multiple benefit packages. CHA covers the services listed in the benefit package. · CCOA: Physical, mental, and dental health car · CCOB: Physical and mental health care · CCOC: Physical and dental health care · CCOE: Physical health care · CCOF: Dental health care · CCOG: Mental and dental health care
For more information about benefits and direct access services, refer to Benefits. Benefits will be reviewed, and may change, biannually.
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Benefits
A member's benefit package will determine which benefits are available to the member. This section provides a brief list of benefits available to members. For a complete list of benefits, refer to Oregon Health Plan's (OHP's) Prioritized List of Health Services. Cascade Health Alliance (CHA) will authorize covered services (according to OHP benefits & CHA authorization grids) for members to see out-of-area providers when there are not local providers available to provide the care/services to members. Providers in local outlying areas such as Medford, Oregon, are considered to CHA as a local option when available. CHA will not assign a member to a Primary Care Provider (PCP) outside of Klamath County. Emergency care is covered even when a member is outside of Klamath County. Benefits will be reviewed, and may change, biannually.
Members are allowed to see an out-of-network provider for a second opinion if another provider is not available in-network. Review the Second Opinions section for details.
Medical Benefits
CHA offers a variety of medical benefits including care from a Medical Doctor (MD), Doctor of Osteopathic Medicine (DO), Nurse Practitioner (NP), and Physician's Assistant (PA). Members also have access to 24-hour emergency care, imaging services, and lab services.
Medical Services Covered by CHA
Diabetes supplies and education Hearing aids and hearing aid exams Hospice Immunizations Medical equipment and supplies (DME) Pregnancy and newborn care Some surgeries Treatment for most major diseases Women's annual exams
Family planning Home health care Hospital stays and care Mammograms for women Physical, occupational and speech therapy Prostate screenings for men Specialist care Well-child exams Yearly check-ups
Dental Benefits
CHA offers a variety of primary care and specialty dental benefits, including 24-hour emergency care.
· Crowns: o Stainless steel crowns on back teeth for adults age 21 and over o Most other crowns for children, pregnant women and adults aged 1820 years old
· Dentures: o Full dentures every 10 years o Partial dentures every five years
· Preventive services including cleanings, fluoride, varnish, sealants for children, and exams · Root canals on back teeth for children, pregnant women, and adults aged 1820 years old · Routine services including check-ups, fillings, X-rays, and tooth removal · Specialist care · Urgent or immediate treatment · More detailed information can be found in the Dental Services section.
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Behavioral Health Benefits
CHA covers a variety of programs and services to help members with their behavioral health (BH).
Behavioral Health Benefits
Assessments and therapy services Hospital stays, care, and medications for mental
illness Wraparound services for youth and children
Emergency services Programs to help with daily and community
living
Substance & Chemical Dependency Prevention & Treatment
Member benefits include treatment for Substance Use Disorders (SUD).
Some covered outpatient and residential treatment services are:
Acupuncture
Detoxification
Individual, group, and family/couple counseling Screening, assessment and physical examination
including urine tests
In addition to treatment, some medications are covered. Covered medications include Buprenorphine, Methadone. Suboxone, Vivitrol, and other medication services that assist with limiting or stopping the use of alcohol or drugs.
Vision Benefits
CHA has limited vision benefits. These benefits include the following.
· Medical services · Services to correct vision for pregnant women and children under aged 21 years old · Glasses are covered for pregnant adults and adults who have a qualifying medical condition, such as
aphakia or keratoconus, or after cataract surgery.
Other Benefits
For the following benefits, please refer to their respective sections.
Prescriptions
Transportation Benefits
Case Management Signature Programs
Pharmacy Signature Programs
Community Health Workers
Some members may be eligible for services from a Community Health Worker (CHW). A CHW can help members manage their health care if they have extra health problems that make it hard for them to improve their health. Please contact CHA with any questions.
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Services Not Covered by CHA
CHA does not cover services like: Breast reductions or implants
Cosmetic surgery
Circumcision or infertility services
The services listed below are covered by OHP Fee-for-Service (FFS) but are not covered by CHA. For
more information on these services, call OHP Customer Service at 1-800-699-9075.
Mid-Wife or Doula home delivery
Death with Dignity
Private duty nursing
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Compliance
Cascade Health Alliance (CHA) maintains a strict non-intimidation and non-retaliation policy.
CHA's Compliance Plan demonstrates CHA's commitment to and ensures compliance with all applicable legal, ethical, and professional standards. This formal corporate Compliance Plan provides a framework of effective internal controls that promote adherence to applicable federal and state laws and regulations, and to the program requirements of Medicaid health plans. The plan serves as a central coordinating mechanism for furnishing and disseminating information and guidance on applicable federal and state statutes, regulations, and other requirements. Senior management and CHA's Board of Directors believe that compliance is an enterprise-wide responsibility. Implementing a Compliance Plan will prevent fraud, waste, and abuse within the organization and reduce risk vulnerabilities, while simultaneously furthering CHA's fundamental mission of providing quality care and services to members.
Refer to the Important Forms and Resources section for more information regarding forms.
Provider and Clinic Responsibilities
CHA expects providers to keep the best interest of members in mind as they provide care.
· FIRST, providers are required to comply with all applicable statutory and regulatory requirements, including following CHA's Compliance Plan.
· SECOND, providers have a duty to Medicaid to report any violations of laws they become aware of. · THIRD, providers have a duty to follow their organizations' Code of Conduct that articulates their and
their organizations' commitment to standards of conduct and ethical rules of behavior. · FOURTH, providers must work with CHA's Quality Management, Claims, and Compliance
departments to accomplish regular monitoring and auditing.
Report non-compliance and fraud, waste, and abuse (FWA)
CHA Compliance Officer
Anonymous Online Reporting
541-883-2947
(on the CHA website under "Contact Us")
abuse@cascadecomp.com
https://cascadehealthalliance.com/contact/
Understand the differences between non-compliance and FWA · Fraud requires the person to have intent to obtain payment and knowledge that their actions are wrong. · Waste and abuse may involve obtaining an improper payment but without the same intent and knowledge
of fraud. · Non-compliance may include failure to abide by a contract, law, or regulation.
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Oregon State Laws
CHA and OHP are governed by the Oregon Administrative Rules (OARs) and the Code of Federal Regulations (CFR). All licensing, certification, monitoring, inspection, or regulatory requirements are developed from current laws. The laws governing the activities and scope of the Public Health Division are defined in the Oregon Revised Statutes (ORS). The OARs determine how those laws will be implemented. The CFR is the codification of the general and permanent rules published in the Federal Register by the executive departments and agencies of the Federal Government. CFRs are divided into 50 titles representing broad areas subject to Federal regulation. Title 42 is the Public Health section.
CHA is committed to adhering to the law and expects providers do so as well. Even though all laws are important, the laws listed below are highlighted because they are more commonly associated with noncompliance. Go to www.oregonlaws.org to find a list of all laws and details about the laws listed below.
Wrongful Claims ORS 411.670411.690
Unlawful Trade Practices ORS 646.605646.656
Perjury and Falsification ORS Chapter 162
Falsification of Business Records False Claim for Healthcare Payment Whistle Blowing Protections
ORS 165.080
ORS 165.690 165.698
ORS 659A.200659A.233
Protected Health Info (PHI)
CHA employees and contractors are expected to comply with the Health Insurance Portability and Accountability Act (HIPAA) legal requirements regarding Protected Health Information (PHI).
PHI includes diagnoses and treatments, personal data, and billing and contract information. PHI is demographic data related to: · The individual's past, present, or future physical, oral, or behavioral health or condition. · The provision of health care to the individual. · The past, present, or future payment for health care provisions to the individual. · Any data that can identifying or potentially identify the individual. · Individually identifiable health information includes many common identifiers (e.g., name, address, birth
date, or Social Security number).
CHA policies regarding handling and use of PHI will be adhered to by all CHA employees.
PHI policies must conform to federal and state laws and are designed to safeguard member privacy. To maintain confidentiality of member information, one must: · Encrypt any member information when sending an email. · Comply with CHA security safeguards. · Never share member information unless it is for approved business operations. · Never access, use, view, or send member information unless authorized and have a valid and approved
business reason.
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Conflict of Interest
CHA is committed to operating with the highest level of integrity in the conduct between CHA and third parties with whom CHA contracts in existing, new, and prospective relationships.
A conflict of interest is a situation in which the personal interests of an Inside Party (including CHA Board of Directors, officers, employees, affiliates, and any other individuals in a position of influence over the affairs of CHA) could affect the ability of the Inside Party to act in the best interest of, and with good faith and loyalty to, CHA. A conflict of interest can be considered to exist in any instance where the actions or activities of an individual acting on behalf of CHA also involve:
· Obtaining direct or indirect personal gain or advantage; or · An adverse or potentially adverse effect on the interests of CHA.
A conflict of interest transaction is one in which CHA and/or any of its Affiliates is a party, and in which an Inside Party has 1) a direct or indirect financial interest or 2) a conflicting fiduciary duty to another party involved in the transaction that, in either case, could influence his or her action on the matter while acting on behalf of CHA.
Record-Keeping and Retention
Record-Keeping
Medical records of members shall be maintained and preserved in accordance with general standards, which reference no less than 10 years. Subject to confidentiality laws, and upon receipt of written notice from CHA, providers shall permit CHA, CHA designated representatives, or applicable state and federal regulatory agencies to inspect member medical records and shall provide copies of such records to CHA upon request. If any litigation or other action involving the records is started before the end of the 10-year period, the records must be retained until all issues arising out of the action are resolved or until the end of the 10-year period, whichever is later. Providers shall also cooperate with CHA, the Oregon Health Authority (OHA), Oregon Addictions and Mental Health Division, the Oregon Department of Justice Medicaid Fraud Unit, and the Centers for Medicare and Medicaid Services, or other authorized state or federal reviewers, for purposes of audits, inspection, and examination of member medical records. Medical records documentation must be sufficiently complete and accurate to permit evaluation and confirmation that coordinated care services were authorized and provided, referrals were made, and outcomes of coordinated care and referrals were sufficient to meet professional standards applicable to the health care professional and must meet the requirements under CHA's policies and procedures.
Record Retention
Law and policy govern the disposal or destruction of all records. The retention of records will be in accordance with legal and regulatory requirements and CHA policy. Records pertaining to litigation or a government investigation or audit shall not be destroyed. Records that are subject to audit or current/threatened litigation shall not be destroyed unless there is written notification of the conclusion of the litigation. Records will be maintained in appropriate format (paper, microfilmed, microfiche, electronic, and image) and available within a reasonable timeframe. When keeping information is no longer needed, the information must be disposed of in a way that makes certain it is kept safe and private until properly destroyed. For more information, refer to the relevant CHA policy or talk with the Compliance Officer.
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Fraud, Waste, and Abuse (FWA)
Providers should facilitate ethical and legal conduct and establish a commitment to high ethical standards. As such, each provider is expected to prevent non-compliance and FWA. CHA has a zero tolerance for the commission or concealment of acts of FWA. Allegations of such acts will be investigated and pursued to their logical conclusion, including legal action where warranted.
Criminal Health Care Fraud
Criminal health care fraud is defined as one who knowingly and willfully executes, or attempts to execute, a scheme or artifice to defraud any health care benefit program OR obtain, by means of false or fraudulent pretenses, representations, or promises, any of the money or property owned by, or under the custody or control of any health care benefit program.(18 United States Code §1347).
