Member Handbook Your guide to benefits and services 3031 NE Stephens St. Roseburg, OR 97470 Customer Care: 541-229-4UHA or 541-229-4842 Toll-Free: 1-866-672-1551 TTY 541-440-6304 UHCustomerCare@umpquahealth.com www.UmpquaHealth.com
OHP-UHA-22-065
July 01, 2023
Umpqua Health Alliance (UHA) and its providers comply with applicable state and federal civil rights laws. We cannot discriminate, exclude, or treat people unfairly in any of its programs or activities because of a person’s age, color, disability, gender identity, marital status, national origin, race, religion, sex, or sexual orientation. UHA does not discriminate against people able to enroll based on their health status or need for health care services.
Everyone (including members and non-members) has a right to enter, exit and use buildings and services. They also have the right to get information in a way they understand. We will make reasonable changes to policies, practices, and procedures by talking with you about your needs.
UHA provides free aids and services to people with disabilities or who do not speak English as their primary language, such as: • Qualified sign language interpreters • Written information in other formats (large print, audio, accessible electronic formats, other formats)
If you need these services, or if you believe that UHA has failed to provide these services or have been discriminated, excluded, or treated unfairly for any of the above reasons, you can contact the following:
UHA’s Appeals and Grievances Coordinator (non-discrimination coordinator) or Customer Care at: • Phone: 541-229-4842; Toll Free: 866-672-1551; TTY: 541-440-6304 or 711 • Hours: Monday to Friday, 8 a.m.-5 p.m. • Fax: 541-677-5881 • Mail: Umpqua Health Alliance, 3031 NE Stephens St, Roseburg, OR 97470 • Website and Complaint Form: www.umpquahealth.com/appeals-and-grievances/ • Email: UHAGrievance@umpquahealth.com
You can also use the contact information above if you need help filing a grievance.
You can also file a civil rights complaint in your preferred language with the U.S. Department of Health and Human?Services, Office for Civil Rights, electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at:? • Oregon Health Authority (OHA) Civil Rights • Web: oregon.gov/OHA/OEI • Email:?OHA.PublicCivilRights@odhsoha.oregon.gov • Phone: (844) 882-7889, 711 TTY • Fax 971-673-1330 • Mail: Office of Equity and Inclusion Division, 421 SW Oak St., Suite 750 Portland, OR 97204
Oregon Bureau of Labor and Industries Civil Rights Division • Website: https://www.oregon.gov/boli/civil-rights/Pages/default.aspx • Phone: 971-673-0764 (voice) or 711 (TTY) • Email: crdemail@boli.state.or.us • Mail: Bureau of Labor and Industries Civil Rights Division,?800 NE Oregon St., Suite 1045, Portland, OR 97232
U.S. Department of Health and Human Services Office for Civil Rights (OCR) • Web: ocrportal.hhs.gov/ocr/smartscreen/main.jsf • Phone: (800) 368-1019, (800) 537-7697 (TDD) • Email:?OCRComplaint@hhs.gov • Mail: Office for Civil Rights, 200 Independence Ave. SW, Room 509F, HHH Bldg., Washington, DC 20201??
call Customer Care at 541-229-4842, toll free 866-672-1551, or TTY 541-440-6304. Members, member representatives, family members and caregivers with hearing impairments or limited English proficiency who need to understand the member’s condition and care can access free certified and qualified sign and oral interpreters. This includes translations and materials, such as Provider Directories, Member Handbooks, Appeals and Grievance Notices, Denials and Termination Notices, a list of covered medications, and any other items, in alternate formats free of charge. All written materials can be provided within 5 business days.
Your use of benefits, grievance, appeals, or hearings will not be denied or limited based on your need for another language, format or auxiliary aids.
You can have a voice or sign language interpreter at your appointments if you want one. When you call for an appointment, tell your provider’s office that you need an interpreter and in which language. Information on Health Care Interpreters is at Oregon.gov/oha/oei.
If you do not get the interpreter help you need, call the state’s Language Access Services Program coordinator at 844-882-7889 or email LanguageAccess.Info@odhsoha.oregon.gov.
llame a Atención al Cliente al 541-229-4842, sin cargo al 866-672-1551 o al TTY 541-440-6304. Los miembros ,los representantes de los miembros, los familiares y los cuidadores con problemas auditivos o con un dominio limitado del inglés que necesiten entender el estado y la atención del miembro pueden acceder gratis a intérpretes orales y de señas certificados y calificados. Esto incluye traducciones y materiales, como directorios de proveedores, manuales para miembros, avisos de apelaciones y quejas, avisos de denegación y rescisión, una lista de los medicamentos cubiertos y cualquier otro artículo, en formatos alternativos y sin cargo. Todos los materiales escritos se pueden proporcionar dentro de los cinco días hábiles.
Su uso de los beneficios, quejas, apelaciones o audiencias no se denegará ni limitará en función de su necesidad de otro idioma, formato o ayudas auxiliaries.
Puede tener un intérprete de voz o lenguaje de signos en sus citas si lo desea. Cuando llame a una cita, dígale a la oficina de su proveedor que necesita un intérprete y en qué idioma. La información sobre los intérpretes de atención médica se encuentra en www.Oregon.gov/oha/oei.
Si no recibe la ayuda de un intérprete que necesita, llame al coordinador del Programa de Servicios de Acceso Lingüístico del estado al 844-882-7889, TTY 711 o envíe un correo electrónico a: LanguageAccess.Info@odhsoha.oregon.gov.
Umpqua Health Alliance (UHA) wants to take good care of you and your family. Your health plan is not here to just take care of you when you are sick. Our goal is to help you and your family get well and stay well. You will have an active role in staying healthy.
Please take a few minutes to read this handbook carefully. It will answer many of the questions you may have about how to use your Oregon Health Plan (OHP) coverage, it will tell you what services are available, and how to get those services. It also tells you what to do in an emergency and explains your rights and responsibilities. UHA also wants to protect the privacy of your Personal Health Information (PHI). If you wish for someone to speak to UHA Customer Care about your health, please make sure to let us know. If you have any questions about your physical or mental health care benefits, please call UHA Customer Care at 541-229-4842. You can also find the UHA handbook online at https://www.umpquahealth.com/umpqua-health-member-handbook/ or request that a copy be sent to you free of charge at any time. We will mail you a copy within 5 business days. If you need help or have questions, or wish to get your communications electronically, call Customer Care at 541-229-4842. You must approve this change.
You may see UHA’s Member Handbook at https://www.umpquahealth.com/umpqua-health-member-handbook/ or ask for one by calling 541-229-4842.
UHA will assign you to or you may choose a Primary Care Provider (PCP). A Dental Care Group (DCG) will be assigned to you. They will look after your health care needs, write prescriptions, refer you to specialty care, and admit you to the hospital if needed. Start your medical care by calling your PCP first and your dental care by calling your DCO or Primary Care Dentist (PCD).
Our Face-to-Face Orientation can be used to help new members learn more about their coverage through UHA. You can also schedule a meeting with us if you have questions about your coverage but would like to meet someone face-to-face.
If you would like to schedule a meeting, please contact UHA Customer Care at 541-229-4842, or click the link on our website: www.umpquahealth.com/ohp/benefits/ and click the button that says, “Zoom Meeting for Face-to-Face Orientation”.
Some UHA members can get extra benefits like FoodSmart, Iris Advanced Care Planning, and trips to the grocery store and farmer’s markets. Call Customer Care at 541-229-4842 to find out more. • Always carry your OHP and UHA member ID card with you. o This will come separately, and you will receive your OHP ID card before your UHA member ID card. • You can find your UHA ID Card in the welcome packet with this member handbook.
Your ID card has the following information: o Your Name o Your ID Number o Your Plan Information o Your Primary Care Provider Name and Information o Customer Service Phone Number o Language Access Phone Number
My Primary Care Provider is _________________ Their number is ________________ My Primary Care Dentist is __________________ Their number is ________________ Other Providers I have are __________________ Their number is ________________
Umpqua Health Alliance Customer Care office is located at: 3031 NE Stephens Street, Roseburg, OR 97470
Hours of operation are: Monday through Friday, 8:00 am to 5:00 pm
Members may reach a person 24 hours a day, seven days a week by calling: 541-229-4UHA (541-229-4842)
Toll Free: 1-866-672-1551
Office Closures: • New Year’s Day • Memorial Day • Independence Day • Labor Day • Veterans Day • Thanksgiving • Day After Thanksgiving • Christmas Eve (Half-day) • Christmas Day
For Non-Emergent Medical Transportation, call: • BCB, Toll-Free: 877-324-8109
For Dental benefits, call: • Advantage Dental Services, LLC, Toll-Free: 866-268-9631
Behavioral Health 24-hour crisis line: • Toll-Free: 1-800-866-9780
• Change address, phone number, family status or other information • Replace a lost Oregon Health ID Card • Get help with applying or renewing benefits • Get local help from a community partner • Hours of operation are Monday through Friday, 8:00 am to 5:00 pm
HOW TO CONTACT OHP CUSTOMER SERVICE: • Call: 800-699-9075 toll-free (TTY 711) • Web: www.OHP.Oregon.gov • Email: Use the secure email site at secureemail.dhsoha.state.or.us/encrypt to send your email to Oregon.Benefits@odhsoha.oregon.gov o Tell us your full name, date of birth, Oregon Health ID number, address and phone number.
If you change your address or phone number, or are moving out of Douglas County, please let OHP Customer Service know. If they do not get your updated information, it may result in you not getting your renewal packet. You may also not get other important information about your healthcare.
ENGLISH You can get this letter in other languages, large print, Braille or a format you prefer. You can also ask for an interpreter. This help is free. Call 541-229-4842 or TTY 711. We accept relay calls. These services are available to members, member representatives, family members and caregivers with hearing impairments or limited English proficiency who need to understand the member’s condition and care. Your use of benefits, grievance, appeals, or hearings will not be denied or limited based on your need for another language, format or auxiliary aids. - You can get help from a certified and qualified health care interpreter.
SPANISH/ ESPAÑOL Puede obtener este documento en otros idiomas, en letra grande, braille o en un formato que usted prefiera. También puede recibir los servicios de un intérprete. Esta ayuda es gratuita. Llame al servicio de atención al cliente 541-229-4842 o TTY 711. Aceptamos todas las llamadas de retransmisión. Estos servicios están disponibles para los miembros, los representantes de los miembros, los familiares y los cuidadores con problemas auditivos o con un dominio limitado del inglés que necesiten entender el estado y los cuidados del miembro. No se le denegará ni limitará el uso de los beneficios, las quejas, las apelaciones o las audiencias en función de su necesidad de otro idioma, formato o ayudas auxiliares. - Usted puede obtener ayudar de un intérprete certificado y calificado en atención de salud.
