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2020 coordinated care organization changes for providers

  Get provider updates and resources about 2020 CCO changes by text or email

What is changing?

Changes are coming to the Oregon Health Plan in 2020. Based on the CCO 2.0 contract awards, providers will see the following changes to CCO service areas. For an overview of CCO coverage in 2020, view the service area map.

Note: Health Share of Oregon has also made changes to their network to better serve Health Share of Oregon members.

PacificSource Community Solutions serves members in Lane, Polk and Marion counties starting Jan. 1, 2020.

​On Nov. 12, 2019, OHA announced that members in Clackamas, Multnomah, Washington, Jackson and Lane counties will be reassigned to different CCOs on Jan. 1, 2020, due to provider network changes.

  • Clackamas, Multnomah and Washington counties: Trillium Community Health Plan does not have a 2020 contract with any Portland-area hospitals, so Health Share of Oregon members will stay with Health Share for 2020. Trillium will be ineligible to enroll members in these counties until at least Apr. 1, 2020.
  • Jackson County: Members have been matched with the CCO that works with their current providers. This means some AllCare CCO members will move to Jackson Care Connect to preserve their current relationships with Primecare medical providers.
  • Lane County: Trillium Community Health Plan does not have a 2020 contract with PeaceHealth clinics and Oregon Medical Group, so members who use these providers for primary care will move to PacificSource Community Solutions for 2020.
The following special populations will not need to choose a 2020 plan, unless their plan is closing and there is more than one plan choice in their area:
  • Members who are dually eligible for Medicare and Medicaid 
  • Members enrolled with the Office of Developmental Disability Services
  • Children and youth enrolled in Child Welfare programs
  • Children and youth enrolled in Oregon Youth Authority programs
CCO closures:
  • PrimaryHealth will no longer serve Josephine, Jackson and Douglas counties.
  • Willamette Valley Community Health will no longer serve Marion, Polk, Linn, Benton, Yamhill and Clackamas counties.
In November, OHA informed PrimaryHealth and WVCH members of the closures and their new CCO for 2020.

The contract and rules governing CCOs have also changed effective Jan. 1, 2020.

Benefits and covered services

Benefits and covered services will remain the same. Each CCO’s specific policies may differ, but coverage must include all benefits defined in the Oregon Health Plan benefit package and cover these benefits for funded conditions on or above Line 471 of the Prioritized List of Health Services.

Contact the CCO to learn about each CCO's specific coverage policies and procedures.

If a CCO denies your claim or authorization request, please contact the CCO to appeal the decision according to their specific process.

If you have appealed the CCO's decision and still think the CCO should cover the service:

​For policies related to Prioritized List coverage, benefit coverage or exclusions, see the General Rules, Oregon Health Plan rules, and the provider guidelines specific to your program.

To find out whether a specific procedure is potentially covered according to the Prioritized List, providers can use the HSC List inquiry on the Provider Web Portal at www.or-medicaid.gov or call the OHP Code Pairing and Prioritized List Hotline at 800-336-6016.

To learn more about identifying a member's OHP benefits, read OHA's one-page overview of how to read benefit plan, managed care enrollment, service coverage and TPL information. More resources by topic are on the OHP Eligibility Verification page.

For prohibitions against billing OHP members, see OHA's Do's and Donts and fact sheet about OHP and Qualified Medicare Beneficiaries.

Continuity of care

Starting Jan. 1, 2020:

  • CCOs will honor all existing service authorizations (physical, oral, behavioral health and prescription drugs) from the member’s 2019 CCO for up to six months.
  • Members will be able to see their current primary care provider for up to 90 days.
  • Members will be able to see their current behavioral health provider for up to 180 days.

This is true even if the member’s current providers do not join the network of the member’s new CCO for 2020.

Read OHA's fact sheet about continuity of care»

For services approved or rendered in 2019, including inpatient hospitalizations with a 2019 admit date, contact the member's 2019 CCO.

For questions about resolving 2019 claims with closing CCOs, contact the closing CCO:

For 2020 services, contact the member's 2020 CCO.

For prescription access help, call the Oregon Pharmacy Call Center at 888-202-2126.

What providers can do

Your patients may ask which CCOs you work with. Members in areas with more than one CCO may still be able to choose a different CCO after Mar. 31, 2020. Learn more by reading OHA's member fact sheet about changing CCO or dental plan enrollment.

​We have received questions from providers who are in areas where OHP members are likely to be served by multiple CCOs. Providers have asked how to respond to OHP members seeking guidance on how to make their CCO selection:

  • Do: Let OHP members know which CCOs you work with so they can make an informed choice. 
  • Don’t: Encourage OHP members to sign up with a specific CCO. OHP members will weigh a variety of factors in making their selections, including other provider relationships. Any provider communications intended to encourage members to sign up with a specific CCO must be reviewed by the CCO and if needed, by OHA. To learn more, read our fact sheet.
  • Do: Encourage members to learn about their choices and get help by calling the dedicated Pick Your Plan phone line at 877-647-0027 (TTY 711) or from a local community partner organization. You can review all the information members have received in the "Sample member letters" section of this page.

​Starting Jan. 1, 2020, please be sure to continue serving all OHP members, regardless of their specific CCO enrollment.

  • Continue to see members and schedule appointments as usual for all care, including filling prescriptions and proceeding with planned appointments, treatments and procedures.
  • Submit new prior authorization (PA) requests, treatment plans and prescription authorizations to the member’s new CCO.
  • For members changing to a new provider, arrange for orderly transfer of all required records and information to the member’s new provider.

Do not cancel or refuse to make appointments because a patient is changing CCOs.

Read OHA's fact sheet about continuity of care»

Contact the CCO to ask about their:

  • Provider enrollment/credentialing requirements and timelines
  • Billing, authorization and coverage policies and procedures
  • Point of sale, billing, eligibility and other electronic health care transactions
  • Other requirements such as reporting and member notification

Credentialing information

To learn about each CCO’s credentialing and provider participation requirements, contact the CCO.

If you are denied participation in a CCO, please first contact the CCO and complete their appeal process.

If you have appealed the CCO's decision and believe the decision was based on your specific license or certification, you can submit a Provider Discrimination Review Request to OHA.

 

Resources

CCO contacts

2020 CCOs:

Closing CCOs:

For members:

Provider webinars

Fact sheets

Sample member letters

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