Key Indicators Potential Provider/Pharmacy Issues
Watch for the warning signs. A few examples of fraudulent behaviors are listed below.
· Does the provider write for diverse drugs or primarily only for controlled substances? · Are the provider's prescriptions appropriate for the member's health condition (medically necessary)? · Is the provider writing a higher quantity than is medically necessary for the condition? · Is the provider performing unnecessary services for the member? · Is the provider's diagnosis for the member supported in the medical record? · Does the provider bill for services not provided?
How to prevent FWA and non-compliance · Make sure to be up to date with laws, regulations, and policies. · Ensure to coordinate with other payers. · Ensure data and billing is both accurate and timely. · Verify provided information. · Be on the lookout for suspicious activity, both internal and external to a given organization.
Consequences of Committing Fraud, Waste, or Abuse
The following are potential penalties. The actual consequence depends on the violation.
Civil Money penalties or civil prosecution
Loss of provider license or credentialing
Criminal Conviction/fines, imprisonment, or both
Exclusion from Federal Health Care programs
Fraud, Waste, or Abuse Policies and Procedures
Every sponsor, first tier, downstream, and related entity are expected to have, and provide upon request, policies and procedures in place to address FWA. These procedures should assist in the detection, correction, and prevention of FWA
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Cooperating with Internal Investigations
When the Compliance Officer or designee learn of potential violations or misconduct, the matter shall be promptly investigated. If the individual determines a material compliance violation has occurred, management shall take steps to rectify it, report it to the government if necessary, and make any appropriate payments to the government. CHA employees and applicable providers are expected to cooperate in the investigation of possible violations but shall not try to investigate by themselves without involving the Compliance Officer.
CHA's policy mandates cooperation with government investigations. All efforts to cooperate with the government shall be coordinated through legal counsel.
Resolution, Communication, and Non-Retaliation
CHA's policy prohibits intimidation or retaliation against any individual who participates in good faith in the organization's Compliance Plan.
· Any CHA employee; first-tier, downstream, and related entities (FDR); or FDR employee who in good faith reports suspected compliance or FWA issues will be protected from retaliation (defined as an adverse action taken because an individual has engaged in protected activities), intimidation, threats of retaliation, discharge, or other discrimination.
· Good faith participation in the Compliance Plan includes but is not limited to reporting potential issues ("whistleblowing"), investigating issues, self-evaluations, audits and remedial actions, and reporting to appropriate officials.
· No employee may be adversely affected because they refused to carry out a directive which constitutes FWA or is a violation of local, state, federal, or other applicable laws and regulations.
Violations and Consequences
Failure to follow CHA's Code of Conduct and any other organization policies, applicable laws, and contractual obligations will compromise CHA's integrity and reputation. No contractor, subcontractor, or provider is ever authorized to commit, or direct another person to commit, an unethical and illegal act. In addition, no person can use a contractor, subcontractor, provider, agent, consultant, distributor, or other third party to perform any act not allowed by law, CHA policies, or any applicable contractual obligation.
Disciplinary action may be initiated against: · Individuals who have failed to comply with CHA's compliance policies or federal or state laws or regulations. · Responsible individuals who fail to detect or report an offense. · Those who have otherwise engaged in wrongdoing that has the potential to impair CHA's status as a reliable,
honest, and trustworthy organization.
CHA shall exercise due care not to delegate to individuals whom the organization knew or should have known through the exercise of due diligence had a propensity to engage in illegal activities.
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Grievance System
The grievance system includes complaints/grievances, appeals, administrative hearings, and provider reconsiderations. This section references applicable member rights and responsibilities. All grievances, appeals, and reconsiderations are confidential; any party who files a grievance or an appeal is protected from any retaliatory action.
CHA provides assistance to members with completion of grievance filing and appeal and hearing requests. Members may be referred to our offices or can call us at 1-888-989-7846 or locally at 541-883-2947.
Refer to the Important Forms & Resources section for links to forms to submit a request.
Complaints/Grievances
A grievance is a verbal or written concern, problem, and/or dissatisfaction with quality of care provided, issue of interpersonal relationship, or a failure to respect a member's rights. Grievances may be clinical or nonclinical.
Who can file a Grievance?
A member, their representative, the representative of a deceased member's estate, or the member's provider can request a grievance.
What does CHA do with a Grievance?
Analyze the grievance in the context of quality improvement: gather information from related parties, review and respond to member of determination, and include the grievance and final decision in quarterly reporting to OHA.
Appeals
An Appeal is a request to review a denial, reduction, suspension, or termination of an authorized, or previously authorized, service.
Who can request an Appeal?
A member, their representative, the representative of a deceased member's estate, or the member's provider (with the member's consent) can request a review of a denial or limitation of requested service.
When can an Appeal be filed?
After a written Notice of Adverse Benefit Determination (NOABD) has been issued, but no later than 60 days from the date on the NOABD.
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When does CHA respond to a submitted Appeal?
Standard appeal reviews must be completed within 16 days of CHA's receipt of Appeal.
Expedited Appeals
If waiting for the standard 16-day Appeal response would put the member's life, health, or ability to function in danger, an Expedited Appeal can be requested. Expedited Appeal reviews must be completed within 72 hours of CHA's receipt.
Appeals with Continuation of Benefits (COB)
If member is being denied a service or medication they had prior to the denial, they can request Continuation of Benefits (COB). Request for this service must be made no more than 10 days after the "Date of Notice" shown on the NOABD, and the member must have been authorized to receive the service or medication within the last 90 days
Appeal Decision
The determination of the Appeal will be sent to the member and copied to their Primary Care Provider (PCP), Primary Care Dentist (PCD), behavioral health (BH) provider, and/or applicable Specialist, in the form of a Notice of Action Resolution (NOAR) within two days of determination.
Administrative Hearings
An Administrative Hearing, or Contested Case Hearing, is a course of action right to a meeting with OHA when CHA upholds an adverse benefit determination (NOABD) upon completion of a requested Appeal.
Who can request a Hearing?
A member, their representative, or provider (with the member's consent) who received a written NOAR that the appealed denial was upheld has the right to request a hearing with Oregon Health Authority (OHA).
When can a Hearing be requested?
A hearing can only be requested after an Appeal has been completed. If an Appeal has not been completed, the member will be directed to file an Appeal prior to Hearing. Hearings must be requested no more than 120 days from the date of the NOAR.
Who attends the Hearing?
The member or individual filing the request, member's representative (if they have one), CHA's Appeals and Hearings Coordinator, and appropriate clinical staff (Medical Director, Pharmacy Director, or Dental Director), the OHA Hearings Representative and the Administrative Law Judge (ALJ).
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Where does the Hearing take place?
All hearings are conducted by telephone. Attending parties are provided with OHA's Conference Call Line and the applicable Participant Code. Hearings are scheduled for one hour and must be completed within that period.
How is determination made?
All information regarding the denial is presented at the Hearing. All attending parties have the opportunity to present their information. The ALJ will ask questions and request clarifications during the Hearing, then review all information presented. All parties will be given the opportunity to respond or question statements made by other parties. The decision (Final Order) is not made during the Hearing but is made within 30 days and mailed to the member and CHA.
Reconsiderations (Provider Appeal)
A reconsideration is considered a Provider Appeal. The provider is to obtain permission from the member to act as the member's representative in making this request.
· The Reconsideration must be initiated within 30 days of the original denial notice. · The Reconsideration must be a written request signed and dated by the provider. · The provider must explain the clinical rationale and/or submit additional information in writing, indicating
their reason for the initial determination to be overturned. · The Reconsideration must be submitted to CHA's Appeals and Hearings Coordinator for presentation to
the Medical Director or Utilization Review (UR) Committee, depending on date and individual who originally denied the authorization. · If the Medical Director or UR Committee overturns the denial, the referring provider will be notified, and the denied authorization will be approved. CHA will notify the requesting provider of the Reconsideration determination in writing, usually within 30 days from the date of receiving the request.
Denial
An adverse benefit determination is defined as the denial, or limited authorization of a requested Covered Service, includes the type or level of service; the reduction, suspension or termination of a previously authorized service; the denial, in whole or in part, of payment for a service; the failure to provide services in a timely manner, as defined by OHA; the failure of Contractor to act within the timeframes provided in 42 CFR 438.408(b) or for a member who resides in a rural Service Area where Contractor is the only Coordinated Care Organization (CCO); or the denial of a request to obtain Covered Services outside of Contractor's Participating Provider panel.
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Procedure Notice of Action
When CHA has made or intends to make an adverse benefit determination, CHA will mail a written Notice of Action/Adverse Benefit Determination (NOABD) letter using OHA's formatting and readability standards and written in language a layperson could understand and make an informed decision about appealing and following the process for requesting an appeal. NOABD letters were previously called Notice of Action (NOA) letters. The NOABD includes the right of the member to be provided, upon request and free of charge, reasonable access to and copies of all documents, records, and other information relevant to the member's adverse benefit determination. This includes medical necessity criteria and any processes, strategies, or evidentiary standard used in setting coverage limits. The NOABD explains the member's right to request an appeal of CHA's adverse benefit determination, including information on exhausting CHA's one level of appeal. The notice also explains the circumstances under which an appeal process can be expedited and how to request it. The NOABD explains the member's right to have benefits continue, continuation of benefits (COB), pending the resolution of the appeal.
The content of the NOABD includes, but is not limited to: · The date of notice · CHA's name and contact information for additional info or assistance in completing the grievance, appeal, or hearing process · Name of PCP, PCD, or BH professional · Service requested or previously provided and the adverse benefit determination that CHA made or intends to make, including whether CHA is denying, terminating, suspending, or reducing a service or denial of payment · Date of service or date service was requested by the provider or member · Name of the provider who performed or requested the service and the effective date of the adverse benefit determination if different from the date of the notice · Whether CHA considered other conditions, such as co-morbidity factors, if the service was below the funding line on the Prioritized List of Health Services · Clear and thorough explanation of the specific reasons for the adverse benefit determination
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NOABD Time Lines
CHA will mail the NOABD for termination, suspension, or reduction of services at least 10 days before the date the adverse benefit determination takes effect.
Exceptions related to advance notice include: · CHA has factual information confirming the death of a member. · CHA received a clear written statement signed by the member stating he or she no longer wants services,
or he or she gives information requiring termination or reduction of services and indicates understanding that this must be the result of supplying said information. · CHA can verify the member has been admitted to an institution where the member is no longer eligible for OHP services. · CHA is unaware of the member's whereabouts and received returned mail directed to the member from the post office indicating no forwarding address and OHA has no other address. · CHA verifies another state, territory, or commonwealth accepted the member for Medicaid services. · CHA verifies the transfer or discharge of a member from a facility will occur in an expedited fashion. · The member's PCP, PCD, or BH professional prescribed a change in the level of health services.
CHA may shorten the period of advance notice to 5 days before the date of action if CHA has facts indicating the action should be taken because of probable fraud by the Member. Whenever possible, these facts should be verified through secondary sources.
CHA may extend to a 14-calendar day NOABD timeframe for standard authorization decisions to deny or limit services up to 14 additional calendar days if the member or provider requests extension. If CHA extends the timeframe, a written notice of the reason for the decision to extend the timeframe and to inform the member of their right to file a complaint if he or she disagrees with that decision. CHA will issue and carry out its prior authorization determination as expeditiously as the member's health condition requires and not later than the date the extension expires.