WORDS TO KNOW 25
WHAT IS THE OREGON HEALTH PLAN (OHP)? 35
WHAT IS A COORDINATED CARE ORGANIZATION (CCO)? 36
WHERE IS MY COVERAGE? 37
HOW WE COORDINATE YOUR CARE 37
DUAL ELIGIBLE: MEMBERS WITH MEDICARE & MEDICAID 38
ENROLLMENT/MEMBER COMMUNICATION 40
HOW TO CHANGE CCOs 42
CONFIDENTIALITY: YOUR RECORDS ARE PRIVATE 45
COPAYS 46
COMMUNICATION AND LANGUAGE ASSISTANCE 46
CULTURALLY SENSITIVE HEALTH EDUCATION 47
NATIVE RIGHTS 48
ACCESS TO CARE 49
COMPLIANCE/FRAUD, WASTE, AND ABUSE 50
PROVIDER AVAILABILITY, TIME, AND DISTANCE STANDARDS 55
OHP MEMBER RIGHTS AND RESPONSIBILITIES 57
GETTING STARTED WITH OHP 62
THINGS TO REMEMBER AT YOUR APPOINTMENT 63
TRANSITION OF CARE (TOC) 63
PRIMARY CARE PROVIDER (PCP) 65
CARE COORDINATION 66
TRADITIONAL HEALTH WORKERS 66
INTENSIVE CARE COORDINATION 68
YOUR OPINION MATTERS 69
HEALTH RISK SCREENING ASSESSMENT 70
COVERED MEDICAL SERVICES 71
SERVICES THAT ARE NOT COVERED 78
PREVENTATIVE SERVICES 79
EARLY AND PERIODIC SCREENING, DIAGNOSIS AND TREATMENT 79
SERVICES COVERED BY THE OREGON HEALTH PLAN 83
VETERANS AND COMPACT OF FREE ASSOCIATION (COFA) DENTAL PROGRAM MEMBERS 85
HEALTH-RELATED SERVICES REQUESTS 85
COMMUNITY BENEFIT INITATIVES 87
IN LIEU OF SERVICE (ILOS) 87
COMPLAINTS, APPEALS, AND FAIR HEARINGS 88
YOU CAN MAKE A COMPLAINT, ALSO CALLED A GRIEVANCE 90
ASKING FOR AN APPEAL 91
QUESTIONS AND ANSWERS ABOUT APPEALS AND HEARINGS 94
PEER TO PEER MEETING 96
NON-EMERGENT MEDICAL TRANSPORTATION (NEMT) DENIALS 96
BILLING INFORMATION 96
MEMBERS WITH OHP AND MEDICARE 100
GETTING APPROVAL, ALSO CALLED PRIOR AUTHORIZATION (PA) 101
PROVIDER REFERRALS AND SELF-REFERRALS 102
SECOND OPINIONS 103
TELEMEDICINE/TELEHEALTH: E.G., Video and Patient Portal 103
MISSED APPOINTMENTS 106
AFTER HOURS, URGENT, EMERGENCY CARE, AND CRISES 106
OUT-OF-TOWN CARE 108
PHARMACY AND MEDICATION COVERAGE 109
UHA MEDICATION FORMULARY 110
VISION SERVICES 111
DENTAL SERVICES 112
ORAL HEALTH COMMUNITY CARE 115
SUBSTANCE USE TREATMENT BENEFITS 115
MENTAL HEALTH CARE BENEFITS 117
BEHAVIORAL HEALTH CRISIS AND EMERGENCIES 118
TOBACCO USE 121
HOSPITAL SERVICES 122
AMBULANCE SERVICES 123
CARE AFTER AN EMERGENCY 123
CARE TRANSISTIONS 123
POST-STABILIZATION SERVICES 124
POST-STABILIZATION SERVICES 124
NEW DAY PROGRAM 125
NEW BEGINNINGS PROGRAM 126
OTHER THINGS YOU NEED TO KNOW 127
FREE RIDES TO CARE 130
END-OF-LIFE DECISIONS AND ADVANCE DIRECTIVES (LIVING WILLS) 133
PORTABLE ORDERS FOR LIFE-SUSTAINING TREATMENT (POLST) 135
IRIS HEALTHCARE (ADVANCE CARE PLANNING) 136
DECLARATION FOR MENTAL HEALTH TREATMENT 137
NURSE ADVICE LINE: 888-516-6166 138
I’M SICK OR HURT, WHERE SHOULD I GO? 139
WHERE OHP MEMBERS CAN FIND URGENT CARE IN ROSEBURG: 140
Acute Inpatient Psychiatric Care: Care you get from a hospital designated to meet the needs of people who have emotional and behavioral issues that put them at risk of harming themselves or others. Emergency inpatient psychiatric care does not need prior approval.
Administrative Hearing: A telephone conference with an Administrative Law Judge to review a decision called a Notice of Adverse Benefit Determination with which you disagree.
Advance Directive: A form that allows you to describe your wishes concerning medical treatment at the end of life.
Assessment: Review of information about a patient’s care, health care problems, and needs. This is used to know if care needs to change and plan future care
Adverse Benefit Determination (ABD): When prior approval of a requested service is limited or denied. This includes determinations based on: • the type or level of service, medical necessity, appropriateness, setting, or effectiveness of a covered benefit; • the reduction, suspension, or stopping of a previously authorized service or the denial of payment for a service; • failure to provide services in a timely manner, as defined by the State; • the failure of UHA to act within the timeframes provided in §438.408(b)(1) and (2) regarding the standard outcome of grievances and appeals; • the denial of a member's request to exercise his or her right, under §438.52(b)(2)(ii), to obtain services outside the network if they are a resident of a rural area with only one managed care organization; • and the denial of a member's request to dispute a financial liability, including cost sharing, copayments, premiums, deductibles, coinsurance, and other member financial liabilities.
Appeal: When you ask your plan to review a decision the plan made about covering a health care service. If you do not agree with a decision the plan made, you can appeal it and ask to have the decision reviewed.
Balance Billing: When a provider bills an insurance and bills the member for the rest of what was not paid.
Behavioral Health: This is mental health, mental illness, addiction, and substance use disorders. It can change your mood, thinking, or how you act.
Care Coordination: The organized coordination of a member’s health care services, support activities, and resources.
Case Management: Services to help you connect with providers for dental, medical, and/or behavioral health needs.
Civil Action: A lawsuit filed to get payment. This is not a lawsuit for crime. Some examples are personal injury, bill collection, medical malpractice, and fraud
Co-insurance: The amount someone must pay to a health plan for care. It is often a percentage of the cost, like 20%. Insurance pays the rest.
Complaint: Also known as a grievance, it’s a way for you to tell us if you are unhappy with UHA, a provider, or a clinic. We must respond to each complaint.
Consultation: Advice given from one professional to another involved in your care.
Consumer Laws: Rules and laws meant to protect people and stop dishonest business practices.
Coordinated Care Organization (CCO): OHP has local health plans that help you use your benefits. These plans are called Coordinated Care Organizations or CCO’s. CCO’s have providers who work together in your community.
Copay or Copayment: Medicare and other plans may pay for services but also charge the member a small fee. This fee is called a copay. OHP and UHA do not have copays.
Crisis: A time of difficulty, trouble, or danger. It can lead to an emergency situation if not addressed.
Daily Structure and Support: Programs to help you with daily tasks or to live in the community. They also help you get along with other people.
Declaration of Mental Health Treatment: A form you can fill out when you have a mental health crisis and can’t make decisions about your care. It outlines choices about the care you want and do not want. It also lets you name an adult who can make decisions about your care.
Deductible: The amount you pay for covered health care services before your insurance pays the rest. This is only for Medicare and private health insurance.
Dental Care Group (DCG): The group that helps you obtain dental care and assigns you to a dentist in your area.
Department of Human Services (DHS): State agency in charge of programs such as Supplemental Nutrition Assistance Program (SNAP) and Medicare. DHS and OHA work together to make sure you have the care you need.
Devices for Habilitation and Rehabilitation: Equipment to help you benefit from habilitation and/or rehabilitation therapy services or meet other clinical or functional needs. Examples include walkers, crutches, canes, glucose monitors, prosthetics and orthotics, oxygen machines, infusion pumps, low vision aids, augmentative communication devices, and complex rehabilitation technologies. These are items like motorized wheelchairs and assistive breathing machines.
Diagnosis: When a provider finds out the problem, condition, or disease.
Durable Medical Equipment (DME): Medical equipment such as wheelchairs and hospital beds. They are durable because they last and they do not get used up like medical supplies.
Emergency Dental Condition: A condition that is potentially life threatening and requires immediate care. This may include severe tooth pain, unusual swelling, or infection.
Emergency Medical Condition: An illness or injury that needs care right now. A physical health example is bleeding that will not stop or a broken bone. A mental health example is feeling out of control or feeling like hurting yourself
Emergency Medical Transportation: Using an ambulance to get care. Emergency medical technicians (EMT) give you care during the ride or flight. This happens when you call 911.
Emergency Room Care: Care you get when you have a serious medical issue and it is not safe to wait. This care happens in an Emergency Room (ER).
Emergency Services: Care you get during a medical crisis. These services can help make you stable when you have a serious condition.
Early and Periodic Screening, Diagnosis and Treatment (EPSDT): Comprehensive and preventative health care services for children from birth to under age 21.
ER and ED: Emergency Room and Emergency Department, the place in a hospital where you can get care right now.
Estate Recovery: After an OHP member dies, OHA will ask to be paid back for services that OHP covered after age 55 for people in long-term care. This is known as estate recovery and is required by Federal and State law. Some of the money from estate recovery goes into DHS programs to help other people. Some is returned to the federal government so Oregon may continue to get federal money for Medicaid programs.
Evaluation: A way to decide your need for physical, dental, or mental health services.
Excluded Services: Things that a health plan doesn’t pay for. Services to improve your looks, like cosmetic surgery, and for things that get better on their own, like colds, are usually excluded.
Family Partner: Also known as Family Support Specialist. A person who is in charge of assessing the mental health and substance use disorder services and support needs of a member. This is done through community outreach. They help members with mental health or substance abuse disorders. • They help: o get access to available services and resources o focus on barriers to services o and provide education and information • This is to reduce the stigma and prejudice toward people who use mental health and substance use disorder services, and to assist the member in creating and maintaining recovery, health and wellness.
Federal and State False Claims Act: Laws that makes it a crime for someone to knowingly make a false record or file a false claim for health care.
Grievance: A formal complaint you can make if you are not happy with your CCO, your healthcare services, or your provider. OHP calls this a complaint. The law says CCOs must respond to each complaint.
Habilitation Services and Devices: Services and devices that teach daily living skills. An example is speech therapy for a child who has not started to talk.
Health Insurance: A plan or program that pays for some or all of its members’ health care costs. A company or government agency makes the rules for when and how much to pay.
Health Risk Screening: A survey will be conducted to assess your overall health and provide individual assistance if needed. This survey will ask you about your emotional, physical, and behavioral health. It will ask about living conditions and your family history. UHA will use this information to connect you with resources and support that will help your overall health.
