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Transitioning to CareOregon Advantage

We want to make sure your transition to our health plan or your start to a new plan year is as smooth as possible.

If you are currently receiving treatment covered by Medicare, or if treatment was planned prior to you becoming a CareOregon Advantage member, we will cover your treatment during the first 90 days you are on our plan. This is known as “continuity of care.” After 90 days, we will require prior authorization and/or require you to receive your treatment from an in-network provider if it is being provided by a provider that is not in our network.

Medicare Part C organization determinations and appeals

Organization determinations

If you, your representative or your health care provider want to request an organization determination or prior authorization for medical services or drugs administered in the physician’s office, here are a few different ways you can make the request.

  • 电话:503-416-4279、免费电话888-712-3258或TTY 711
  • 传真:
    Part B Drugs: 503-416-4722
    Medical Services: 503-416-3671
  • Mail: CareOregon Advantage
    Attn: Clinical Operations
    315 SW Fifth Ave
    Portland, OR 97204

申诉

您、您的代理人或您的医生可以通过多种方式提出申诉:

  • 电话:503-416-4279、免费电话888-712-3258或TTY 711
  • You can write out your request and fax or mail it to us
    传真:
    Part B Drugs: 503-416-1428
    Medical Services: 503-416-8118
    Mail: CareOregon Advantage
    Attn: Clinical Operations
    315 SW Fifth Ave
    Portland, OR 97204

Coverage policies

CareOregon Advantage makes coverage decisions based on National Coverage Determinations, Local Coverage Determinations or other CMS published guidance. If guidelines are absent or vague, CareOregon Advantage may develop and maintain our own clinical policies.

Covered medical services, limitations, and exclusions can be found in the CareOregon Advantage Evidence of Coverage and Summary of Benefits.

Continuous glucose monitors prior authorization criteria  

Medical services and Part B drugs that require prior authorization  

Part B drug step therapy criteria 

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