Member Dissatisfaction
If a member is not satisfied with the decision of a denial of service, he or she has a right to appeal and/or request a hearing through Oregon Medical Hearings or directly through CHA. This includes member representative or legal representative of a deceased member's estate. Providers may submit an appeal of a denial directly to CHA through a Reconsideration Request. CHA and its subcontractors and providers will cooperate with DHS' Governor's Advocacy Office, the Authority's Ombudsman, and Hearing Representatives in all of the Authority's activities related to members' grievances, appeals, and hearings including providing all requested written materials.
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Case Management
Case Management (CM) is a collaborative process of assessment, planning, facilitation, care coordination, evaluation, and advocacy for options and services to meet an individual's and family's comprehensive health needs through communication and available resources to promote patient safety, quality of care, and costeffective outcomes. Case Management Services include transitions of care, complex case management, care conferences, collaboration with Primary Care Provider (PCP) and other providers, and active discharge planning. Transitions of care is for short term skilled nursing care with a goal of transitioning the member back to prior level of care. Complex case management involves long term case management and chronic conditions.
CHA Case Managers
The goal of Cascade Health Alliance (CHA) case managers is to empower members to be accountable for their care by engaging members to learn how to manage their conditions.
Coordination of Care
To ensure members achieve optimal health outcomes, CHA will assist members in gaining access and in coordinating health services to all providers including out-of-network providers and/or services that are considered non-covered by the Oregon Health Plan (OHP).
CHA will ensure that the cost of the member for covered services provided by out-of-network provider(s), is no greater than if services were provided in network. Out-of-network provider(s) must coordinate with CHA Case Managers with respect to care needs, in line with the current Oregon Administrative Rules (OARS).
Case Management will be responsible for coordinating out-of-network care needs as requested by the
provider for the member. For example:
Discharge needs from out of area hospital stay
Member needs to transfer to skilled nursing facility
for Transitional Care Unit (TCU)
Member needs to be transferred to Acute Inpatient Assist with transportation needs for medical care
Acute Rehab
with in-network and out-ofnetwork provider(s)
Behavioral Health (BH) Case Management
Behavioral Health (BH) Case Management involves case management, utilization monitoring, and concurrent review of authorizations. This includes assistance with BH and Substance Use Disorder (SUD) referrals to local BH providers and coordination of out-of-area services.
Coordination of Out-of-area Services Behavioral Rehabilitation Services (BRS) placements
o Youth are sometimes sent out of the area when their needs are too high to manage locally SUD/BH residential placements
Please refer to Community Health Partnerships for more information. 30
Prenatal Case Management
CHA assists in the plan of and management of a member's prenatal care. Case Managers can tell members about rewards they can earn after completion of activities to improve their health and the health of their baby. These activities include: seeing an obstetrician (OB) early and continuously during pregnancy, seeing a dentist, taking prenatal vitamins, and registering with WIC (a Special Supplemental Nutrition Program for Women, Infants, and Children). CHA offers the book `Your Pregnancy Week by Week' to help members learn about what is happening in their body each week of their pregnancy. Members also learn what is happening in their baby's body.
High Risk Maternity Case Management
CHA monitors all pregnant members; however, CHA has a special program for the pregnancies identified as high risk. This program involves:
· Home visits when requested by provider · Advocacy and coordination of care · Prenatal Incentive Program
· Concurrent Review when hospitalized · Baby followed to 6 weeks, longer if needed · Encourage and coordinate access to dental care
High risk pregnancies include, but are not limited to, health problems like:
Hypertension Homelessness
Gestational diabetes Pre-eclampsia
Premature labor
Abuse issues
Substance abuse problems
Refer to Case Management
A member should be referred to Case Management when BH concerns, complex needs, or overutilization is present.
Behavioral Health Concerns Emergency department (ED) visit
for BH needs
ER visit for SUD
BH diagnosis with unmet needs
Complex Needs High risk pregnancy
Inadequate support system for activities of daily living (ADL's) and no primary caregiver
Transportation to medical appointments
Cancer diagnosis with unmet needs
Primary caregiver with inadequate support for ADL's
Five or more chronic conditions not wellmanaged
Requires referral to community services
Overutilization Three or more ED visits in six months
Over three unscheduled acute admissions 31
Case Management Signature Programs
Transitions of Care
A collaborative process that facilitates the safe transition of a member from one level of care to another. Focused on improving member experience, improving health, and containing costs.
Flex Funds
Flex funds are intended for items not usually covered by CHA. These items could benefit the health of the member or assist with PCP treatment plan. The link to the Flex Fund Request Form is located in the Important Forms & Resources section.
Requirements · Member needs to be on CHA health plan for one year to be eligible for this benefit. · Limited to $250 per member per calendar year. · Must be requested by PCP with rational for need and how it pertains to treatment plan.
Gap Care
CHA contracts with Oregon Mobile Healthcare (OMH) to take care to members. They can provide a variety of services for members at home, including follow-up care for members post-hospitalization. To refer a member to OMH, submit the Oregon Mobile Healthcare Referral form or call the Case Management department.
Follow-up Care includes:
· Care to members that are at risk for developing further health conditions due to persistent care access barriers.
· Helps to prevent member(s) from returning to the ED or being readmitted to the hospital.
Examples of other services provided: HbA1c tests Blood pressure
screenings
Wellness assessments
Deliver CRC screening FIT kits, with option of pick-up
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Utilization Review
The Utilization Review (UR) department primarily processes authorizations, not to be confused with referrals. An authorization is the process used to confirm an intended service is a covered benefit and will be paid for by Cascade Health Alliance (CHA). A referral is the act of one provider recommending another provider to evaluate or provide treatment to a patient. Authorization polices will be reviewed, and may change, biannually. CHA encourages use of the Provider Portal for any need related to authorizations.
Refer to the section Important Forms and Resources for more information regarding authorization forms.
Utilization Review involves the following services: Prior Authorizations
Standard: 14 days Concurrent Review
Urgent: 72 hours
Hospital Stays In-network Out-of-network
Skilled Nursing Facilities Prior authorizations are required Fee-for-service (FFS)
Acute Inpatient Rehab Facilities Prior authorizations are required Paid by diagnosis (DRG)
Notes
Emergency Room Visits Prior authorizations are NOT required.
Home Health Prior authorizations are required by certification period.
Steps to verify a service is covered
To help streamline the authorization process, make sure a service is covered before submitting an authorization by following the steps below. If the diagnosis is below the line of or if the procedure is not covered, authorization will be denied. Members are not to be billed for authorized services.
· Verify client eligibility using the Provider Portal or Medicaid Management Information System (MMIS) on the date of service.
· Search the Prioritized List for procedure and diagnosis pairing and funding. o The Funded Line is changed annually. Please visit OHA's website at the link below for the current Prioritized List of Health Services and location of the Funded Line. http://www.oregon.gov/oha/HSD/OHP/Pages/Prioritized-List.aspx
· The Prioritized List and Oregon Administrative Rules (OARS) determine covered benefits. · CHA uses MCG Guidelines internally to help ensure members are receiving quality care. CHA hopes
providers use similar guidelines as they choose how to provide care to members. · Review the Fee-for-Service (FFS) Fee Schedule. Some codes may be covered according to the
Prioritized List of Health Services, but they may only be covered by a plan, not fee-for-service. o Open Card http://www.oregon.gov/oha/healthplan/pages/feeschedule.aspx
· Documentations must support diagnosis. · Some items have limits.
Refer to the authorization grids for physical health, dental care, and behavioral health. Links to these documents are located in the Important Forms and Resources section.
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Authorizations
Prior authorizations are required for a variety of office visits and procedures. Please be sure authorizations are complete upon submission. For questions or assistance, contact CHA.
All authorizations require the following:
Accurate and current ICD 10 Accurate and current CPT
code
and/or HCPCS codes
Current supporting clinical documentation
· Codes need to be of the highest specificity based on documentation. · The request cannot be reviewed without these mandatory items. These items must come from the
provider; CHA cannot provide them.
Provider Portal
Submit and review the status of authorizations via the CHA Provider Portal. Modified authorizations cannot be submitted through the Provider Portal; view the Authorization Modifications section to learn how to submit this type of authorization.
To request access to use the Provider Portal, fill out the online Provider Portal Access Request Form.
CHA offers a training to any organization who is new to working with CHA or who needs a refresher course. Refer to the User Guide located online for questions.
Reminders
Use valid ICD-10, CPT, and HCPCS codes to the highest specificity. Be sure to attach or fax documentation when submitting an authorization. Complete all required fields, then click submit.
Authorization Submission
To ensure the authorization is processed timely, follow CHA's authorization procedures.
Make the Process Timely
Use the Provider Portal whenever possible. The status of an authorization request can be checked using the Provider Portal. Please fill out the authorization request in its entirety. Omission of vital information regarding the member's demographics, diagnosis, procedure codes (CPT or HCPCS) will delay action on the authorization. Chart notes and other clinical documentation are mandatory for a complete authorization.
Faxing Authorizations
When faxing forms for multiple authorization requests, please ensure a blank page is included between each request. This helps CHA staff differentiate between each request and log them appropriately. Urgent requests MUST be faxed individually. Please fax documents right side up.
Authorization Modifications
Requests to modify or change an authorization must be in writing and faxed within 90 days of the original authorization.
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A modified authorization is a request for one of the following: · A change to a requested/servicing provider. · An extension of an expiration date.
o The modified expiration date may not extend beyond 364 days from the original request date. · An addition of a CPT or HCPC code left off the original approved or modified authorization.
A modified authorization cannot be made if one of requests below exists. If such a requested is needed, a new authorization must be requested. Always makes sure appropriated documentation is included. · Authorizations cannot be modified more than three times. · The addition of multiple codes. · Requests to add additional units or visits to an existing authorization through a modification will be denied.
A modification is not needed for an authorization when of the following are needed. In these cases, a new authorization is not required. · An MRI without dye changed to an MRI with dye (if the code is in the same code set) · Decrease the quantity of units or visits.
Retro Authorizations
Per OAR 410-120-1320 (5) (C), CHA will not provide authorization for services after 90 days from the date of service unless documentation is provided showing the authorization could not have been obtained within 90 days of the date of service. The authorization request must have corresponding chart notes for that date of service.
Urgent Authorizations
A prior authorization request is considered urgent when an injured or sick person may suffer from irreversible complications or even death if the injury or illness is not treated in a timely manner. Retroactive authorizations are not considered urgent. Scheduling issues are not considered urgent unless they meet the above criteria. If urgent criteria are met, urgent authorizations are processed within 72 hours.
Specialist Authorizations
A primary care provider (PCP) can decide when a referral to a specialist is needed. Referrals to some specialties require prior authorizations while other specialties do not. Please refer to the CHA Authorization Grid for details.
When a prior authorization is required for a referral, use the following process to submit the authorization. · The PCP submits the initial authorization to CHA. · All follow up authorizations may be submitted by the specialist. · CHA faxes authorizations to both the PCP and the specialist when a fax number is available.
o Authorizations are available on the Provider Portal.
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Authorizations NOT Required
The following services do not require a prior authorization:
· Local Cataract Surgery (Klamath Falls/Medford) · Emergency Services · Hospitalizations - local · In Network Specialties includes initial evaluation plus two follow ups · Local wound care clinics · Up to 6 visits for nutritional and diabetic management counseling alternate diagnosis · IV Hydration at Sky Lakes Medical Center (SLMC)/Outpatient · Blood Transfusion/Platelets/RBS @ SLMC/Outpatient · CT Myelogram at SLMC · Prostate Biopsies performed Locally · Sweat Tests at Rouge Regional Medical Center (RVMC) and other locations · Placement and/or removal/care of declotting Vascular Devices · Pacemaker Clinic in Medford and Klamath Falls · Cardiology in Medford and Klamath Falls
CHA/MCR Duals
Authorizations are REQUIRED for all NON MCR Covered Services ONLY. CHA is the secondary insurance when members are also covered by ATRIO.