Hearing: When you ask the Oregon Health Authority (OHA) to review a decision UHA made about covering a health care service. Hearings are held by an administrative law judge who is not part of your CCO or the Oregon Health Plan. A hearing can only be requested after you have appealed the adverse benefit determination (reduced, suspended or terminated service that was previously authorized. Or a denial in whole or part of a service authorization or claim) and the decision was not changed (upheld).
Home Health Care: Services you get at home to help you live better. For example, you may get help after surgery, an illness or injury. Some of these services help with medicine, meals, and bathing.
Hospice Services: Services to comfort a person and their family during end-of-life care.
Hospital Inpatient and Outpatient Care — Inpatient care is when you get care and stay at a hospital for at least three nights. Outpatient care is when you get care at a hospital but, do not need to stay overnight.
Hospitalization: When someone is checked into a hospital for care.
In Lieu of Service (ILOS): Services and settings that are offered as an option for members. These are for services that are not usually covered by OHP.
Intensive Care Coordination: Some members with special health care needs (e.g., older adults, disabled individuals, individuals with multiple and chronic conditions, children with behavioral problems, individuals using IV drugs, women with high risk pregnancy, veterans and their families, and those with HIV/AIDS or tuberculosis) will receive additional assistance and resources to help them manage their health.
Intensive Care Coordination Plan (ICCP): Collective, all-inclusive, unified and interdisciplinary-focused written documentation. This document includes details of the supports, desired outcomes, activities, and resources required for an individual getting ICC Services. The goal is to achieve and maintain personal goals, health, and safety. It identifies certain assignments for the functions of specific care team members. It also addresses relevant medical, social, cultural, developmental, behavioral, educational, spiritual, and financial needs in order to achieve optimal health and wellness outcomes.
Interpreter Services: Language or sign interpreters for persons who do not speak the same language as the provider or for persons who are hearing impaired.
Iris: Provides Advance Care Planning services to members dealing with serious illness. They help members complete advance directives.
Job Opportunities and Basic Skills (JOBS) Treatment: Programs that help you function better in employment settings.
Long-term Care or Long-Term Services and Supports (LTSS): Medicaid funded long-term services and supports services. These include a range of social and health services to eligible adults. Eligible adults are aged, blind, or have disabilities for extended periods of time. This includes nursing homes, behavioral health care, and state psychiatric hospitals.
Medicaid: A national program that helps with the healthcare costs for people with low income. In Oregon, it’s called the Oregon Health Plan.
Medically Necessary: Services and supplies that your doctor says you need. You need them to prevent, diagnose or treat a condition or its symptoms. It can mean services that a provider accepts as normal treatment.
Medicare: A health care program for people 65 and older, or people with disabilities at any age.
Medication Management: The ordering and monitoring of your medications. This does not include covering the cost of your medications.
Network: The group of providers that UHA contracts with to provide services. They are the doctors, dentists, therapists, and other providers that work together to keep you healthy.
Network Provider: A provider UHA contracts with for services. If you see network providers, UHA will pay. Also called a “Participating Provider”.
Notice of Appeal Resolution (NOAR): A letter that tells you when a decision is made about your appeal.
Non-Network Provider: A provider that does not have a contract with UHA. These providers may not accept UHA’s payment for their services. You might have to pay if you see a non-network provider. Also called a “Non-Participating Provider”.
Notice of Action (NOA): Our written response to you denying any request for service or payment for service.
OHP Agreement to Pay (OHP 3165 or 3166) Waiver: A form that you sign if you agree to pay for the services that OHP does not pay for. It is only good for the exact dates and service that is listed on the form. For more information, please see the Billing Information section of this handbook.
Participating Provider: A provider UHA chooses to have a contract with. If you see network providers, UHA will pay. This is also called a “Network Provider”.
Personal Care Services: A benefit that helps members with everyday tasks. These tasks are important activities of daily living. The services are provided by someone who is qualified to provide such services and who is not a legally responsible relative of the member. The services may be furnished in a home or other similar location.
Physician Services: Services that you get from a doctor.
Plan: A company that arranges and pays for health care services. Most plans have physical, dental and mental health care.
POLST - Portable Orders for Life Sustaining Treatment (POLST): A form that you can use to make sure your care wishes near the end of life are followed by medical providers.
Post-Stabilization Care: This is care you get after you have gotten emergency medical services. It helps to improve or fix your health issues, or stop it from getting worse. It does not matter whether you get the emergency care in or outside of our network. We will cover services medically necessary after an emergency. You should get care until your condition is stable.
Preapproval (Preauthorization, or PA): Permission for a service. This is usually a document that says UHA will pay for a service. Some plans and services require this before you get care.
Premium: What a person pays for insurance.
Prescription Drug Coverage: Health insurance or plan that helps pay for medications.
Prescription Drugs: Medications that your doctor tells you to take.
Prevention: What is done to help keep you healthy and stop you from getting sick. This can be check-ups and flu shots.
Primary Care Dentist (PCD): The main dentist who takes care of your teeth and gums.
Primary Care Provider or Primary Care Physician (PCP): The medical professional who takes care of your health. This is usually the first person you call when you have health issues or need care. Your PCP can be a doctor, nurse practitioner, physician's assistant, osteopath, or sometimes a naturopath.
Provider: A licensed person or group that offers health care services. Examples are a doctor, dentist or therapist.
Rehabilitation Services and Devices: Special services and devices to help you get back to better health. These help usually after surgery, injury, or substance abuse.
Representative: A person chosen to act or speak on your behalf.
Residential Care Program: A facility providing room and board, mental health, and SUD services. The program helps you function at home, school, and in the community.
Screening: A survey or exam to check for health conditions or care needs.
Second Opinion: An opinion from a doctor/healthcare provider that is not your regular doctor/healthcare provider. They give you their view about your health issue and how to treat it.
Skilled Nursing Care: Help from a nurse with wound care, therapy, or taking your medicine. You can get skilled nursing care in a hospital, nursing home, or in your home.
Skills Training: A program to help you function socially. It helps you manage money. It also helps you eat right and teaches you how to cook.
Suicide: The act of taking one’s own life.
Special Health Care Needs: Members who have high health care needs, multiple chronic conditions, mental illness, or substance use disorders and may also: • Have functional disabilities, • Live with health or social conditions that place them at risk of developing functional disabilities (like serious chronic illnesses, or certain environmental risk factors such as homelessness or family problems that lead to the need for placement in foster care), or o Are a member that is identified by OHA who needs priority care.
Specialist: A provider trained to care for a certain part of the body or type of illness. Some specialists require a prior approval.
Subcontractor: Means any individual, entity, facility, or organization, other than a participating provider, that has entered into a subcontract with UHA or with any subcontractor for any portion of the work under UHA.
Telehealth: Video care or care over the phone instead of in a provider’s office.
Therapeutic Group Home: A care setting that helps you develop home and social skills.
Therapy: Care you receive to try and aid a health problem. Therapy can be a treatment for dental, medical, or behavioral health.
Transition of Care: Some members who change OHP plans can still get the same services and see the same providers as before. That means care will not change when you switch to a different CCO or move onto/from OHP fee-for-service. If you have serious health issues, your new and old plans must work together to make sure you get the care and services you need.
Treatment Foster Care: A program that helps you develop skills allowing you to live alone.
Urgent Care: Care that you need the same day. It could be for serious pain, to keep you from feeling much worse, or to avoid losing function in part of your body.
Youth Partner: An individual providing services to another individual who shares a similar life experience with the peer support specialist (addiction to addiction, mental health condition to mental health condition).
Whistleblower: Someone who reports waste, fraud, abuse, corruption, or dangers to public health and safety.
The Oregon Health Plan (OHP) is a program that pays for the healthcare of low-income Oregonians. It can be Managed Care or Fee-For-Service. The State of Oregon and the US Government’s Medicaid program pay for it. The OHP program covers: • Doctor’s visits • Prescriptions • Hospital stays • Dental care • Mental health services • Help with addiction to cigarettes • Drug and alcohol treatment • Free rides to covered health care services
OHP can cover hearing aids, medical equipment, and home health care if you qualify. OHP Supplemental is a benefit for children through age 20, and pregnant women. It covers glasses and other dental care.
• Improve the lifelong health of all Oregonians • Increase the quality, reliability, and availability of care for all Oregonians • Lower or contain the cost of care so it is affordable for everyone
OHP does not cover everything. A list of covered services, called the Prioritized List of Health Services, is online at www.oregon.gov/oha/HPA/DSI-HERC/Pages/Prioritized-List.aspx. For more information on these services, please see page 78. To find the most up-to-date list, please look for the “Current Prioritized List and Associated Documents” section. From there, under “Documents”, the newest Prioritized List will have a current date next to the name. The lines below 471 are not funded. Those services may be covered, if treating them will help a covered condition.
Umpqua Health Alliance (UHA) is a Coordinated Care Organization (CCO). CCO’s are a type of managed care. The Oregon Health Authority (OHA) wants people on OHP to have their health care managed by local healthcare networks. CCO’s consist of all types of providers. They work together to provide patient centered care. OHA pays CCO’s a set amount each month to give their members the health care services they need.
Health services for OHP members not in a CCO are paid directly by OHA. This is called Fee-For-Service (FFS). FFS means OHA pays providers a fee for services they give. It is also called an Open Card. Native Americans, Alaska Natives, and people on both Medicare and OHP can be on a CCO or Open Card. Any CCO member who has a medical reason to have FFS can ask to leave managed care. OHP Client Services can help you understand and choose the best way to get your health care. Their number is 1-800-273-0557.
If you have questions about coverage for you or your family, please call UHA Customer Care at 541-229-4842.
UHA is a group of all types of health care providers. They work together for people on OHP in our area. Some groups in our CCO are: • Adapt, a provider of alcohol and drug treatment, primary care services, and mental health services • Advantage Dental Services, LLC, a dental care provider, 866-268-9631 • ATRIO Health Plans, a provider of Medicare Advantage insurance, 877-672-8620 • Aviva Health, a Federally Qualified Health Center (FQHC) • Cow Creek Health & Wellness Center, an Indian Health Service Clinic providing medical care for tribal members as well as the general public, 800-929-8229 • Mercy Medical Center, the community hospital in Roseburg; • Umpqua Health Newton Creek, LLC, a Rural Health Clinic (RHC) providing medical care • Umpqua Health-Transitional Care Clinic, a health center that provides care after being discharged from the hospital until you can get an appointment with your assigned PCP
Umpqua Health Alliance’s network covers most of Douglas County with the exception of some areas in Reedsport, Gardiner, Winchester Bay, and Scottsburg.
