Provider Newsletter July 2020

Practice Tactics

Case Management @ UHA

Umpqua Health Alliance offers a robust Case Management Program.  We collaborate with providers, clinics, hospitals, and community entities to ensure our members are connected with resources and are engaged with their appropriate level of case management.

Program Offerings Include:

•New Day

•New Beginnings

•Hepatitis C Treatment

•Diabetes-Coming Soon

•Flex Spending—financial assistance for various matters

•Medication Management

•Free Medicaid Phone

Case Management Services:

•Behavioral Health Care Coordination

•Chronic Disease Management

•Intensive Case Management

•Transitional Care-from inpatient setting to home, from snf to home

•Community Healthcare Worker—member liaison

To submit a referral for services: Email Case Management at  Be sure to include: name/DOB/HPI/Reason/Need


Complete a Case Management Referral form located at

Prior Authorizations

Providers can find the prior authorization (PA) requirements in our Prior Authorization Grid on our website at This was last updated on 5/26/20.

 New to submitting requests via our CIM Provider Portal?

Step-by-step instructions for both our Medical and Pharmacy submissions can be found on our webpage


Expedited requests must meet OHA’s definition “that taking the time for a standard resolution could seriously jeopardize the member’s life, health, or ability to attain, maintain, or regain maximum function). By selecting the expedite, the submitter is certifying this statement is true. Please include an explanation of medical necessity for the rush in the Comment of the PA or on the cover letter of the supporting documentation. Expedited requests are not appropriate for billing issues, closely approaching appointments, etc.

Authorization Type

Not sure which Auth/Referral Type to select when submitting a prior authorization (PA)?  After searching for the member and selecting “submit a pre-auth,” decide if the authorization request is for a Pharmacy, Medical or Behavioral Health and select this option. For Medical, the auth/referral type is dependent on the location of the service and then the specialty of the provider.

Location of Procedure
Auth/Referral Type
“Inpatient Surgery/Services”
Outpatient facility/Surgery Center
“Outpatient Surgery/Services”
In Office
Specialty of the delivering provider
Example: “Podiatry”

Clinical Corner

Expanded Coverage for DOACs!

The UHA Pharmacy and Therapeutics (P&T) Committee has decided to expand coverage of Direct Oral Anticoagulants (DOACs) effective July 15th. While these drugs still require prior authorization, we will allow coverage for all FDA-approved indications without a trial and failure of warfarin. However, for conditions where another anticoagulant is preferred based on safety and efficacy data, we will still require the preferred agent:

•Liver disease (LMWH preferred);

•Renal disease with CrCl less than 30 ml/min (warfarin preferred);

•Thrombolytic therapy use (UFH infusion preferred);

•Pregnancy or pregnancy risk (LMWH preferred);

•Valvular disease including mechanical heart valves or moderate to severe mitral stenosis (warfarin preferred);

•Left ventricular thrombi (warfarin preferred); and

•Antiphospholipid syndrome (warfarin preferred), or antithrombin deficiency (warfarin preferred).

The UHA P&T Committee also wants providers to be aware that data are limited on the efficacy and toxicity of DOACs in obese individuals. Based on a 2016 review of available literature, the International Society of Hemostasis and Thrombosis (ISTH) recommends avoidance of these agents in individuals with a body mass index (BMI) >40 kg/m2, or weight ≥120 kg. While we want providers to be aware of this, the Committee has ultimately determined that the decision of whether to use DOACs in obese individuals will be left to the provider’s clinical judgment.

The following table summarizes the approved indications, dosing and treatment costs associated with each drug in this class.

Vision Coverage ReduxIf referring a member for vision services alone, an optometrist may be the best choice.

We need to remind providers that the Oregon Health Plan has limitations on what services are covered for eye conditions.

•Some medical conditions of the eye are covered for diagnosis and treatment. (Those below the line can be considered by exception to rule, based on comorbidity).

•Vision services for refraction and visual acuity correction are limited to:

-Children under 21 years of age

-Pregnant women

-Adults with a few medical conditions, including aphakia, keratoconus, or after cataract surgery

When you refer any OHP member other than those listed above for visual acuity evaluation, the ophthalmologist/optometrist will inform them of their financial liability.  Informing the member of this ahead of time will avoid a lot of confusion/frustration!

On the Lookout

Douglas Public Health Network officials are working to address COVID-19 in Douglas County.

Click for information on how to keep up with the latest local news related to coronavirus, and be sure to request their expanded daily report of COVID-19 related news to be sent to your inbox.

CME for Thee

Recorded Webinar: Help adolescents get back on track with immunizations: You are the key to HPV cancer prevention. Free CME.

Oregon has seen reduced adolescent immunization rates across the state during COVID-19 while in-person adolescent well visits were put on hold. As those visits begin to resume, this recorded webinar, hosted by the Oregon Pacific Area Health Education Center, will help all immunization providers make an effective recommendation for HPV vaccination and answer parents’ questions.

•Register here:

•Contact: Anona Gund (

•Audience: All immunization providers.

Patient-centered Counseling Virtual Trainings (no-cost CME available). August–December 2020

Registration is open for full-day virtual trainings focused on motivational interviewing and other patient-centered counseling skills.

•Who: Primary care, behavioral health and dental care providers; clinic staff; and traditional health workers serving Oregon Health Plan (Medicaid) members.

•What: Dana Sturtevant, MS, RD, will lead sessions focused on increasing your confidence and skills to facilitate conversations with patients about sensitive topics. Examples will draw from tobacco use, diabetes management, adolescent immunization, well visits, and other priority topics related to CCO metrics and COVID-19. Evidence-based health communication models will include motivational interviewing, the FRAMES model and Five A’s for tobacco cessation counseling.

•When: 10 dates to choose from, August–December 2020

•Where: Live Zoom videoconferencing

•Register here:

Questions: Contact Laura Kreger at

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