Surgery Smoking Cessation
CHA follows the rules set by OHP when reviewing authorization requests for surgery.
The following Guideline Notes are used during this review. Search for descriptions of these Guideline Notes using OHA's Searchable List.
Smoking cessation is required for at least four weeks prior to surgery. · Guideline Note A4 Smoking cessation and elective surgical procedures
Smoking cessation is required for at least six months prior to the procedure · Guideline Note 8 Bariatric surgery (OAR 410-130-0200) · Guideline Note 100 Smoking and spinal fusions (non-emergent) · Guideline Note 159 Lung volume reduction surgery
CHA refers to the following Oregon Administrative Rules (OARs) when making decisions regarding these procedures.
OAR 410-120-1320(2)
OAR 410-120-0000 (145) (a-e) OAR 410-120-0000(146) (a-e)
OAR 410-120-1200(2)(b)(c) OAR 410-141-0480(2)(3)
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Smoking Cessation and Elective Surgical Procedures
Surgical procedures are deemed elective when they are flexible in their scheduling because they do not pose an imminent threat nor require attention prior to the cessation requirements being met. Reproductive (i.e. for contraceptive purposes), cancer-related, and diagnostic procedures are excluded from these guidelines.
Smoking Cessation Confirmation
Members have two options to prove they quit smoking.
1. Members can come to CHA's office to get an exhaled carbon monoxide test, Monday through Friday 8:30 am 4:30 pm. No appointment is needed. a. To prove the member quit smoking for four weeks, the member will need to pass two tests, four weeks apart. b. To prove the member quit smoking for six months, the member will need to pass two test, six months apart.
2. The members' PCPs can order a urine cotinine test. a. The member will have to pass two tests.
Refer to the Pharmacy Signature Programs section to learn about the ways CHA helps members quit smoking.
Second Opinions
All members have the right to seek a second opinion from a qualified health professional for any covered benefit. The request can be for in- or out-of-network as necessary.
Second Opinion Process Primary Care Provider
If a member desires a second opinion based on a diagnosis from their PCP, the member may request their PCP submit an authorization to see a specialist. If a member is uncomfortable asking their PCP for a referral, they can ask CHA Member Services to reassign them to a new PCP.
If the member has been reassigned sometime in the previous six months, they will be directed to a case manager who will discuss their concerns and handle/assign their case as appropriate.
Second Opinion Process Specialist
If the member is seeking a second opinion after seeing a specialist, the member should seek that opinion through their PCP. The PCP will submit a new authorization request, explicitly identifying the authorization is for a second opinion. The authorization will be handled as a traditional authorization in accordance to the Case Management Department's standard procedures.
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CHA Durable Medical Equipment
CHA covers a variety of Durable Medical Equipment (DME) and dispenses some supplies out of the office. Refer to the Important Forms and Resources section for links to DME order forms.
Authorization Requirements · Complete DME form(s) with the correct ICD 10 diagnosis code and HCPCS Code. · A physician signature on the order form or an attached prescription signed by ordering provider. · Attach recent (within the last three to six months) chart notes or discharge summary/progress notes. o Chart notes supporting why the member needs these supplies. · Please put the requesting provider fax number on the authorization request. · Submit the authorization via the Provider Portal or a fax to CHA · If there are any DME needs that are not listed on the DME form, the request needs to include an appropriate outside Vendor who can provide the requested service. · New prescription is required yearly or if change in need occurs.
Incontinence Supply Selection Process
Refer to the form CHA Durable Medical Equipment (DME) for Incontinence Supply selection process, sizing guide, and order form that include codes and quantities for incontinence supplies. When incontinence supplies are requested, the diagnosis must meet Oregon Health Plan (OHP) rules. CHA cannot change determinations without a written provider order.
Incontinence supply authorization requests must include the following information.
Size
Type
Thickness/absorbency
Length of time member needs Reason for need
supplies
(diagnosis/condition)
Nocturnal enuresis is not covered per OHP guidelines. Refer to OAR 410-122-0630 - Incontinent Supplies.
Insulin Pump Selection Process
CHA may supply insulin pumps and/or continuous glucose monitoring (CGM) devices to eligible members, per OAR 410-122-0525 External Insulin Infusion Pump. The DME order forms provide information regarding insulin pump selection process and codes and quantities for insulin pump supplies.
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Clinical Practice Guidelines
The use of clinical practice guidelines helps ensure members receive high quality cost effective care. CHA adopts guidelines based on need as identified by areas of high cost, high degree of variation, and high degree of member morbidity or mortality. CHA uses these guidelines for coverage determinations and encourages providers to use them to guide care. For care not addressed below, CHA encourages providers to follow guidance from their certifying board or professional organization. Providers are also encouraged to share with members any guidelines relevant to their care. These Clinical Practice Guidelines are located on CHA's website for providers and members to access. CHA encourages provider suggestion for additional guidelines that would help to improve the care of members.
Health Evidence Review Commission (HERC)
CHA relies heavily on the OHA Health Evidence Review Commission (HERC) Prioritized List of Health Services and accompanying practice guidelines. The list is used to make coverage determinations, but it also contains 21 diagnostic guidelines and 176 Clinical practice guidelines. The Prioritized List of Health Services and accompanying practice guidelines can be found at the following link. https://www.oregon.gov/OHA/HPA/CSI-HERC/Pages/Searchable-List.aspx
Gold Initiative for Obstructive Lung Disease (GOLD)
CHA uses the Gold Initiative for Obstructive Lung Disease (GOLD) for guidance on Chronic Obstructive Pulmonary Disease (COPD) and other lung diseases. Details can be found at the following link. https://goldcopd.org/
American Diabetes Association
CHA uses the American Diabetes Association recommendations on the treatment of diabetes. Review these recommendations at the following link. https://professional.diabetes.org/content-page/standards-medical-care-diabetes
National Comprehensive Cancer Network (NCCN)
CHA uses National Comprehensive Cancer Network (NCCN) for chemotherapy and genetic testing determinations. Refer to these guidelines at the following link. https://www.nccn.org/professionals/physician_gls/default.aspx
Centers for Disease Control and Prevention (CDC)
When prescribing opioids, refer to the CDC Guideline for Prescribing Opioids for Chronic Pain. This can be found at the following link. https://www.cdc.gov/drugoverdose/prescribing/guideline.html
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Dental Services
Primary Care Dentists (PCDs) are available for general dental health care needs. PCDs may refer to a specialist when they cannot or do not provide a specific service. Cascade Health Alliance (CHA) can be contacted for PCD assignments.
To learn more about Oregon Health Plan's (OHP's) Dental Services Program, go to Oregon Health Authority's (OHA's) website. Please refer to OHA's Dental Service Administrative Rulebook for a list of Oregon Administrative Rules (OARs) CHA uses for guidance. The Current Rulebook was effective on August 1, 2018.
Dental Authorizations
The Utilization Review section explains how the CHA authorization process works for physical health, dental care, and behavioral health. Use the Provider Portal to submit and to review the status of an authorization. Refer to the CHA Dental Authorization Form for dental services that require a prior authorization. All dental authorizations are good for one year and cannot be extended. A new authorization request would need to be submitted after a year.
Proper Dental Documentation To increase the timeliness of authorization determinations, CHA encourages providers to have complete documentation. Complete documentation includes:
· Current and complete chart notes for all authorizations o Partials Include which teeth the partial is replacing If applicable, document previous partial(s) and when the member had them o Full dentures If applicable, document previous dentures and length of time member had them If applicable, document need of alveoplasty or tori removal · If alveoplasty or tori removal are not covered, advise member the procedures needs to be perform before dentures can be made
· Complete authorization form · If available, most current x-rays and panoramic CTs
Dental Benefits
A brief list of dental benefits can be found in the Benefits section. This list is like the one members receive in their Member Handbook. OHA's website contains the most complete list of dental benefits. Review the documents Covered and Non-Covered Dental Services and Dental Services Prioritized List. Additional benefits may be available for members under the age of 21 or pregnant women. Please ensure alveoli and tori plasty are covered benefits for a member before the member's teeth are extracted.
Special Care Members
Contact CHA for assistance with special needs and bariatric members.
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Pharmacy Services
Cascade Health Alliance's (CHA's) Pharmacy Services department oversees the authorizations of prescriptions, the distribution of certain supplies, and member education related to their signature programs.
Approved Drug List (Formulary)
Find CHA's Drug Formulary on CHA's website. Prescriptions cannot be filled outside of Klamath county. Contact CHA Pharmacy Services for exceptions.
Pharmacy Signature Programs
All supplies available at CHA office Monday Friday from 8:30 am 4:30 pm.
Weight Management
In partnership with Sky Lakes Wellness Center.
Tobacco Cessation
Free classes offered every 8 weeks.
SIGNATURE PROGRAMS
Respiratory Care Management
Supplies available at CHA office.
Call 541-883-2947 for Additional Information.
Diabetes Care
Management
Supplies available at CHA office.
Respiratory Supplies (Respiratory Care Management)
CHA will dispense peak flow meters, nebulizers, and aero chambers from the CHA office (prescription required) and will provide the necessary nebulizing supplies such as tubing, pediatric masks, and medicine cups (limited to two per month as needed). Additionally, CHA gives information on how to correctly use and clean nebulizers and other respiratory supplies.
Dispense supplies
Chronic obstructive pulmonary disease (COPD) education
Asthma education
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Diabetes Care & Education (Diabetes Care Management)
Supplies are dispensed according to Oregon Health Plan (OHP) guidelines while additional supplies are authorized with supporting documentation from the member's provider. CHA will contact a member's provider if a member needs a new prescription for any supplies including syringes, test strips, and lancets. Members are asked to bring their meters each time. CHA downloads results to track them and can send test results to the provider. Type 1 and type 2 diabetics are allowed an annual eye exam without a referral.
Type Of Diabetes Type 2
Insulin/Non-Insulin Non-Insulin
# Strips/Lancets
50 strips and 100 lancets per 90 days, additional 50 strips for acute change in control or medication adjustment
Type 1 or Type 2
Multiple Daily Insulin Injections 100 strips and lancets per month
Gestational
ALL
150 strips and 200 lancets per month up to 60 days beyond duration of pregnancy
Regulations
· Monitors are limited to one monitor per two calendar years · Maximum of a three-month supply dispensed at a time · Automatic refills are not allowed, even if the member has authorized this service · One lancet device covered every six months Excluded Services
· Peroxide, Betadine, or Phisohex · Alternate site blood glucose monitors · Monitors and supplies to be used on an "as needed" basis · Blood glucose test or reagent strips that use a visual reading and are not used in a glucose monitor · Disposable gloves · Home blood glucose disposable monitors that use a visual reading and are not used in a glucose monitor · Home blood glucose disposable monitors · Jet injectors · Reflectance colorimeter devices used for measuring blood glucose levels in clinical settings · Urine test or reagent strips or tablets
Pharmacy Technicians are certified by the American Academy of Diabetes Educators (AADE) to provide education and care. CHA has a trained Lifestyle Coach on staff and can also download data from Medtronic Insulin pumps.
Hepatitis C Treatment
Treatment is overseen by an independent medical doctor. This treatment is funded through the state, so identification of Hepatitis C patients is required throughout Oregon.