UHA coordinates the care you get. Instead of just treating you when you get sick, we work with you to help keep you healthy. • We can work with you to prevent unneeded trips to the hospital or ER. • You will get the tools and support you need to help you stay healthy. • We offer advice about your care that is easy to understand and follow. • We will coordinate the care we give by working with your providers. We give them information that will help you get healthy and help keep you healthy. • All of your providers will work together, with you, to improve your health. They make sure all of your medical, dental, and mental health needs are met. • We offer prevention programs to help keep you and your family from getting sick.
We want you to get the best care possible. Sometimes we provide health-related services (formerly called flexible services) that OHP doesn’t cover. These are non-medical services that CCO’s may pay for in special situations. Health-related services can be for one person, or for a community, to benefit the broader population. For more information, call UHA Customer Care at 541-229-4842. UHA does offer “In Lieu of Service” (ILOS) services. For more information about these services, see pages 87-88.
Another way we coordinate your care is by asking our providers to be recognized by OHA as a Patient Centered Primary Care Home (PCPCH), or other primary care team. That means they can get extra funds to follow their patients closely. They make sure all your medical, dental, and mental health needs are met. You can ask your clinic or provider’s office if they are a PCPCH. UHA’s Care Coordinators can help you understand the healthcare system. We have experts in many different areas of healthcare. These experts are here for you and your family members. Want to know more? Call UHA Customer Care and ask for Care Coordination. Our goal is to be a partner on your journey toward better health and wellness.
Some people have both Medicaid and Medicare benefits. They are called Full Benefit Dual Eligible (FBDE). OHP helps cover Medicare premiums, co-pays for office visits, and other things Medicare does not cover. UHA covers rides to appointments, mental health services, and dental care. Let us know before you go onto Medicare so we can help.
UHA is joined with a Medicare Advantage plan called ATRIO Health Plans. This plan has Medicare Part D coverage. ATRIO also offers Dual Special Needs Plans (D-SNPs). This plan manages OHP and Medicare benefits for members who have special needs or need a lower-cost plan. You may get a letter or phone call from the local APD office. They will ask if you need help getting the right plan. If you are Dual Eligible, make sure your provider knows. Medicare should be billed first. You will get a Medicare Explanation of Benefits (EOB) in the mail. If Medicare denies any of your covered services, don’t worry. Call UHA Customer Care and let us know you got a bill. You are not liable for paying the co-insurance, co-pay, or deductible for covered services. UHA will pay the rest of the charges for covered services. Your provider will send UHA all of the bills. UHA will coordinate your Medicare services with your OHP covered services.
If you get care from a provider that is not in UHA’s network, you may have to pay the bill. Out-of-network services are only covered for emergency care. If you want to see a provider that is not in UHA’s network, ask your PCP for a referral. You can find a list of our providers in the Provider Directory. This can be found at www.umpquahealth.com/ohp/. Click on “Find a Provider” on the drop-down menu named OHP MEMBERS.
Please contact UHA’s Customer Care at 541-229-4842 if you have any questions or need help. If you would like to know more about getting help with coordinating your care, please see the Intensive Care section of this handbook on pages 68-69.
Umpqua Health Alliance’s (UHA) goal is to help you have a healthier life. We have a local office here in Roseburg. Our staff will work with you one-on-one. Douglas County has a small feeling of community.
We offer a number of classes and programs for better health. There are diabetes classes to help you manage the disease. We have a Community Advisory Council where members and county residents give advice on how to better address the needs of the residents in Douglas County.
We offer dental and hearing aids. We also offer free rides. This includes rides to your doctor appointments or mileage reimbursement. Some Medicare plans may not cover vision. UHA offers vision exams once every 24 months for members 21 and older. Medicare doesn’t always cover the Durable Medical Equipment (DME) and supplies you need. UHA contracts with many suppliers for items like incontinence supplies, diabetic supplies, oxygen, and CPAP machines.
No, UHA does not require co-pays for any covered benefits except for Medicare Part D. If there is a medication that Medicare doesn’t cover, if it’s covered by UHA, we will cover the co-pay.
Yes, UHA requires you to have a PCP. You do have the freedom to pick whomever you want in our network. UHA will assign you a PCP in the first week of your enrollment with us. If you do not like your provider or want to change your provider, you can give us a call and we will be happy to change it for you.
UHA contracts with over 400 providers and clinics in Douglas County alone, including mental health providers and specialists. We also work with hundred of providers outside of Douglas County to get the care you need.
You can find all of our network providers on our website www.umpquahealth.com or call UHA Customer Care at 541-229-4842. We can send you a list of our providers that are in our network.
When you enroll with OHP, you will get letters in the mail letting you know how the coverage works. You will get the following in the mail:
OHP Coverage Letter: OHP sends you a letter with your benefit package and CCO information. It also shows you the coverage for everyone in your home who is eligible for OHP. You do not need to take the letter to your appointments or pharmacy. OHP will send you a new letter if you ask for one or if your plan changes.
OHP Medical ID Card: OHP also sends you an Oregon Health ID. This card has your name, client number, and the date the card was issued. All eligible members in your household get their own ID card. You must keep it with you and show it to all of your medical providers. If you lose your ID card, call OHP Customer Services at 1-800-699-9075 for help.
UHA Medical ID Card: Each member of UHA will also get a UHA Medical ID Card. The ID card is sent out attached to a welcome letter within a week of your UHA enrollment. Please punch out the ID Card and keep it with you at all times. Show the card wherever you get medical services.
Member Handbooks: If you would like another copy of this handbook, please call UHA Customer Care You can request a new one at any time, free of charge. You can also find the online version of our handbook on our website at www.umpquahealth.com/ohp/. It is located under the MEMBER FORMS/NOTICES section.
Newborn Coverage: If you are covered by UHA, your newborn will also be covered. However, please enroll your baby as soon as possible. You must tell OHP Customer Services about your baby’s birth. Call them at 1-800-699-9075. When your baby is eligible, OHP will send you a coverage letter. Even if you are not eligible for coverage, your child may still be covered.
Coordinated Care Organization (CCO) Enrollment: Most people with OHP benefits are enrolled in a CCO. Your CCO pays for your health care. For most people, the CCO pays for medical, dental, and behavioral health (mental health and substance use disorder treatment) services. Your OHP coverage letter and UHA ID Card lists the type of care your CCO covers. Below is a list of coverage types UHA offers: • CCOA: Medical, dental, and behavioral. • CCOB: Medical and behavioral health care. OHP pays for dental care. • CCOG: Dental and behavioral health care. OHP pays for medical care. • CCOE: Behavioral health care only. OHP pays for medical and dental care. • CCOF: Dental care only.
You or your representative may request to disenroll from our CCO orally or in writing if another CCO is available in your service area. The effective date of the disenrollment will be the first day of the month following OHA approval of the disenrollment. If you want to change to a different CCO, call OHP Client Services at 1-800-273-0557 or 1-800-699-9075 or use your online account at ONE.Oregon.gov or email Oregon.Benefits@odhsoha.oregon.gov. You can also request to change to another CCO by writing. If another CCO in your area is open for enrollment, you may be able to switch. Some people can ask to change or leave a CCO at any time. These members are: • Members with Medicare and OHP (Medicaid) can change or leave the CCO they use for physical care at any time. However, members with Medicare must use a CCO for dental and behavioral health care • American Indian and Alaska Native with proof of Indian Heritage who want to get care somewhere else They can get care from an Indian Health Services facility, tribal health clinic/program, or urban clinic and OHP fee-for-service.
There are several chances for you to change, which include but are not limited to: • If you do not want the CCO you’ve been assigned to. You can change during the first 90 days after you enroll. • You may request to change your CCO enrollment within 30 days of an enrollment error • When you renew your OHP coverage (usually once a year). • Whenever OHA re-determines your coverage. • After you have been enrolled in a CCO for six months. • Once a year, for any reason. • If you move to a place that your CCO does not serve. To update your address, please inform OHP Customer Services at 1-800-699-9075 or Client Services Unit at 1-800-273-0557. They will confirm whether you need to be placed in a different CCO. • If you are a Native American or Alaska Native, you can ask to change or leave your CCO anytime. • If you are on Medicare, you can ask to change or leave your CCO anytime. However, you must have a CCO for dental and mental health care. • If you lose OHP for less than 2 months, are reenrolled into a CCO and missed the chance to pick the CCO when you would have renewed your OHP. • When OHA has set sanctions on UHA, including not allowing new enrollment {42 CFR 438.702(a)(4)}
Other reasons you might choose to leave UHA’s CCO on your own may be: • UHA has moral or religious objections about the service you want. • You need “related” services to be done at the same time. o i.e., a C-section and tubal ligation. o Not all related services are available in our network. Also, your PCP decides if getting the services separately would cause you unnecessary risk. • Other reasons including, but not limited to, poor care, lack of access to covered services, or lack of access to network providers who are experienced in your specific health care needs. • You move out of the service area. • Services are not provided in your preferred language. • Services are not provided in a culturally appropriate manner; or • You’re at risk of having a lack of continued care.
Disenrollment: UHA does not control disenrollment. UHA may ask OHA to remove you from the plan if you: • Are abusive, uncooperative, or disruptive to CCO staff, property, or your providers. Unless when the behavior is due to your special health care need or disability. • Commit fraud or other illegal acts, for example letting someone else use your benefits, changing a prescription, theft, or other criminal acts. • Are violent or threat violence. This could be directed at a health care provider, their staff, other patients, or UHA staff. When the act or threat of violence seriously impairs UHA ability to furnish services to either you or other members. • Move outside of the service area of your plan. • Loss of OHP eligibility.
OHA will review any request for disenrollment by the CCO for the reasons above. If you are not happy about the disenrollment or if you disagree with the decision, you can make a complaint. See pages 88-96 for how to make a complaint or ask for an appeal.
When you have a problem getting the right care, please let us try to help you before you change CCO’s. Call UHA Customer Care and ask for a Care Coordinator. If you still want to leave, change your CCO, or have any questions about your options for disenrollment, please contact OHP Client Services at 1-800-273-0557. You will get a letter with your disenrollment rights at least 60 days before you need to renew your OHP.
• Your health status gets worse. • You don’t use services. • You use many services. • You are about to use services or be placed in a care facility (like a long-term care facility or Psychiatric Residential Treatment Facility). • Special needs behavior that may be disruptive or uncooperative. • Your protected class, medical condition or history means your will probably need many future services or expensive future services. • Your physical, intellectual, developmental, or mental disability. • You are in the custody of ODHS Child Welfare. • You make a complaint, disagree with a decision, ask for an appeal or hearing. • You make a decision about your care that UHA disagrees with.
We only share your records with people who need to see them for treatment, payment and healthcare operations reasons. You can request a limit on who can see your records.
A law called the Health Insurance Portability and Accountability Act (HIPAA) protects your medical records and keeps them private. This is also called confidentiality. UHA has a confidentiality policy called Notice of Privacy Practices (NPP). This policy explains in detail how we use our member’s Personal Health Information (PHI). We will send you the policy if you ask. Call UHA Customer Care at 541-229-4842 to request a copy of the NPP. We will send it to you, free of charge, within 5 business days.
