Referrals & authorizations

Learn which services need prior authorizations, which services are not covered, and which are not medically necessary.

New! Submit your prior authorization request electronically

• EOCCO Auto Auth Application How To Guide 

Changes to retro authorizations

To align with Oregon Administrative Rule 410-120-1320 (Authorization of Payment), effective with dates of service 1/1/2025 and forward, EOCCO will only accept retroactive authorizations if the following criteria are met.

• The client was made retroactively eligible or was retroactively disenrolled from a CCO or PHP on the date of service; and
• The services provided meet all other criteria and Oregon Administrative Rules, and;
• The request for authorization is received within ninety (90) days of the date of service;

Any requests for authorization after ninety (90) days from date of service require documentation from the Provider that authorization could not have been obtained within ninety (90) days of the date of service.

Please contact eoccoproviderinquiry@modahealth.com with any questions or to request additional information regarding this change.

EOCCO Medical Necessity Criteria

• Air Ambulance
• Allergy testing-blood
• Anesthesia for Routine Endoscopic Procedures
• Balloon Dilation of Eustachian Tube
• Intravitreal Avastin
• Knee Cartilage Transplants
• Mobile Outpatient Cardiac Telemetry (MOCT)
• Push-Rim.Activated.Power.Assist.Device
• Serum Anitbodies for Diagnosis of Inflammatory Bowel Disease
• Skin & Tissue Substitutes
• Treatment or Removal of Benign Skin Lesions
• Vagus Nerve Stimulation (VNS)
• Vitamin D testing

Guidelines

Please review the Prior Authorization Guidelines and instructions for information on referral and authorization requirements and submission instructions. Also included below are the lists of items and services that require prior authorization. Please choose the list(s) appropriate for the specific item, service, or population.

The injectable Medication, advanced imaging, and cardiology lists apply to all populations regardless of age.

• Prior authorization guidelines and instructions
• EOCCO injectable PA list
• EOCCO prior authorization list
• EOCCO Prior Authorization Ages Under 21 - also Young Adults with Special Healthcare Needs (YSCHN)
• EOCCO Site of Care Policy
• EOCCO Site of Care FAQ
• eviCore Advanced Imaging PA
• eviCore Cardiology PA
• Medicaid Telemedicine and Telehealth Overview and Guidelines (June 4, 2020)
• eviCore website
  
• Covered and Non-Covered Behavioral Health Services List

Clinical Practice Guidelines

• EOCCO Clinical Practice Guidelines
• Advantage Dental Clinical Guidelines
• ODS Community Dental Clinical Guidelines
• Behavioral Health Clinical Guidelines

Clinical Practice Guidelines Policy

• EOCCO Clinical Practice Guidelines Policy

Forms

Medical

• Case Management Referral Form
• Transition of Care Form
• Referral/Authorization - for all EOCCO Counties
• Cribs for Kids© Program Referral Form
• EOCCO Flexible Services Request Form
• Multidisciplinary team flyer
• Multidisciplinary team referral form FAQ
• Multidisciplinary Team Referral Form

Behavioral Health

• Behavioral Health Authorization Form
• Behavioral Health Care Management Referral Form
• Psychological and Neuropsychological Evaluation Behavioral Health Authorization Form
• Out of Network (OON) Provider Behavioral Health Authorization Form