To determine eligibility screen and/or check the following:
Hepatitis C
Viral count/load
Fibrotest
Genotype
Please refer to Important Forms and Resources section for a link to the Hepatitis C Treatment Request Form. 42
Wellness Program (Sky Lakes Live Young Weight Management)
Regular lab draws
20 empowering group classes
5 body composition
analyses
Wellness Program
Prizes
Regular visits with an obesity
doctor and dietician
Year-long
The Wellness Program discusses weight loss and food choices.
For CHA to process referrals, a member must meet three qualifiers:
· Provider referral required · Member must be 18 years of age or older · Member must meet one of the following criteria
o Body mass index (BMI) >30 o BMI between 25 and 29 and two qualifying
disease states i.e. hypertension, Type 2 diabetes, dyslipidemia,
metabolic syndrome
Smoking Cessation
CHA offers free classes to help members quit. The classes are designed to work with counseling and/or medication. Classes are offered six times a year and each run for seven weeks. There is also a pizza party in the last class!
Nicotine Replacement Therapy
Smoking Cessation Classes
Telephonic Counseling for Smoking Cessation
Please visit CHA's website for a schedule of classes or call Member Services for more information.
Freedom from Smoking Program
The Freedom from Smoking Program is taught by trained American Lung Association-certified smoking cessation facilitators. Media and DVDs are shown regarding cessation, as well as presentations from guest speakers includes exsmokers. Members must agree to expectations required in the contract.
Nicotine Replacement Therapy (NRT) · Patches, lozenges, and gum do not require prior authorization. · Chantix approved upon demonstrated class attendance.
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Claims
Please use this document for basic claims information. For specific questions, contact the Claims Department.
Claims Submission
To submit claims electronically, use EDI Payer ID 7749 for the clearing house Relay Mckesson/Change Health or CHA01 for the clearing house Trizetto. Any electronic claims submitted to Cascade Health Alliance (CHA) must comply with requirements set by 45 CFR Part 162. CHA will process electronic claims consistent with these requirements for standard transactions. Claims must include the member's diagnostic code(s) to the highest level of specificity and the appropriate procedure codes(s). See Oregon Administrative Rules (OARs) 410-130-0160 and 410-120-1280.
The following items are required for each claims submission.
Member name
Member address
Member's date of birth
Member's gender
Member's ID number
National Provider Identification Number (NPI)
Federal Tax Identification Number (TIN)
Current diagnosis codes
Correct zip codes
If applicable, referral # on specialists' claims
If member has another insurance primary to CHA, Indication of job-related injury or illness or an
add the prime insurance name, ID number, and
accident-related illness or injury
group policy number (if available)
o Include pertinent details
Admission date (for inpatient hospitalizations;
Place of Service 21)
Timely Filing
Eligible claims for covered services must be received within 120 days from the date of service per OAR 410141-3420 (1). If CHA is the member's secondary insurance, claims must be submitted within 365 days from the date of service.
Exceptions to the timely filing rule includes the following. Submission of proof is required. · CHA is secondary to Medicare or another insurance company · Maternity-related expenses · Newborns · Claims denied by Workers' Compensation · Claims processed or adjusted after retroactive eligibility changes · Errors causing the provider not to be able to bill · Court or hearing officer orders payment
Timely Payment
CHA pays providers by the 30th day after a clean claim is received. A clean claim is complete, correct, and has valid diagnostic and CPT codes. Claims requiring additional review and/or information take longer to process. They are to be paid within 30 days after the completion of review or receipt of additional information.
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DMAP ID Number
The Department of Medical Assistance Programs (DMAP) Identification (ID) number is considered a minimum requirement for claims processing and must be maintained. In order to process a claim, CHA verifies the NPI of the rendering, attending, and billing provider's is eligible to receive payment by DMAP and enrolled with an ID number. A provider's DMAP ID can be inactivated due to several reasons including license expiration and returned mail.
Verify active enrollment status with DMAP · To verify active enrollment, click on the following link.
o https://www.or-medicaid.gov/ProdPortal/Home/ValidateNPI/tabId/125/Default.aspx · Enter the provider NPI and date of inquiry (e.g. date of service). · Click search.
If the provider NPI is not actively enrolled for the date of service entered, submit claims to CHA and simultaneously complete and submit the Oregon Medicaid ID Application Form. CHA will enroll the NPI and automatically reprocess any previously denied claims received with the dates of service within the previous calendar year for that reason.
ALERT! CHA does not enroll out-of-area and non-participating providers without first receiving a claim. These providers can submit claims and the DMAP ID Application Form simultaneously. CHA will not enroll providers until a claim has been received.
Locum Tenens Claims and Procedures
Per Centers for Medicare and Medicaid Services (CMS) guidelines, CHA allows licensed providers acting in the Locum Tenens capacity to substitute for another provider for 60 days. CHA allows the Locum Tenens to temporarily submit claims under another licensed provider's NPI number when that provider is on leave from his or her practice. The Locum Tenens provider must have the same billing type or specialty as the provider on leave. Payment is sent to the billing office of the provider on leave. The provider on leave and the Locum Tenens provider are responsible for compensation arrangements. Providers serving in a Locum Tenens capacity should bill with Modifier Q6 to indicate the Locum Tenens arrangement.
Interim Billing
Facilities reimbursed based on Diagnosis Related Group (DRG) methodology are paid when the patient is discharged, and the final billing is received. If a facility is not reimbursed at DRG rates, CHA reimburses for the first and subsequent interim billings. Interim claims must be submitted in sequential order and in 30-day increments. Each claim must be complete as described in the claim submission and authorization guidelines.
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Claims Reconsideration or Disputes
CHA follows Health Insurance Portability and Accountability Act (HIPAA) guidelines for transaction codes and data sets.
CHA refers to the following Oregon Administrative Rules (OARs) during claim disputes.
OAR 410-120-1560
OAR 410-120-1570
Providers may dispute a claims payment decision by requesting a claim reconsideration. One must resubmit the claim with the supporting documentation to the claim. Please contact the Claims Department for any questions regarding claims reconsiderations.
Providers have 120 days from the claim processing denial date to request a claim reconsideration. CHA will review and process reconsiderations or disputes within 30 days from requested date.
Claims Appeals
Contact CHA's Claims Department to appeal an action including but is not limited to the denial, in whole or in part, of payment for service.
Reconsideration for Payment Denied for missing information or documentation Duplicate claims Timely filing denials
Clinical Review of Claims and Services Procedure
CHA uses a clinical editing system to ensure the efficiency and accuracy of the claims payment system.
The clinical editing system involves: · Re-bundling lab, X-ray, medicine, anesthesia, and surgical procedure codes · Denial warning message when:
o A surgery is inconsistent with the diagnosis o A patient's age does not fall into the normal age range for the procedure or diagnosis · Denial of a procedure/services o Considered integral to another billed procedure o Not customarily billed on the same day as a surgical procedure o Normally included as follow-up care associated with a surgical procedure
Valid exceptions to clinical editing exist. CHA reviews records for unusual or extraordinary circumstances that may influence the benefit.
Readmissions to Diagnosis Related Groups (DRG) Hospitals
Readmissions within 30 days of discharge are considered part of the initial admission and are included in payment for the initial admission when an additional surgery or follow-up care was planned at the time of discharge or treatment for the same condition due to an inadequate discharge plan occurs.
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Adjustment-Overpayment Process
To recover overpayments, CHA uses an auto-debit method. The appropriate group of claims is negated once the overpayment is identified. Future payment of claims is automatically debited until the outstanding overpayment balance is settled. Please contact the Claims Department for all refund concerns.
Billing Members
Contracted providers are expected to accept compensation solely from CHA and not from members. This includes situations where CHA has denied a claim and is in compliance with OAR-141-3395. Participating providers are prohibited from billing a member, sending members' a bill to collection agency, or maintaining civil actions against a member to collect money owed by CHA for which the member is liable (OAR 41014103395(5)). This does not prohibit the participating providers from collecting deductibles, copayments, coinsurance, or for health services not covered by CHA as long as valid DMAP 3165 form is signed by the member, prior to service as required by OAR 410-141-3395 (6) I, OAR 410-120-1280, and OAR 410-1410420.
Billing for non-covered services
The provider will inform the member when a requested service is not covered. If the member chooses to proceed with a service, the provider of service, regardless of network affiliation, will inform the member in writing, with a current OHP-approved waiver, that the member will be responsible for payment of the procedure. The current and approved OHP payment acknowledgement and responsibility waiver must be signed by the member prior to rendering the service. The Form DMAP 3165 OHP Client Agreement to Pay is the only recognized form for a provider to receive payment from a member prior to rendering the service. The link to this form can be found in the Important Forms & Resources section.
Billing for members with other insurance
CHA is always payor of last resort. Bill all prior resources (third-party liability, or TPL) before billing CHA. If the member has both Medicare and Medicaid, Medicare may not be required to be billed first if the claim meets criteria outlined in OAR 410-172-0860. Do not collect TPL coinsurance, copayments, or deductibles from the client if CHA is also being billed for what TPL will not pay. If CHA is billed as secondary carrier, make sure to include the primary carrier's Explanation of Benefits (EOB) with the claim. Claims must be received within 365 days from the date the claim was processed on the primary EOB.
For clients with TPL (including Medicare), CHA pays the Medicaid allowable rate or fee, minus the previous amount paid.
· If TPL denies the claim, CHA will pay the Medicaid allowable amount of the claim for the covered services. o If TPL pays part of the claim, and their allowable is less than CHA's, then CHA will pay the Medicaid allowable amount, minus the amount TPL paid.
· If TPL pays part of the claim, and their allowable is equal to or more than CHA's, then OHA will consider the claim paid in full and the provider/clinic will not receive additional payment from OHA.
· If Medicare pays part of the claim, CHA will pay the difference up to the Medicare or Medicaid allowable, whichever is less.
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Low and Zero Dollar Claims
Please remember to submit low and zero-dollar claims. This helps CHA track provided services in the community.
Procedure Specific Claims
Some procedures and services require a special claims process.
Hysterectomy and Sterilization
Informed consent must be obtained from a member who wants a hysterectomy or voluntary sterilization, including tubal ligation or vasectomy, per OAR 410-130-0580. Without proper informed consent, state and federal money cannot be used to pay for hysterectomies and voluntary sterilizations. Providers must submit a completed and signed (by member and provider) consent form with hysterectomy and sterilization claims. Otherwise, CHA cannot reimburse providers for these procedures without proof of informed consent. Refer to the Important Forms and Resources section for links to the consent forms.
Hysterectomies
Hysterectomies performed for the sole purpose of sterilization are not a covered benefit.
If a member is not sterile, a Hysterectomy Consent form must be signed by the member. The provider must complete Part I of the Hysterectomy Consent Form.
If a member is sterile, a Hysterectomy Consent form does not need to be signed by the member. The provider must complete Part II of the Hysterectomy Consent form.
When consent cannot be obtained during a life-threatening emergency, the provider must complete Part II of the Hysterectomy Consent form.
Voluntary Sterilization
The Consent to Sterilization form must be signed and dated by the member at least 30 days, but not more than 180 days, before the tubal ligation or vasectomy procedure.
A member may sign the sterilization consent form fewer than 30 days but more than 72 hours before a
sterilization procedure in the case of one of the following.
Premature delivery
Emergency abdominal surgery
The address of the facility where consent was obtained must be provided. If an interpreter helps the member, the interpreter must sign and date the consent form.