Privacy is important to your health plan. All PHI is private. This includes anything in your medical record, and anything you give to us. It also includes anything you tell your provider and clinical staff. If you need to have your medical records sent to another provider, you will need to sign a Records Release form. Chemical dependency and HIV information will not be released unless you give permission on the signed release form.
There are state and federal laws that protect your privacy. PHI will not be released by UHA or our providers without your approval, except in an emergency, or when required by state and federal regulations. However, your clinical records may be reviewed by the state or federal government to see if we gave you the best possible care.
What can you do with health records?
• Send your record to another provider as needed. • Ask to fix or correct your records. • Get a copy of your records, including, but not limited to: o Medical records from your provider o Dental records from your dentist o Records from UHA
There may be times when the law restricts your access. You may be charged a reasonable amount for a copy of the requested records.
Some behavioral health records cannot be shared. A provider cannot share records when, in their professional judgement, sharing the records could cause a “clear and immediate” danger to you, others, or to society. A provider also cannot share records prepared for a court case.
Do I have a copay? No, UHA does not have copays. You do not have to pay to see a provider, to fill your medicine, or for any other covered service. If your provider asks for a copay, do not pay it. Please call UHA Customer Care at 541-229-4842 first
Some people who also have Medicare coverage may have a small copay for prescriptions.
All members have a right to know about Umpqua Health Alliance’s programs and services.
This includes: • Members • Potential members • Member representatives • Family members • Caregivers with hearing impairments who need to understand the member’s condition and care
Those who do not speak English as their primary language and who have a limited ability to read, speak, write, or understand English are called Limited English Proficient or LEP. Anyone who is LEP can have language help for healthcare services and benefits.
We provide the following at no cost to you: • Sign language interpreters • Spoken language interpreters for other languages • Written materials in other languages • Braille • Large print • Audio • Auxiliary Aids and other formats
Your use of benefits, grievance, appeals, or hearings will not be denied or limited based on your need for another language, format or auxiliary aids.
All written materials can be provided within 5 business days. If you need help or have questions, please call UHA Customer Care at 541-229-4842, toll free at 1-866-672-1551, TTY 541-440-6304 or 711.
If you feel more comfortable speaking a different language, please tell your doctor’s office or call UHA Customer Care. We can have a free qualified or certified interpreter available to you for your doctor visit. We also have many doctors in our network who speak or sign other languages. You may also ask for our documents in your preferred written language by calling our UHA Customer Care team.
We respect the dignity and the diversity of our members and the areas where they live. We want to serve the needs of people of all cultures, languages, races, ethnic backgrounds, abilities, religions, genders, sexual orientation, gender identification, and other special needs of our members. We want everyone to feel welcome and well-served on our plan.
Transgender Health: UHA respects the healthcare needs of all of our members. This includes members who are or identify as: • Trans Men • Trans Women • Two-Spirit • Non-binary • Gender Nonconforming
For more information on transition coverage, please contact UHA Customer Care at 541-229-4842.
We have several healthy living programs and activities for you to use. Our health education programs include self-care, prevention, and disease self-management. For more information about these services, please call UHA Customer Care.
Early Childhood Cavities can be Prevented: Healthy baby teeth are important for good health and normal growth. Brush your baby’s teeth every day. Never put your baby to bed with a bottle. Lift your baby’s lip and check their front teeth regularly for white or brown spots. Be sure to bring any concerns to the attention of your Dental Care Provider or your PCP.
Child Immunizations (shots) are also covered by UHA: Aviva Health has clinics that provide shots to children and adults. They are available Monday through Friday. Please call Aviva Health at 541-672-9596 for more information regarding shots, services, and hours. You may also check with your pediatrician to see if they provide shots. Shots may also be obtained at the “Shots for Tots” clinics held in Douglas County.
Women’s Annual Exams are covered: The exam includes a general physical exam, pelvic exam, review of health history, evaluation of health screen tests, mammogram (breast x-ray), Pap smear, tests for sexually transmitted diseases, and discussion of any sexual concerns.
Support Groups for various disorders (health problems) are available in Douglas County. If you have a disorder and would like to find out more about joining a support group, call UHA Customer Care. You can also ask about other social services that are available in Douglas County. One of UHA’s nurse case managers will be able to answer your questions.
For more information about these services, please call Customer Care. At 541-229-4842.
American Indians and Alaska Natives with proof on Indian Heritage can get their care from an Indian Health Service (IHS) clinic or tribal wellness center. You can be seen by a Native American Rehabilitation Association of the Northwest (NARA) if referred by an IHS or tribal wellness center. This is true whether you are in a CCO or have FFS. The clinic must bill the same as network providers.
• UHA is contracted with Cow Creek Health and Wellness. Address: 2371 NE Stephens St Suite 200 Roseburg, OR 97470 Phone: 541-672-8533, Toll-Free 1-800-929-8229
American Indian and Alaska Natives don’t need a referral or permission to get care from these providers. These providers must bill UHA. We will only pay for covered benefits. If a service needs approval, the provider must request it first. American Indian and Alaska Natives have the right to leave UHA at any time and have OHP Fee-For-Service (FFS) pay for their care. Learn more about leaving or change your CCO on pages 42-44.
See how to contact our Tribal Liaison below: Kat Cooper kcooper@umpquahealth.com 541-229-7038
Access means you can get the care you need. You can get access to care in a way that meets your cultural and language needs. If UHA does not work with a provider who meets your access needs, you can get these services out-of-network. All members must be able to have ongoing primary care that meets their needs. A PCP is chosen to be responsible for coordinating your care.
When medically appropriate, UHA and our in-network providers are to be available 24 hours a day, 7 days a week. Members who should get this priority care are: • Pregnant women and IV drug users • Members with opioid use • Veterans and their families • Members who need Medication Assisted Treatment
Members who are new to OHP or UHA may need prescriptions, supplies, or other items or services as soon as possible. If you can’t see your primary care provider (PCP) in your first 30 days with UHA
• Call Customer Care at 541-229-4842 and ask for Care Coordination. They can help you get the care you need. (See 66 for Care Coordination) • Make an appointment with your PCP as soon as you can to be sure that you get any ongoing care that you need. You can find their name and number on your UHA ID card. • Call Customer Care if you have any questions and want to learn about your benefits. They can help you with what you need • If you are on Medicare, or a new Medicare enrollee, we can assist you with prescriptions, supplies, or other items and services as well. Please contact UHA and ask for Care Coordination.
Umpqua Health Alliance is committed to preventing fraud, waste, and abuse and doing the right thing. We have a Fraud, Waste, and Abuse (FWA) Plan that we must follow. This plan is to ensure that we are complying with State and Federal laws and regulations. UHA will follow all related laws, including the State’s False Claims Act and the Federal False Claims Act.
Examples of Fraud: • Billing for services that were not done. • Providing inaccurate diagnosis to justify doing tests and surgeries that aren't medically necessary. • Letting someone else use your insurance benefits.
Examples of Waste: • A doctor ordering tests that are not necessary. • Mail order pharmacy sending medications to a member without confirming they are still needed.
Examples of Abuse: • When a doctor provides treatment that does not match up with the original diagnosis (the reason you went to the doctor in the first place). • Billing for an office visit that was 45 minutes long when they only saw the patient for 15 minutes. • Letting someone use your prescription medications.
Please help us. Report health care fraud if you suspect it. You do not need to give your name when you make a report. Whistleblower laws protect people who report fraud, waste, and abuse. You will not lose your coverage if you make a report. It is illegal to harass, threaten, or discriminate against someone who reports fraud, waste, or abuse. You can make a report of fraud, waste and abuse a few ways. Please call, fax, submit on-line, email or write directly to UHA.
Phone: Toll Free 844-348-4702; TTY: 711 Fax: 541-229-9982 Submit a report online: www.umpquahealth.ethicspoint.com Email: compliance@umpquahealth.com Mail: Attention To: Chief Compliance Officer Umpqua Health Alliance, 3031 NE Stephens St, Roseburg, OR 97470
We report all suspected fraud, waste, and abuse committed by providers or members to the state agencies listed below.
• Medicaid Fraud Control Unit (MFCU) Oregon Department of Justice 100 SW Market St Portland, OR 97201 Phone: 971-673-1880 Fax: 971-673-1890
• OHA Office of Program Integrity (OPI) 3406 Cherry Ave. NE Salem, OR 97303-4924 Fax: 503-378-2577 Hotline: 1-888-FRAUD01 (888-372-8301) Website: www.oregon.gov/oha/FOD/PIAU/Pages/Report-Fraud.aspx
• DHS Fraud Investigation Unit PO Box 14150 Salem, OR 97309 Hotline: 1-888-FRAUD01 (888-372-8301) Fax: 503-373-1525 Attn: Hotline Website: www.oregon.gov/oha/FOD/PIAU/Pages/Report-Fraud.aspx
Do you think UHA or a provider treated you unfairly? We must follow state and federal civil rights laws. We cannot treat people unfairly for any reason because of a person’s: • Age • Color • Disability • Gender identity • Marital status • National origin • Race • Religion • Sex • Sexual orientation • Health status • Need for healthcare services
Everyone has a right to enter, exit, and use buildings and services. They also have the right to get information in a way they understand. We will make feasible changes to policies, practices, and procedures. We will talk with you about your needs.
To make a report on discrimination or get more information, please call UHA Customer Care, or send a letter to: • UHA Customer Care 3031 NE Stephens St Roseburg, OR 97470
You also have the right to file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights, UHA Nondiscrimination, Diversity, Inclusion and Civil Rights Executive Manager, Oregon Health Authority (OHA) Civil Rights, Bureau of Labor and Industries Civil Rights Division (BOLI). Please see pages 53-54 for contact information to make a report.
To report your concerns or get more information please contact UHA’s Nondiscrimination, Diversity, Inclusion and Civil Rights Executive Manager: • Phone: 541-229-4842; Toll Free: 866-672-1551; TTY: 541-440-6304 or 711 • Hours: Monday to Friday, 8 a.m.-5 p.m. • Fax: 541-677-5881 • Mail: Umpqua Health Alliance, 3031 NE Stephens St, Roseburg, OR 97470 • Website and Complaint Form: www.umpquahealth.com/appeals-and-grievances/ • Email: UHAGrievance@umpquahealth.com
You also have a right to file a Civil Rights Complaint with the U.S. Department of Health and Human Services, Office for Civil Rights (OCR). Contact that office one of these ways: • Web: ocrportal.hhs.gov/ocr/smartscreen/main.jsf • Email: OCRComplaint@hhs.gov • Phone: 800-868-1019, 800-537-7697 (TDD) • By Mail: U.S. Department of Health and Human Services Office for Civil Rights 200 Independence Avenue SW Room 509F HHH Bldg. Washington, DC 20201
To report your concern, you can also fill out the Report of Discrimination Form in your preferred language. You can get these forms at: www.oregon.gov/oha/OEI/Pages/Public-Civil-Rights.aspx • Email: OHA.PublicCivilRights@odhsoha.orgeon.gov • Fax: 971-673-1330 • Phone: 844-882-7889, 771 TTY • By Mail: OHA Office of Equity and Inclusion Attn: Diversity, Inclusion & Civil Rights Manager 421 SW Oak St, Suite 750 Portland, OR 97204
You can also call UHA Customer Care Monday—Friday, 8:00AM—5:00PM to file a complaint over the phone. To find out more information about how to file a complaint, please see pages 88-91 of this handbook.