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Vaccines for Children (VFC) Billing
Vaccines for Children (VFC) provides vaccine for free for children 18 and younger; however, CHA does not pay for the administration service codes. The administration of the vaccinations is paid when billed with the proper vaccination service code. Use standard billing procedures for vaccines not included in the VFC program. Click on the following link to learn more about vaccines and immunizations in Oregon. http://public.health.oregon.gov/PreventionWellness/VaccinesImmunization/Pages/index.aspx
Newborn Claims
Newborns of CHA mothers are CHA's responsibility; however, newborns are initially put onto OHP Open Card. If open card is billed, the claim will eventually be denied and the provide services will not be paid for. Allow up to one month for newborns to receive a member ID number. If the baby has an ID number, the provider should bill CHA regardless if Medicaid Management Information System (MMIS) is showing baby as Open Card or CHA. Newborns should be a CHA member from birth if mother was a CHA member with medical benefits. Contact CHA Customer Service for questions and enrollment verification.
Labs
For PCPs, labs are only paid in office if the lab is a stat lab. The labs that are not stat need to be done at Sky Lakes Medical Center Laboratories. Special circumstances apply for specialists.
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Quality Management
Cascade Health Alliance (CHA) is committed to its members receiving the best care possible. To that end, CHA's Quality Management program is designed to ensure the care provided to its members is timely, easily accessible, cost effective, improves members' overall health, and reflective of best practices in health care. CHA is held accountable to positive health outcomes by the Oregon Health Authority (OHA) and the Center for Medicare and Medicaid Services (CMS). The Quality Management program is designed to meet the mandates of the Triple Aim:
Better Health Increased access to health care
for Oregonians
Better Care
Improved health of Oregonians through quality of care and access to preventive services
Lower Costs Contained cost of health care
Quality Metrics
The OHA uses quality health metrics to demonstrate how well Coordinated Care Organizations (CCOs) are improving care, making quality care accessible, eliminating health disparities, and curbing rising health care costs. A primary source of the metrics is the Health Effectiveness Data and Information Set (HEDIS) and the National Committee for Quality Assurance (NCQA). The measures are chosen by the OHA's Metrics and Scoring Committee. Financial incentives are awarded to CCOs based on their performance against the measures. The metrics, including targets and benchmarks, change annually based on performance and focus areas as determined by the OHA.
Quality Metrics Web Resources
To find Quality Metrics on OHA's website:
Follow the link:
Search:
http://www.oregon.gov/OHA/HPA/ANALYTICS/Pages/CCO-Baseline- CCO Incentive Metrics
Data.aspx
To find Quality Metrics on CHA's website:
Follow the link: https://cascadehealthalliance.com/quality-initiatives/
Search: Locate the Quality Initiatives page under the "Providers" tab
To review the annual report on the performance of all CCOs on OHA's website:
Follow the link:
Search:
https://www.oregon.gov/oha/HPA/ANALYTICS-MTX/Documents/2017- CCO Incentive Metrics
CCO-Metrics-Report.pdf
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Performance Improvement Projects
OHA mandates CCOs conduct Performance Improvement Projects (PIPs) based on seven clinical focus areas: · Reducing preventable re-hospitalizations and Emergency Department utilization · Addressing population health issues (such as diabetes, hypertension and asthma) · Care Coordination using "care teams" to improve care and reduce preventable and/or costly utilization of services · Integrating primary care, behavioral health, and oral health · Ensuring appropriate care is delivered in appropriate settings · Improving perinatal and maternity care · Improving primary care for all populations through increased adoption of the Patient-Centered Primary Care Home (PCPCH) model of care throughout the CCO network.
In addition to the focus areas above, CHA conducts other performance improvement projects based on member and/or community needs as well as CHA's performance against quality metrics or to improve the quality of services provided to members. CHA also participates in state-wide PIPs as mandated by the OHA.
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Important Forms & Resources
Many forms are available on CHA's website "Providers" at https://cascadehealthalliance.com/policiesprocedures-and-forms/ . However, Cascade Health Alliance (CHA) can also provide these tools to providers and clinics. Refer to General Information, Contact Information, and Web Resources for more information.
Appeals & Grievance Forms & Resources
The listed forms are required by members to file a complaint, request an appeal or hearing, and to provide Oregon Health Plan (OHP) members their rights regarding appeals, hearings, and complaints. These forms must be available at provider offices, per Oregon Health Authority (OHA).
Appeals & Grievances Forms
OHP 3001 - OHP Complaint MSC 443 - Administrative Hearing Request OHP 3302 - Appeal and Hearing Request
OHP 3001 - OHP Complaint (Spanish) MSC 443 - Administrative Hearing Request (Spanish) OHP 3302 - Appeal and Hearing Request (Spanish)
Appeals & Grievances Resources
OHP 3030 - Notice of Hearing Rights PP2003 - CHA Grievance System policy
OHP 3030 - Notice of Hearing Rights (Spanish)
The required forms and all other OHA/OHP forms can be found using the following methods.
OHP Forms and Publications - http://www.oregon.gov/OHA/HSD/OHP/Pages/Forms.aspx · Enter the required form number into the search box. Download any version of the form that is required.
DHS/OHA Publications and Forms - https://aix-xweb1p.state.or.us/es_xweb/FORMS/ · Only enter the form number in the search box, not the proceeding letters. · Refine the search further through the drop-down menu.
Google · Search: "FORM# Oregon". o For example, to find MSC 443, search: "MSC 443 Oregon" and click on the PDF link.
Authorization Forms & Resources
To ensure an authorization can be processed in a timely manner, make sure authorization requests are complete and contain the accurate and current ICD 10, CPT, and/or HCPC codes. Current supporting clinical documentation is required.
Authorization Forms
CHA Authorization Form DME Authorization Request Form
CHA Dental Authorization Form Incontinence Authorization Request Form
Authorization Resources CHA Behavioral Authorization Grid CHA Medical Authorization Grid
CHA Dental Authorization Grid
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Case Management Forms & Resources
Contact the Case Management department with any questions.
Case Management Forms & Resources Case Management Request Form CHA Rapid Referral for Behavioral Health Oregon Mobile Health (OMH) Referral Form
Flex Fund Request Form CHA Rapid Referral for SUD Services
Claims Forms & Resources
Contact the Claims department with any questions.
Claims Forms
OHP 3165 - OHP Client Agreement to Pay for Health Services (for Non-Covered Services) OHP 3165 - OHP Client Agreement to Pay for Health Services (for Non-Covered Services) (Spanish) OHP741 - Hysterectomy Consent Form OHP741 - Spanish Hysterectomy Consent Form (Spanish) OHP 742A - Sterilization Consent Form Ages 21 years and older OHP 742A - Sterilization Consent Form Ages 21 and older (Spanish) OHP 742B - Sterilization Consent Form Ages 15-20 OHP 742B - Sterilization Consent Forms Ages 15-20 (Spanish)
Pharmacy Forms & Resources
The following screening tools and guidelines are used by the Pharmacy department and Medical Director.
Pharmacy Forms & Resources CHA Opioid Tapering Plan Keele StarT Back Pain Screening Tool
Hepatitis C Treatment Referral Form Oswestry Low Back Pain Disability Questionnaire
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Community Health Partnerships
Each organization has a unique mission; however, all strive to help the community.
Mental Health Emergency
Klamath Basin Behavioral Health
541-883-1030 Crisis support available 24 hours per day, 7 days a week
Oregon Warmline
1-800-698-2392 Free, confidential support from
trained peers
Oregon Youthline
1-877-968-8491 (call) Text teen2teen to 839863 Free teen to teen crisis support
Behavioral Health Services
Many organizations provide behavioral health services in Klamath County. These organizations include, but are not limited to, Klamath Basin Behavioral Health (KBBH), Lutheran Community Services Northwest (LCS), BestCare, Transformations Wellness Center, Klamath Open Door Family Practice (KOD), Cascades East Family Medicine, and Psychiatry Mental Health Associates.
Klamath Basin Behavioral Health
KBBH mission: "To establish, develop, maintain, and operate the highest quality mental and behavioral health programs for Klamath County's adults, children, adolescents, and families."
Services and Programs
24-hour crisis line Case Management Substance Use Disorder Mobile Crisis Team Suicide/Risk Assessments Mental Health Assessments Mental Health Consultations Psychiatric Clinic Services Crisis Services
Operated at Klamath Corrections
Sex Offender Treatment Services
Adult Respite Services Adult Residential Services Health Families of Klamath County In-Home Safety and Reunification Services Adolescent Respite/Residential Services Intensive Community Treatment Services for Children Counseling for Children, Adolescents, Adults, and Families Day Treatment Services for Children and Adolescent Groups School-based Service
Batterer's Intervention Program
Contact Information
Phone
Fax
541-883-1030 541-884-2338
Email info@kbbh.org
Address 2210 Eldorado Ave Klamath Falls, Oregon 97601
Hours
Monday Thursday 7:15am 6:00pm Friday 7:15am 6:00pm
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Klamath County Community Corrections
Klamath County Community Corrections mission: "Promoting Public Safety through Positive Offender Change"
Services and Programs
Alcohol and drug treatment Employment services Cognitive programming Women and Adult Victims services Dental and physical health screening and referral Skill building and Carey Guide sessions Parenting classes Mental health services
(MRT, Breaking Barrier, and MET)
Vocational Rehabilitation services GED and credit recovery Veteran services Religious and mentor services Nutrition and Wellness Budget and financial classes Community support groups Peer restructuring Assistance with obtaining Social Security card,
birth certificate, and identification
Contact Information
Phone 541-880-5500
Address 3203 Vandenburg Road Klamath Falls, Oregon 97603
Hours:
Monday Thursday 8:00 am 11:30 am 1:00 pm 5:00 pm
Friday 8:00 am 11:30 am
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Substance Use Disorder Services
Substance Use Disorder (SUD) Programs include, but are not limited to, KBBH, LCS, BestCare Treatment Services, Lutheran Community Services Northwest, and Transformations Wellness Center. Student Assistance Program (SAP) with the Klamath County and City Schools is another available resource SUD resource. To receive more information regarding this program, a member needs to contact the school the child in need of services attends.
BestCare Treatment Services
BestCare mission: "To advocate and provide compassionate care in the treatment and prevention of addictions and mental illness"
SUDS Outpatient Services Alcohol Services Drug Services
o Dual Diagnosis Services Pain Management Mental Health Services Spanish-Speaking Rehab Alcohol Services
Detoxification Level III.7
o Open: 24 Hours Every Day Outpatient Services 0.5 to II
Open: 8:30 am 6:30 pm Residential Level III.5
Open: 24 Hours Every day
Residential Contact Information
Phone 541-883-2795
Fax 541-883-8194
Address 2555 Main St. Klamath Falls, Oregon 97603
Websites http://www.bestcaretreatment.org/klamath-falls-residential.html
Hours Open 24 hours
Outpatient Contact Information
Phone
Fax
541-205-359 541-883-8194?
Address 4775 S. 6th St.
Klamath Falls, Oregon 97603
Website http://www.bestcaretreatment.org/klamath-falls-outpatient.html
Hours
Monday Thursday 7:15am 6:00pm Friday 7:15am 5:00pm
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Lutheran Community Services Northwest
LCS mission: "Your partner in Health, Justice and Hope"
SUDS Outpatient Services
Drop-in Screenings
o No-Cost Orientations: 15-20 minutes with a counselor to learn if LCSNW meets the member's needs
o Open:
M/W/F 10:00 am 5:30 pm
Thursday 10:00 am 4:00pm
Project Changes Alcohol, tobacco, and other Drug Prevention/Intervention Services
Therapeutic Foster Care
Physical Therapy
Supported Employment
Mental Health Counseling & Medical Management
Life Skills
Addiction Treatments (Alcohol/Drug Counseling)
Contact Information
Phone 541-883-3471
Fax 541-883-3524
Address 2545 N. Eldorado Ave Klamath Falls, Oregon 97601
Website https://lcsnw.org/office/klamath-falls/
Hours
Monday; Wednesday-Friday 8:30am 5:30pm
Closed: 12:00pm-1:00pm Tuesday
1:00pm-5:30pm
Transformations Wellness Center
Transformations Wellness Center mission: "Transformed, fulfilled, healthy and empowered individuals, families and communities."
SUDS Services - Level 111.1-5 Longer-Term Residential
Inpatient Alcohol and Drug Abuse Rehabilitation Treatment Services
Open: 24 hours, 7 days a week Evidenced-Based Programming Psycho Education Groups Family Education and Support Cognitive Behavioral Therapy Dialectical Behavioral Therapy
Relapse Prevention Anger Management Life Skills Development Yoga and Mediation Therapeutic Outings Trauma Informed, Individualized, Culturally, and Spiritually
Sensitive Services
Community Partnerships and Referrals
Dual Diagnosis Medication Management Mental Health Counseling
Physical Health and Wellness (including Smoking Cessation) Employment & Vocational Rehabilitation Services Community Support Groups
Contact Information
Hours
Phone
Toll Free
541-884-5244 877-775-6999
Fax 541-884-1105
Address 3647 Highway 39 Klamath Falls, OR 97603
Website
www.transformwc.org
Monday Friday 8:00am-5:00pm
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Other Resources
A variety of organizations strive to help the community.
Life Recovery Network
Life Recover Network mission: "We believe that the door to salvation is always open and so are the doors to our church. Our mission is to be fully devoted to Jesus by opening our arms to those in search of the truth. We show God's love and concern for our fellow man at every opportunity. Through opening our doors to listen and love, we feel that we are walking in the footsteps of Jesus Christ in our recovery."
Programs and Services
Sunday Morning Service 10:00 am
Wednesday Night Small Groups 6:00 pm Dinner 6:30 pm Worship
7:00 pm Small Groups
Support Groups Anger
Sexual Addictions
Men's Addictions Recovery
Teen Recovery
Fright Night Recovery 6:00 pm Family-style Dinner 7:00 pm Worship & Message
8:00 pm Support Groups 9:00 pm Dessert & Fellowship
Women's Addictions Recovery
Bible Study
Parenting
Contact Information
Phone
Address
(541) 891-0071
115 Crater Lake Parkway
(541) 892-1672
Klamath Falls, OR 97601
Websites
https://www.liferecoverynetwork.org/
Hours See program times above.
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Oregon Vocational Rehabilitation Services Department
Oregon Vocational Rehabilitation Services Department mission: "The Oregon Vocational Rehabilitation Services Department (OVRS) represents one of Oregon's greatest untapped labor pools: skilled, motivated, responsible men and women willing workers who happen to have disabilities. Motivated, Reliable, and Dependable; what every employer is looking for in an employee. We understand employers need to find the best candidates. They're not looking for a hand-out, just the same thing that other job candidates hope for: a chance to prove themselves."
Programs and Services
Programs and Services
Evaluations to determine job skills and interests Vocational Counseling Job interview skills
Assistance with training or education Assistance with getting to training or job sites and
other work-related needs.
Contact Information
Phone
Fax
541-883-5614 541-883-5621
Email vr.info@state.or.us
Address 801 Oak Ave. Klamath Falls, OR 97601
State Contact Information
Phone 503-945-5880
Toll Free 877-277-0513
Fax 503-947-5010
Hours
Monday Friday 8:00am-5:00pm
Veterans Enrichment Center
Veterans Enrichment Center mission: "The Veterans Enrichment Center of Klamath County, Oregon, was established to support transitioning Veterans by providing a safe and sober living environment. We are disabled Veterans who have united to found a 501(c)3 Non-profit Organization to assist our local Veterans in eliminating life's barriers. The ultimate goal of the Veterans Enrichment Center is to rebuild the foundation of our Veterans to once again become productive members of society."
Programs and Services
Houses between 20-24 Veterans All- inclusive operations fee ($400 per
month) includes: internet, telephone, water, garbage, cable, and electricity
Computer access Job search help Bring in a counselor or create personal goals Network and support each other in a residential setting
Contact Information
Phone 541-331-9975 or 541-331-9979
Address 1431 Avalon Street Klamath Falls, Oregon 97603
Mailing Address P.O. Box 931
Klamath Falls, Oregon 97601
Website www.veteransenrichmentcenter.org
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Klamath County Resource Guide
Current as of March 2019.
The following resources may be helpful for members. If a resource cannot be found in this guide, dial 2-1-1 or visit www.211info.org to find available resources.
Emergency 9-1-1 Klamath Co. Sheriff's Office (541) 883-5130
American Red Cross (503) 378-2911 Natural disaster relief
KBBH at Phoenix Place (541) 883-1030 Mental health related crisis Oregon Youthline 1-877-968-8491 Text teent2teen to 839863 Get free teen to teen crisis support Veteran's Crisis Center (800) 273-8255
Cascade East Family Practice (541) 885-6733
Klamath Co. Health Dept (541) 882-8846
Pregnancy Hope Center (541) 883-4357 Free Pregnancy Testing, Peer Counseling and Parenting Classes
Emergency Services Klamath Co. Fire District (541) 885-2056 Veterans Hall (541) 884-9125 (Available to Veterans on Wednesdays)
Crisis Child Welfare (541) 883-5570 Report child abuse
Klamath Tribes Healing Winds (800) 524-9787 ext 173
Salvation Army (541) 882-5280
Klamath Falls City Police (541) 883-5336
State Police Dispatch (541) 883-5711
Crisis Helpline/Marta's House (541) 884-0390 (800) 452-3669 (Toll Free) Crisis referral services for domestic violence and other emergencies Oregon Warmline 1-800-698-2392 Free, confidential support Sky Lake Medical Center ER (541) 883-6176
Victim Assistance (541) 883-5147 *3167
Medical/Health Lions Club-Vision (Hotline) (800) 635-4667
Klamath Open Door (541) 851-8110
Sky Lakes Medical Center (541) 882-6311
OR Prescription Drug Program
(OPDP)
(800) 913-4146; www.opdp.org
Klamath Tribal Health &
Family Services
Chiloquin
(541) 783-3293
Klamath Falls (541) 882-1487
Veterans Clinic
(541) 273-6206
Behavioral Health/Substance Use Disorders
Above All Influences (541) 205-8398 www.aboveallinfluences.com Peer support for drug and alcohol addiction providing activities and
Best Care Treatment Services In-patient Treatment (541) 883-2795 Out-patient Treatment (541) 205-3459
Dragonfly Transitions (541)850-0841
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other resources
Klamath Basin Behavioral Health (KBBH) (541) 883-1030 Counseling and Medication Management Klamath Tribal Youth (541) 884-1841
National Alliance On Mental Illness (NAMI) (541) 885-4909
Klamath County Corrections 541-880-5500
Life Recovery Network (541) 891-0071 Drug and Alcohol Addiction, Anger Management, Parenting, and Life Skills Oregon Pain Guidance Stay Safe Oregon 800-923-4357 (HELP) https://staysafeoregon.com/
KBBH at Phoenix Place (541) 883-1030
Lutheran Community Services (541) 883-3471 Various classes and counseling services
Transformations Wellness Center (541) 884-5244
Dental
Primary Care Dentists (PCDs) are available for general dental health care needs. PCDs may refer to a specialist when they cannot or do not provide a specific service.
CHA can be contacted for PCD assignments.
Health/ Wellness Resources
Blue Zone Project (541) 359-2802 www.healthyklamath.org/bluezone s Healthy Klamath (541) 882-6311
Chiloquin First Coalition (541) 887-3569
Hispanic Advisory Board (541) 883-1122
SLMC Outpatient Care Mgmt (541) 274-7250
Klamath Regional Health (541) 883-1122
Live Young: SL Wellness Center (541) 880-2770 Liveyoung.skylakes.org
4-H (541) 883-7131
Child Care Resource & Referral (541) 882-2308 (800) 866-9835 (Toll Free) www.ccrnso.org www.oregonchildcare.org Referrals to in-home and centerbased care: 700 Klamath Ave, Ste 100 Family Support &Connections (541) 883-5695 Integral Youth Services (IYS) (541) 885-4929 Shelter, education, jobs, advocacy,
Klamath Basin Senior Center Health and Exercise classes (541) 883-7171 www.klamathseniorcenter.com
Families/Children/Youth Assistance League® (541) 883-1721 Operation School Bell: referred by schools only, school supplies and clothes for low-income children Citizens for Safe Schools (541) 882-3198
Foster Grandparents Program (541) 892-4521 Klamath County CASA (Court Appointed Special Advocate) (541) 885-6017
Klamath Basin Research and Extension Center (541) 883-7131 Food & nutrition classes/programs
Boy Scouts of America (541) 882-4611
Family/Child Support Division (541) 883-4265
Girl Scouts (541) 773-2022 Klamath Co. Early Childhood Intervention (541) 883-4748
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services for homeless children Klamath Family Head Start (541) 882-5988
Teen Parent Program (541) 885-4274
Assistance League of KFO (541) 883 1721 Lions Club (541) 545-6705
Crater Lake National Park (541) 594-3000 Friends of the Children (541) 273-2022 Moore Park (541) 883-5351 Wiard Park (541) 884-8816
Aging & People w/ Disabilities (541) 883-5551
Disabled American Veterans (541) 884-9125 Klamath Hospice and Palliative Care (541) 882-2902 (877) 882-2902
Oregon Helps www.oregonhelps.org
Seventh-Day Adventist Church (541) 882-2466 Hygiene/cleaning supplies 1735 Main St 1st Tuesday/9:00 am (first come first served) Social Security (SSDI, SSI, SSB) (800) 772-1213
Veterans Enrichment Center 541-331-9975 or 541-331-9979
OR Child Development Coalition (OCDC) (541) 884-8812
Youth Rising (541) 205-4777