If it is within 180 days of the alleged discrimination • US Health and Human Services Office of Civil Rights Michael Leoz, Regional Manager Office for Civil Rights U.S. Department of Health and Human Services 90 7th Street, Suite 4-100 San Francisco, CA 94103 • Customer Response Center: (800) 368-1019 • Fax: 202- 619-3818 TDD: 1-800-537-7697 • Email: ocrmail@hhs.gov
OR
• US Department of Justice • Civil Rights Division 950 Pennsylvania Avenue, N.W. Washington, D.C. 20530 • Phone: 888-736-5551 or 202-514-0716 (TTY)
Within one year of alleged discrimination Oregon Bureau of Labor and Industries (BOLI)
• 800 NE Oregon Street, Suite 1045 Portland, OR 97232 • Phone: 1-971-673-0764 or 711 (TTY) • Email: crdemail@boli.state.or.us
Other relevant policy and procedures for non-discrimination:
• Oregon Administrative Rules - Nondiscrimination policy and procedures • Notice under the Americans with Disabilities Act (ADA) • OHA Request for Modification Policy • OHA Director's Civil Rights Memo • OHA Nondiscrimination Policy for the Public Poster • OHA Language Access Policy for the Public Poster
UHA’s Nondiscrimination policy complies with all state and federal laws including:
• Title VI of the Civil Rights Act of 1964 • Americans with Disabilities Act of 1990 (as amended) • Section 504 of the Rehabilitation Act of 1973 • Oregon Revised Statute Chapter 659A • Section 1557 of the Affordable Care Act
The laws can all be found online at: www.oregon.gov/oha/OEI/Pages/Public-Civil-Rights.aspx.
UHA makes sure we have enough providers. We do this by: • Reviewing grievances and appeals from members. • The types of member complaints filed. • How services are used. • Requests for out-of-network services. • Requests for special accommodations. o To get these services, please let your provider know what your needs are. • Requests for second opinions. • Community health assessments. • Member satisfaction survey results.
UHA’s providers are required to meet the following availability standards for appointment wait times.
Physical Health: • Routine Appt: Within 4 weeks. • Urgent Appt: Within 72 hours. • Emergency Care: Immediately or referred to the Emergency Room depending on your condition. • Follow up ER visit: Within 72 hours.
Specialists: • Routine Appt: Within 4 weeks. • Urgent Appt: Within 72 hours.
Dental Care Providers: • For Routine Care: Within 8 weeks, unless there is a written, special medical reason that allows longer. • For Urgent Care (Adults, non-pregnant members): Within 2 weeks. • For Urgent Care (Children or Pregnant members): Within 1 week. • Emergent Care: Seen or treated within 24 hours.
Behavioral Health Providers: • Non-urgent behavioral health: Within 7 days from the date of request • Urgent behavioral health: Within 24 hours • Specialty care for Priority Populations: o If you cannot be seen within the above timelines, the office must put you on a waitlist, and must try to get you in within 72 hours from being put on the waitlist. They must provide services for you as close as possible to the care you are used to. o This might include: ? Referrals ? Methadone Support ? HIV/AIDS testing ? Risk lowering ? Outpatient Substance Use services ? Residential services for Substance Use ? Manage withdrawals ? Evaluations and other services
Specialty Behavioral Health Providers for priority populations: For Pregnant women, women with children, Veterans and their families, unpaid caregivers, families, children ages birth through five, children with serious emotional disturbance, individuals with HIV/AIDS or Tuberculosis, individuals at risk of first episode psychosis, and the I/DD population: • Immediate assessment and entry. o If you need care in the meantime because an office cannot get you in, they must provide the same level of care that you are used to. They must also try to get you in within 120 days from being put on the waitlist.
For IV Drug users, including Heroin: Immediate entry and assessment. • Admission for services in residential care: within 14 days of request. o If you cannot be seen, and you need care while you wait, admission must take place within 120 days of being put on a waitlist.
For Opioid Use Disorder: Assessment and entry within 72 hours.
Medication Assisted Treatment: As quickly as possible, and not more than 72 hours for assessment and entry.
Children with serious emotional disturbance as defined in OAR 410-141-3500.
UHA makes sure that its provider network is meeting the following time and distance access standards. For all providers: Acceptable travel times and distances may not exceed the following: • In urban areas, 30 miles, 30 minutes • In rural areas, 60 miles, 60 minutes Douglas County is a rural community. For more information, please contact UHA Customer Care.
Primary Care Providers (PCPs) or PCPCH Standards: • Travel time for member to PCP: 30 min urban/60 min rural • Distance for member to PCP: 30 miles urban/60 miles rural
The time and distance standards for all specialists is 60 min/60 miles of member. This includes: • Dental • Endocrinology • Gynecology (OB/GYN) • Infectious Diseases • Oncology (Medical/Surgical) • Oncology (Radiation/Radiology) • Behavioral Health • Pediatrics • Cardiology • Rheumatology • Hospitals • Outpatient Dialysis • Inpatient Psychiatric Facility Services • Pharmacy • Federally Qualified Health Center • Hospital, acute psychiatric care • Rural Health Clinic • Post-hospital skilled nursing facility • Urgent Care Centers
RIGHTS
Access • To have access to covered services during the same office hours as everyone else. • Get emergency and urgent care when you need it without a prior authorization. Any time of day or night, including weekends and holidays. • To have needed and reasonable services to diagnose the current problem. • To choose a diverse provider, if available within the network, in any settings. One that is also easy for families to access. • To be treated by in-network providers with the same dignity and respect as other people who get care, not on OHP. • Get information about all of your covered and non-covered care options. This is to allow you to make informed choices about your care. • To get community-based care that is in as natural and serene of a place as possible. This includes oversight, care coordination, transition and discharge planning by UHA. This is in hopes of keeping you out of the hospital. • Get help with addiction to cigarettes, covered mental health, substance use disorder treatment, family planning, or related services without a referral. • Get a referral to a specialist for covered services. • To get a referral or a second opinion at no cost to you, with UHA’s policies followed. • To receive care at places that offer equal access to males and females under the age of 18. This includes services and care available through human services and the juvenile corrections program provided by or funded by the State of Oregon (ORS 417.270).
Care • To choose a Primary Care Provider (PCP) and be able to change your provider as allowed by UHA’s policies. • To get notice of canceled appointments in a timely manner. • Help make decisions about your health care. This includes refusing care, except when court ordered. • To have one source of person-centered care and services that give you choices, independence, dignity, and that meet the standards of medical care and fitting to your medical needs. • To have regular contact with a care team. They are responsible for managing your care. • To help get health care, local and social support services, and statewide services. Your care team may include: the use of certified or qualified health care interpreters, and certified traditional health workers. These include community health workers, peer wellness specialists, peer support specialists, doulas, and personal health navigators. This is to provide cultural and language help in making decisions about your care and services. • Actively help make a treatment plan. To have your family involved. To talk openly with your provider about treatment choices that are medically necessary for your conditions, no matter the cost or benefit coverage. • To have a clinical record that notes conditions, services you got, and referrals made. • To execute a statement of wishes for treatment. This includes the right to accept or refuse medical, surgical, or behavioral health treatment and the right to execute directives and powers of attorney for health care established under ORS 127. • To execute a Declaration of Mental Health Treatment in accordance with ORS 127.703, and to file a complaint if a Declaration of Mental Health Treatment is not followed. • To get covered preventative services.
Support • To get services and supports that fit your cultural and language needs and provided in your community. This means in a way that respects your culture. Including the use of auxiliary aids. This is to help those with disabilities get access to health information as required by law (Section 1557 of the PPACA). • To have providers that make sure you will have physical access, reasonable accommodations and accessible equipment. o To get these services, please let your provider know what your needs are. • To get written materials that tell you about your: o Rights and responsibilities o Benefits available o How to access services • What to do in an emergency. • Have a friend or helper come to your appointments and other times as allowed by clinical rules. • To have written materials explained in a way that you understand. This includes how coordinated care works and how to get services in the coordinated health care system. • To get free certified or qualified health care interpreter services, and to have information given to you in a way that works for you. For example, you can get information in other languages, in Braille, in large print, or other formats such as electronic, audio, or video. • To have care coordination and transition planning from UHA in a language you understand and in a way that respects your culture. • To get information according to the law (42CFR438.10) within 30 days after your enrollment and within the timeframe Medicare requires for FBDE members. You have the right to get this information at least once a year. • UHA will make sure staff who have contact with potential members are fully trained on plan policies. The training will include the policies on Enrollment, Disenrollment, Fraud, Waste and Abuse, Grievances and Appeals, and Advance Directives. Also including the Certified and Qualified Health Care Interpreter services available and the in-network medical practices and facilities who have bilingual providers or staff.
Nondiscrimination • To be treated with dignity and respect. • To be free from any form of restraint or seclusion. • To freely exercise your rights. The exercising of those rights will not change the way UHA, our network providers, or the State Medicaid agency treats you. • Know how to make complaints and get a response without a bad reaction from the plan or provider. • Complain about different treatment and discrimination. • The ability to make a report if you believe your rights are being denied, your health information isn’t being protected, or you feel that you have been discriminated against. You may do one or more of the following: o File a complaint with UHA o File a complaint with the Client Services Unit for the Oregon Health Plan o Get written notice of UHA’s nondiscrimination policy and process o Ask for and get information on the structure and operation of UHA or any physician incentive plan • To request a hearing. • To get information and help to appeal denials and ask for a hearing. • Get a Notice of Adverse Benefit Determination (NOABD) letter if you are denied a service or there is a change in service level. • To know that your medical record is confidential, with exceptions determined by law. To get a notice that tells you how your health information may be used and shared. With the right to decide if you want to give permission before your health information can be used or shared for certain purposes. • To transfer, or have UHA transfer, a copy of your clinical record to another provider. • To have access to your own clinical record unless restricted by law. To get a copy, and have corrections made to your health record. • To exercise all rights, even if the member is a child, as defined by OARs. There are times when people under age 18 may want or need to get health care services on their own. To learn more about the rights of a minor, please go here: sharedsystems.dhsoha.state.or.us/DHSForms/Served/le9541.pdf. • Ask the Oregon Health Authority Ombudsman for help if a complaint or grievance was not resolved in your favor. You can call them at 877-642-0450, TTY 711. You can also fax them at 503-934-5023, or email them at OHA.OmbudsOffice@dhsoha.state.or.us.