Service Organizations Kiwanis Club (541) 884-8663 Soroptimist International of KF (541) 331-4060 Recreational Parks/Activities Discover Klamath (541) 882-1501 Klamath Falls City Park (541) 883-5316 Steen Sports Park (541) 850-9571 YMCA of Klamath Falls (541) 884-4149
Benefits/Other Assistance Area Agency on Aging (541) 205-5400
Klamath Adult Learning Center (541) 883-4719 Legal Aid Services of Oregon (541) 273-0533 (800) 480-9160 (Toll Free) www.oregonlawhelp.org 832 Klamath Ave OR Telephone Asst Program (OTAP) (800) 848-4442 Senior Citizens Center 541-883-7171
Pregnancy Hope Center (541) 883-4357 Free Pregnancy Testing, Peer Counseling and Parenting Classes
Klamath Rotary (541) 884-7446 Kingsley Field (541) 885-6350
Ella Redkey Municipal Pool (541) 273-1477 Klamath Tribal Youth (541) 884-1841 The Yeti's Lair Climbing Gym (541) 882-5586
DHS Self-Sufficiency (541) 883-5511 Food Stamps High Desert Hospice (541) 882-1636 Migrant Education Program (541) 273-2098
Representative Payee Services (541) 882-1950
Sky Lakes Palliative Care (541) 882-6311
Spokes Unlimited (541) 883-7547 Resource center for people with disabilities Veterans Services (541) 883-4274 (800) 382-9296
Utility/Weatherization
United Way (541) 882-5558
Vocational Rehabilitation Services (541) 883-5614
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Avista (800) 227-9187 Energy Efficiency Rebates al- Ore (541)887-8211 Direct Tv (800) 490-4388 Energy Trust of Oregon (866) 368-7878 Home Energy Audit KLCAS (541) 882-3500 Low-income energy assistance Klamath Tribes (541) 783-2219 (800) 524-9787 (Toll Free) Utility/weatherization Metro PCS (541) 851-9191
Salvation Army (541) 882-5280 Utility assistance
Sprint (541) 850-1200
U.S. Cellular (541) 882-1100 Waste Management (541) 884 7706
Fair Housing Council of Oregon (800) 424-3247 http://fhco.org Housing Consumers info: renters, buyers, loan applicants, etc
Klamath Tribes (541) 783-2219 (800) 524-9787 (Toll Free) Rental assistance ext 163
Charter Communications (541) 882-5533
Chiloquin Water (541) 783-2717 Dish Network (855) 318-0572 Enterprise Irrigation District (541) 884-4986
Klamath Irrigation District (541) 882-6611
Malin Water (541) 723-2021
Century Link (877) 657-4775
Clough Oil Company (541) 882-4444 Ed Staubs & Son's (541) 884-5167 Ferrell's Fuel Network (541) 273-5481
Keno Water Company (541) 884-5275
Merrill Water (541) 798-5808
OR Human Development Corp Weatherization (541) 883-7186 option 2 Emergency utility (541) 883-7186 option 1 South Suburban Sanitary Dist. (541) 882-5744
T-Mobile (541) 887-2601
USPS General Information (541) 884-9846
Pacific Power (888) 221-7070
Sprague River Bridges Connection No Phone Calls Limited burning firewood United Christian Ministries No Phone Calls Utility help - must bring in shutoff notice; Intake on the 2nd Wednesday of the month 9:00am 11:00am (first come first served) 235 S Laguna Verizon wireless (541) 884-1136
Housing Resources IYS-Transitional Living Program (541) 885-4929 Ages 16-21
Rental Assistance Salvation Army (541) 882-5280 Rental assistance
Klamath & Lake Homeownership Center (541) 882-3500 Homebuyer Education; State of Oregon Mortgage Payment Assistance
United Christian Ministries No Phone Calls Intake on the 2nd Wednesday of the month from 9:00 am - 11:00 am (first come first served)
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KLCAS (541) 882-3500
Goodwill Industries (541) 883-3546 Klamath Falls Gospel Mission (541) 882-4895 Furniture and clothing
IYS - Exodus House (541) 884-2319 Emergency shelter for ages 7-17 Veteran's Homeless Hotline (877) 424-3838
Amtrack (541) 884-2822 Crater Lake regional airport (541) 883-5372
Klamath Basin Senior Citizen's Association Rides (541) 883-7315 For Senior and Disabled only Quail Trail Public Transit (541) 783-2219 (800) 524-9787
Klamath Housing Authority (541) 884-0649 HUD (Section 8) and Public Housing Clothing & Household Resources Hospice Thrift Shop Treasures (541) 880-0596
Oregon Employment Dept (541) 850-4554 Veterans Only, Orlando Williams
Temporary Assistance Program (541) 850-5217 Vouchers: Wednesdays ONLY; ID Required 10:00 am-5:00pm 1:00-3:30 pm; at Pumpkin Patch
Shelters Klamath Falls Gospel Mission (541) 882-4895
235 S Laguna OR Human Development Corp (541) 883-7186 option 1 Emergency rental
Integral Youth Services (IYS) (541) 885-4929 By appointment only; age 0-18 Sprague River Bridges Connection No Phone Calls 23070 Sprague River Highway Wednesdays; 9:00 am - 1:00 pm
Marta's House (Crisis Center) (541) 884-0390 Shelter for women and children fleeing domestic violence
Transportation
Basin Transit Service (BTS) (541) 883-2877 www.basintransit.com Dial-A-Ride (541) 883-2877 www.basintransit.com Transportation service for seniors and disabled; applications Klamath Tribes (541) 783-2219 ext 174 or 175
DAV Transports (White City) (541) 273-0256
Klamath Basin Medical Transport (541) 882-1875
ODOT (541) 883-5665
Translink-Medical Transports (888) 518-8160 Oregon Plus Packages
Gaucho Collective (763) 232-8257
Klamath IDEA
Economic
Klamath County Chamber of Commerce (541) 884-5193 South Central Oregon Economic
Klamath Falls Downtown Assoc. (541) 539-6212
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(Inspire Development Energize Action) (541) 887-8332
Klamath County School Dist. (541) 883-5000 Klamath Basin Research & Extension Center (541) 883-4590 Oregon Health & Science Univ. (503) 494-8311
Express Personnel (541) 273-5000
Klamath Works (541) 887-8495
Administration Council (541)883-5316 City Attorney's Office (541) 883-5323 Finance Department (541) 883-5307 Parks Division (541) 883-5351 TTY (541) 883-5324
Wastewater/ Geothermal (541) 883-5384
Assessor's Office (541) 883-5111 Clerk's Office/ Elections (541) 883-5134 Tax Office (541) 883-4297
Bly Branch (541) 353-2299 Chiloquin Branch (541) 783-3315
(541) 850-9438
Education Klamath City School Dist. (541) 883-4757 Klamath Community College (541) 882-3521
Klamath Family Head Start (541) 884-1712 Migrant Education Program (541) 884-8812
Oregon Health & Science Univ. at OIT (541) 885-1000
Employment Elwood Staffing (541) 8841410
Labor Ready (541) 850-3845
Oregon Tech (541) 885-1000
Klamath Tribes Education and Employment (541) 783-2219 SOS Employment Group (541) 884-1410
Southern Oregon Goodwill (541883-3546
Klamath City Departments Accounts Payable (541) 883-5308 Code Enforcement (541) 883-5358 Maintenance Division (541) 883-5397 Planning (541) 883-4950 Utility Billing/Water/Sewer Hookups Customer Service (541) 883-5301 Wildfire Information (541) 552-2490
Klamath County Departments Building Department (541) 883-5121 EXT 1 Planning Department (541) 883-5121 EXT 2
WorkSource Klamath/ Employment Department (541) 883-5630 www.workinginoregon.org
City Recorder (541) 883-5325 Engineering (541) 883-5368 Municipal Court (541) 883-5311 Public Works (541) 883-5363 Water Division (541) 883-5388
Chamber of Commerce (541) 884-5193 Public Health (541) 882-8846
Libraries
Bonanza Branch (541) 545-6944 Gilchrist Branch (541) 433-2186
Chemult Branch (541) 365-2412 Keno Branch (541) 273-0750
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Main Library (541) 882-8894 Senior Center Branch (541) 205-8220
Herald & News (541) 885-4410 Basin Mediactive (541) 882-8833 Mybasin.com
Integral Youth Services (IYS) (541) 885-4929 Sack lunches available during the summer at multiple sites in the community
Klamath Tribes (commodities) (541) 883-2876
Produce Connection Winter sites: Thursdays: SL Live Young Wellness Ctr. 128 N. 11th St. 12:00 - 1:30 pm Chiloquin Care Program 225 Hwy 455 South, Chiloquin 11:30 am - 12:00 pm
Malin Branch (541) 723-5210 South Suburban Branch (541) 273-3679
Media Klamath Talks Radio (541) 882-4656 Basin Life Magazine Info@BasinLife.com www.basinlife.com
Food Resources Klamath Basin Senior Citizen's Association (541) 883-7171 Meals on Wheels and meals on-site
Klamath Sustainable Communities (541) 884-9942 TANF/SNAP (Food Stamps) (541) 883-5511
Merrill Branch (541) 798-8393 Sprague River Branch (541) 533-2769
KOTI (541) 882-2222 Wynne Broadcasting (541) 882-4656 www.klamathradio.com
Klamath Falls Gospel Mission (541) 882-4895 Hot meals served daily Breakfast 6:30am weekdays
9:00am Sat/Sun Lunch 12:00 pm Dinner 5:00 pm Oregon Family Nutrition (541) 883-7131 Free if eligible for Food Stamps Women, Infants, & Children (WIC) (541) 883-4276
Meals/Food Boxes
Weekdays
Klamath/Lake Co. Food Bank (541) 882-1223 3231 Maywood Dr
Faith Tabernacle (541) 882-1668 Food Pantry 11:00 am - 3:00 pm Tower Shopping Center, 1743 Washburn Way
Mondays
Klamath Lutheran (541) 884-3452 3rd, 4th, and 5th Monday of each month from 5:30pm - 7:00pm 1175 Crescent Ave
Seventh-Day Adventist Church (541) 882-2466 Meal served 5:30 pm 1735 Main St
Mondays-Thursdays
Klamath Christian Center (541) 882-4646 Food Box Monday, Wednesday Thursday; 9:00 am - 3:00 pm Tuesday; 1:30-3:30 6100 Church Hill Dr
Tuesdays, Thursdays, and Fridays
Salvation Army (541) 882-5280 Tuesdays 8:00 am - 10:00 am Thursdays/Fridays 8:00 am - 11:00 am 2960 Maywood Dr, Suite #12
Tuesdays
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Chiloquin Christian Center No Phone Calls Soup/bread is served: 11:30 am - 12:30 pm 301 S Chiloquin Blvd
Saving Grace (541) 882-4629 2nd and 4th Tuesdays 3:00 pm - 4:30 pm Keno
Friends Church No Phone Calls Last 2 Tuesdays of each month 4:30 pm - 6:30 pm 1910 Oregon Ave (house next to church)
Living Springs Fellowship (541) 545-6671 3rd Tuesdays; 9:00 am - 11:00 am 31897 Mission St, Bonanza
Tuesdays and Fridays
Tuesdays and Sundays
Freewill Church (541) 882-1303 Meal served at 11:30am 420 Market St.
First United Methodist Church (541) 884-4053 Palm Dinners 5:00 pm - 6:30 pm 230 N 10th St (enter at the basement on High St)
Wednesdays
Bly Chapel No Phone Calls 3rd Wed 9:30 am - 11:30 am 61125 Hwy 140 E Sprague River Bridges Connection No Phone Calls 9:00 am - 1:00 pm 23070 Sprague River Hwy
Chiloquin Care No Phone Calls 4th Wed 10:00 am - 1:00 pm 121 N 1st St St. Paul's Church (541) 884-3585 9:00 am - 12:00 pm 801 Jefferson Street
Merrill Civic Center No Phone Calls 2nd Wed 10:00 am - 12:00 pm 365 E Front St St. Vincent de Paul (541) 281-5345 4:30 pm - 6:00 pm 4880 Bristol Ave food box only
Wednesdays and Fridays
Fridays
Life Recovery Network (541) 891-0071 Meal for members 6:00 pm 115 Crater Lake Pkwy
Bible Baptist Church (541) 883-2289 3rd Fridays 1:00 pm - 4:00 pm 4849 S 6th St
Stewart Lennox Baptist (541) 884-6854 2nd/4th Fri 4:30 pm - 5:30 pm 3510 Emerald Ave
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2909 Daggett Ave, Suite 225 Klamath Falls, OR 97601 Phone: 541-883-2947 Fax: 541-882-6914
CascadeHealthAlliance.com
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