Getting Care • Find a doctor or other provider you can work with. Tell them all about your health. • Help the provider or clinic get clinical records from other providers. This may include signing a Release of Information. • Give accurate information to your provider for your medical records. • Help make a treatment plan with your provider and follow the agreed upon plan. Be actively engaged in your health care. • Use information provided by UHA’s providers or care teams to make informed decisions about care before it is given. • Follow your providers and pharmacist’s directions. Ask questions about conditions, treatments, and other issues related to care that you do not understand. • Call your provider at least one day before if you can’t make it to an appointment.
Things You May Have to Pay for • To pay for services not covered by OHP described in OAR 410-120-1200 (Excluded Services and Limitations) and 410-120-1280 (Billing). • To pay your monthly OHP premium on time if you have one. • To help UHA find any third-party coverage you have. Pay UHA back for benefits we paid, for an injury or any recovery you may have gotten due to that injury.
What to Do Next • Have yearly check-ups, wellness visits, and other services to prevent illness and keep you healthy. • Be on time for appointments. Call ahead of time to cancel if you can’t keep the appointment or if you think you’ll be late. • Bring your Medical ID Cards to appointments. Tell the receptionist or provider that you have UHA/OHP or any other health insurance before you receive services. Tell them if you were hurt in an accident. • Treat providers, their staff, and UHA with the same respect you want. • Obtain a referral to a specialist from the PCP or clinic before seeking care from a specialist (unless self-referral to the specialist is allowed). • Proper use of urgent and emergency services. As well as notify your PCP or clinic within 72 hours of using emergency services. • Use your PCP or clinic for all your non-emergent medical care. Only use the ER for emergencies. • Call OHP Customer Services at 1-800-699-9075 if you are pregnant or no longer pregnant. Also tell them when your child is born. • Call OHP Customer Services at 1-800-699-9075 or tell your Authority worker of a change in address or phone number. Also tell them if any family member moves in or out of the household. • To bring issues, complaints, or grievances to the attention of UHA. • Tell the Department or Authority worker if you have any other insurance coverage.
As a member of OHP, you will get several letters in the mail. Some of the letters you will get are: • When you are first approved for OHP, this will include your OHP ID card. • When OHP transfers your coverage to a CCO. • If your benefit package changes in other ways. • Once you are enrolled in a CCO, you will get your Member ID card as well as a Member Handbook. • Your CCO will send out a letter for any benefit changes within 30 days of the change or as soon as possible. • OHP will send out multiple letters when it is time to re-enroll. They space them out as reminders to re-enroll. • If OHP requires any more information from you. This could be regarding proof of income, or proof of residency. The letter will list the items they need.
Once you have been transferred onto UHA, what do you do next? • When you get your UHA Member ID Card, it will list who your assigned PCP office is and their contact phone number. Call your PCP to set up an appointment. Even if you do not feel ill, it’s always a good idea to get to know your provider so that they can have all of your medical history already on hand in case you do get sick.
At your doctor’s appointment: • Always be on time, if for some reason you are unable to make your appointment, call their office and let them know. Preferably at least 24 hours before your scheduled appointment. • Relax, your doctor is here to help. Remember to breathe. Take slow, deep breaths. • Make sure to talk to your doctor about any medical needs or concerns you may have. • You can write a list of your medical needs or concerns to bring with you to your appointment. • If you do not understand what your doctor is telling you, don’t be afraid to ask them to repeat themselves or to have them explain it to you differently.
Before you leave your doctor’s appointment: • Make sure you know what the next treatment plan is. Do you need to follow up with your PCP or a specialist? Are there any tests that need to be ran? Do you have any prescriptions you need to pick up? • Make sure you understand why and how you are to follow your treatment plan. • Do you know when you are to follow up with your PCP or a specialist?
Care while you change plans. Some members who change OHP plans can still get the same services and see the same providers. That means care will not change when you switch CCO plans or move to/from OHP fee-for-service. If you have serious health issues, your new and old plans must work together to make sure you get the care and services you need.
You can still have the same access to services and prescription coverage when on UHA. You can still see your provider even if they are not in UHA’s network until one of these happen:
• The minimum or approved prescribed treatment course is completed or • The reviewing provider decides that the care is no longer medically needed. If the care is by a specialist the treatment plan will be reviewed by a qualified provider
Transition Period. You will still get the medical, dental, behavioral health services, and drugs that were approved for you. The transition time frames are the shorter of: • 30 days for physical and oral health; or • 60 days for behavioral health; or • Until the new physical, oral, or behavioral health provider, depending on the type of care needed, reviews your treatment plan. • 90 days for members who are dually eligible for Medicaid and Medicare
We will work with you to assign you to a Primary Care Physician (PCP), Primary Care Dentist (PCD), and behavioral health provider that best meets your health care needs. Please schedule an appointment with these providers in the first month of your coverage, if possible.
Who can get the same care while changing plans? There is help for members who have serious health issues, need hospital care, or inpatient mental health care. Members who need this care are: • End stage renal disease care. • Medically fragile children. • Breast and Cervical Cancer Treatment program members; • Prenatal or postpartum care. • Transplant services (including per and post-transplant care) • Any member who, without continued access to services may suffer serious health issues or be at risk of going to the hospital or an institution. • Members receiving CareAssist assistance due to HIV/AIDS. • Transplant services. • Radiation or chemotherapy.
Some types of care will continue until complete with the current provider. These types of care are: • Care before and after you are pregnant/deliver a baby (prenatal and postpartum). • Transplant services until the first-year post-transplant. • Radiation or chemotherapy (cancer treatment) for their course of treatment. • Medications with a defined least course of treatment that is more than the transition of care timeframes above.
If you need care while you change plans, please call UHA Customer Care. You can learn more about our Transition of Care policy at www.umpquahealth.com/ohp/. It is under the Member Forms/Notices section.
UHA assigns a PCP within 30 days of your enrollment. You may choose a different in-network provider at any time. A current list of participating providers and hospitals can be found in the Provider Directory. You can find this on our website at www.umpquahealth.com/ohp/. Go to “Find a Provider” to search by provider or facility name, gender, and specialty. You can get it in another format (such as other languages, large print, or Braille) for free. Call UHA Customer Care at 541-229-4842 if you would like a copy.
Here are examples of information you can find in the Provider Directory: • If a provider is taking new patients. • Provider type (medical, dental, and behavioral health, pharmacy, etc). • How to contact them. • Video and phone care (telehealth) options. • Language help (including American Sign Language, translations, and interpreters). • Accommodations for people with physical disabilities. o To get these services, please let your provider know what your needs are.
If at any time you want to change your PCP, call UHA Customer Care. If you have a hearing impairment, please use TTY numbers below. The change is effective the same day.
If you would like a copy of our PCP Assignment Policy, including information on changing PCP’s, please call UHA Customer Care. We will mail you a copy, free of charge, within 5 business days.
There is a limit to your freedom of choice of our in-network PCP’s. Some PCP’s are not accepting new patients. UHA is also unable to assign to PCP’s that are not in our coverage area.
Care Coordination - The organized coordination of a member’s health care services, support activities, and resources. Care Coordination occurs between, and among, two or more participants deemed responsible for the member’s health outcomes. This includes, at minimum, the member (and their family/caregiver as appropriate) and the member’s assigned Care Coordinator. Care Coordinators are here to help you with your healthcare and social needs. They offer help in navigating you through the healthcare system, and provide options to connect you with resources. These resources include housing, transportation, Temporary Assistance for Needy Families (TANF), Women, Infants and Children (WIC), in-home caregivers, United Community Action Network (UCAN), Uplift, interpreter/translation services, and much more. Care Coordination is available for all members.
What services can Care Coordination offer? • Free transportation to and from appointments • Health Related Services (see pages 85-87 for more information) • Coordination of services among providers • Resources for free services • Referrals to internal and external programs • Access to free cell phones
Also, all Full Benefit Dual Eligible (FDBE) members have Integrated Care Coordination with Medicare available to them. This includes being sent an initial and annual health risk screening that is combined with a behavioral health screening. An Integrated Care Coordinators (ICC) offer continuous care management to those members who are not designated as needing Intensive Care Coordination. The Care Coordinators work with UHA’s Medicare partners to provide coordinated care.
To get connected, talk to your provider, call UHA Customer Care at 541-229-4842 and ask for your Care Coordinator, or email Care Coordination at Casemanagement@umpquahealth.com. We’re here to help you explore healthcare opportunities!
Traditional Health Workers - There may be times when you need help getting the right care. Your primary care team may have people specially trained to do this. These people are called Traditional Health Workers (THW). THW is a blanket term for public health workers who work in the community under the direction of a licensed medical provider. They are known as Care Coordinators. Examples of these helpers are:
• Birth Doulas: Helps women and their family with pre-natal, childbirth and post-partum care. • Personal Health Navigators (PHN): Helps patients make good health care decisions. • Peer Support Specialists (PSS): Focus on recovery from addiction/mental health conditions. • Peer Wellness Specialists (PWS): Focus on recovery from addiction/mental health and physical conditions. • Community Health Workers (CHW): Helps people and their community to achieve positive health outcomes. • Family Support Specialist (FSS): Helps parents with children who have a mental health condition. • Youth Support Specialist (YSS): Helps youth get treatment for addiction/mental health and other supportive services. • Tribal Traditional Health Workers: Someone who helps tribal or urban Indian communities improve their overall health. They provide education, counseling, and support which may be specific to tribal practices.
THW can help you with many things, like: • Finding a new care provider. • Receiving the care you need. • Understanding your benefits. • Providing information on behavioral health services and support. • Advice on community resources you could use.
Contact our Lead Care Coordination Navigator at 541-673-8982, or email Casemanagement@umpquahealth.com to find out more about UHA’s THW staff and how to use their services.
We will update UHA’s website if the name and/or the contact information for UHA's THW staff changes. You can find these notices at www.umpquahealth.com/case-management/. You can also call UHA Customer Care and ask for updated information.
Intensive Care Coordination - An Intensive Care Coordinator (ICC) helps members that have complex medical needs, special healthcare needs, or behavioral healthcare needs. This program is designed for people who have: • High health care needs. • Multiple chronic conditions. • Medicaid-funded long-term care services and supports (LTSS). • Mental illness or at risk of first episode psychosis, and those with an Intellectual and Developmental Disability (IDD). • Substance Use Disorder and are receiving medication assisted treatment or are IV drug users in need of withdrawal management. • HIV/AIDS or tuberculosis. • Children ages 0-5 who have early signs of social, emotional, or behavioral problems, or a diagnosis of Severe Emotional Disturbance. • Women who have been diagnosed with a high-risk pregnancy. • Children with neonatal abstinence syndrome. • Children in Child Welfare. • Older adults or someone who is hard of hearing, deaf, blind, or has other disabilities; and • Veterans and their families or are a member who OHA says needs priority care.
If you are someone who has one or more of the needs described above, you will be assessed for ICC services. This assessment will be done within 10 calendar days of completing a Health Risk Assessment (HRA) screening. The assessment is updated every 90 calendar days or sooner if needed due to your health condition. The ICC assessment will add to the answers you have given in the HRA assessment. We will ask about your physical, oral, social, cultural, developmental, behavioral, educational, spiritual, and financial needs. UHA ICC will talk with you about the answers to the questions and work with you to develop a care plan that is unique to you. They will work with other UHA coordinators and departments to make sure you are connected to all services you need to reach optimal health. The UHA ICC will also work with physical, oral, and mental health network providers, community support agencies, and other case managers that you work with outside of UHA to make sure you reach your overall health goals. For more information on the Health Risk Assessment screening, see pages 70-71.
UHA’s ICC will help you work through the healthcare system. ICC services are provided in addition to the general care coordination UHA offers. See pages 66-67 for more information on Care Coordination that is available to all members. The additional ICC services include the following: • Help you understand how UHA works. • Find a provider who can help with special health care needs. • Get a timely appointment with a primary care provider, dentist, specialist, or other health care provider. • Get equipment, supplies or services you need. • Coordinate care among all of your doctors, other providers, community support agencies, and social service agencies. • Provide an extensive health assessment. • Develop an Intensive Care Coordination Plan (ICCP). An ICCP helps you and your team in reaching and keeping your health goals. • Making sure the services and supports on a person’s care plan are helping them and their family.
Intensive care coordination services are available Monday through Friday 8:00 a.m. to 5:00 p.m. If you can’t get ICC services during normal business hours, UHA will give you other options. All members have direct access to ICC services. To get help from an ICC, please contact UHA’s Customer Care. Anyone who qualifies for ICC services is assigned to an ICC care coordinator within 3 business days of the request for help. Members or member representatives enrolled in ICC are given the name and phone number of the ICC Care Coordinator.
ICC’s also can help if you are on Medicare and are within the first month of your enrollment. If you need help getting services because you are unable to get an appointment with a provider, or get new orders for drugs, DME supplies, and other necessary items or services, please contact UHA and ask for Care Coordination. The ICC’s are available Monday through Friday, 8:00 a.m. to 5:00 p.m.
Umpqua Health Alliance strives to better serve our community through meeting the health care needs of our members. Randomly selected members who have gotten care from our in-network providers may also get a Consumer Assessment of Healthcare Providers and Systems (CAHPS) survey. If you get this survey, please take a few minutes to answer the questions. This information can show us your health care concerns or needs, so that we may better serve you as our member.
All new UHA members will get a health risk assessment survey by mail. This is included in the new member packet. UHA asks that all newly enrolled members complete the survey. If you haven’t filled out the form already, please take a few minutes to answer the questions and mail it back to us. Our address is: • UHA Customer Care 3031 NE Stephens St. Roseburg, OR 97470
If you do not send the completed survey back by mail, a Care Coordinator will attempt to reach you by phone or by text message. UHA will make three attempts to complete this survey within 90 days of enrollment, or sooner for members who have special health care needs. You will get another survey annually or if there is a change in your health status.
The Health Risk Screening is a survey with questions about your general health with the goal of helping reduce health risks, maintain health, and prevent disease.
The survey asks about: • Your habits (like exercise, eating habits, and if you smoke or drink alcohol). • How you are feeling (to see if you have depression or need a mental health provider). • Your general well-being and medical history. • Your primary language.
Your answers help us find out: • If you need any health exams, including eye or dental exams. • If you have routine or special health care needs. • Your chronic conditions. • If you need long-term care services and supports. • Safety concerns. • Difficulties you may have with getting care. • If you need extra help from care coordination.
Once we have a completed survey, UHA’s Care Coordinators may reach out to you with information or resources based on your answers. You may qualify for Intensive Care Coordination services, please see pages 68-69 for more information.
UHA’s Care Coordinators may share your survey answers with your provider and other case managers you work with. UHA will only share information that is needed to support your needs. We will ask for your permission before sharing sensitive diagnosis information. By sharing your survey answers, we can work closer with your healthcare team to give you better whole-person service and care. You will also receive a copy of your care plan.
If you would like to speak to a Care Coordinator or complete your health assessment over the phone, please call 541-229-4842 8 a.m. to 5 p.m., Monday through Friday and ask for Care Coordination.
Covered Medical Services Include but are not limited to:
Service Amount, duration and scope of benefits Referral or preapproval required? CCO Benefit Plan
Care Coordination Services No limits Direct access No PA required for in-network or out-of-network services CCOA CCOB CCOE CCOG CCOF
Comfort Care & Hospice Services Approval based on OHP guidelines. Contact UHA Direct access PA required for out-of-network services CCOA CCOB
Diagnostic services No limits No PA required for in-network services. PA required for out-of-network services Self-referral allowed CCOA CCOB
Durable Medical Equipment Some examples are: Medical supplies (including diabetic supplies), Medical appliances, prosthetics and orthotics Oxygen rentals - 36 months A referral and preapproval may be required. For more information, please see our PA Grid at www.umpquahealth.com/prior_authorizations/ CCOA CCOB
Early & Periodic Screening, Diagnosis and Treatment (EPSDT) services Members from birth to under age 21 can receive EPSDT service. For more information on these services, please see pages 79-83. No PA required for in-network or out-of-network services CCOA CCOB CCOE CCOG CCOF
Elective surgeries/procedures Approval based on OHP guidelines. Contact UHA All out-of-network requests require a PA CCOA CCOB
Emergency medical transportation Ambulance rides covered for emergencies only. Direct access No PA required for in-network or out-of-network services CCOA CCOB CCOE CCOG CCOF
Emergency Services No limits Direct access No PA required for in-network or out-of-network services Self-referral allowed CCOA CCOB Family Planning Services Some examples are: birth control and annual exams. No limits Direct access No PA required for in-network or out-of-network services CCOA CCOB
Health Risk Screening for Intensive Care Coordination No limits Direct access No PA required for in-network or out-of-network services CCOA CCOB CCOE CCOG CCOF
Hearing Services Some examples are: Audiology and Hearing Aids Approval based on OHP guidelines. Contact UHA PA required for all hearing aids CCOA CCOB
Home Health Services Approval based on OHP guidelines. Contact UHA PA required for out-of-network services CCOA CCOB
Inpatient Hospital Services Rehabilitative, and Habilitative Services Approval based on OHP guidelines. Contact UHA PA required for: • Acute Physical Rehabilitation • Skilled Nursing Facilities No PA required for: • Acute Care Hospital • Long Term Acute Care CCOA CCOB Intensive Care Coordination (ICC) Services No limits Direct access No PA required for in-network or out-of-network services CCOA CCOB CCOE CCOG CCOF
Interpreter Services No limits Direct access No PA required for in-network or out-of-network services CCOA CCOB CCOE CCOG CCOF
Laboratory Services, X-Rays, and other procedures Approval based on OHP guidelines. Contact UHA PA required for out-of-network services CCOA CCOB
Maternity Services (such as checkups, immunizations, or annual screenings) No limits No PA required for in-network services. PA required for out-of-network services CCOA CCOB Non-Emergent Medical Transportation (NEMT) services Limited for VA and COFA members, see page 85 for more information Preapproval may be required CCOA CCOB CCOE CCOG CCOF
Outpatient Hospital Services Some examples are: Chemo, Radiation, and Pain Management Approval based on OHP guidelines. Contact UHA PA required CCOA CCOB
Pharmaceutical Services (Prescription Medication) Most drugs have a 90-day supply option at a participating network pharmacy, except for specialty medications. Some medications may require prior authorization. For more information see pages 110-111. CCOA CCOB CCOE CCOG CCOF
Physical Health Specialists for those with special health care needs receiving ICC and LTSS services. No limits Direct access No PA required for in-network or out-of-network services Self-referral allowed CCOA CCOB
Physical Therapy Occupational Therapy Speech Therapy Limited to a combined 30 visits total per 12 months No PA required for evaluations No PA required for the first 8 visits PA required for visits 9-30 CCOA CCOB
Preventive services. Some examples are: physical examinations, well-baby care, immunizations, women’s health (mammogram, gynecological exam, etc.), screenings (cancer, etc.), diabetes prevention, nutritional counseling, tobacco cessation services, etc. No limits Direct access No PA required for in-network or out-of-network services CCOA CCOB
Primary Care Provider Visits No limits PA required for out-of-network services CCOA CCOB
Sexual Abuse Exams No limits Direct access No PA required for in-network or out-of-network services Self-referral allowed CCOA CCOB
Specialist Services Approval based on OHP guidelines. Contact UHA PA required for out-of-network services CCOA CCOB CCOE CCOG CCOF
Surgical procedures Approval based on OHP guidelines. Contact UHA All out-of-network requests require a PA CCOA CCOB
Telehealth Services Some examples are: Telemedical services, Virtual visits, and Email visits Approval based on OHP guidelines. Contact UHA PA required for out-of-network services CCOA CCOB CCOE CCOG CCOF
Traditional Health Worker (THW) services No limits Direct access No PA required for in-network or out-of-network services Self-referral allowed CCOA CCOB
Urgent Care Services No limits Direct access No PA required for in-network or out-of-network services Self-referral allowed CCOA CCOB
Women’s Health Services (in addition to PCP) for routine and preventative care Approval based on OHP guidelines. Contact UHA No PA required for in-network or out-of-network services Self-referral allowed CCOA CCOB
Vision Services Members 0-20 can have one routine eye exam and pair of glasses per year. Members on pregnancy tier can have one routine eye exam per year, and one pair of glasses every 24 months. Routine vision services are covered for 12 months after the pregnancy ends (postpartum period). Members 21+ who are not on the pregnancy tier are eligible for one medical eye exam every 24 months. PA required for out-of-network services CCOA CCOB
For any questions about benefits, call UHA Customer Care at 541-229-4842.
Above is not a full list of services that need preapproval. Our full list of requirements is on our PA Grid at www.umpquahealth.com/prior_authorizations/. If you have questions about preapprovals, please call UHA Customer Care at 541-229-4842. There is an additional dental chart on page 113-114 as well as SUD and Mental Health charts on pages 116-117.
UHA will notify members of changes in access to benefits by mail. We will notify you of any changes in contracted providers, which includes your primary care provider. Notification will be sent the later of 30 calendar days before the date of the change, or 15 days after we receive notice of the change. UHA does not deny or reduce the amount, duration, or scope of a required service solely because of your diagnosis, type of illness, or condition. If you would like a free copy of UHA’s summary of benefits, please contact UHA Customer Care at 541-229-4842.
Family Planning Services: You do not need a referral for family planning services and supplies. You can go to any OHP provider that is willing to provide these services. Examples of family planning services and supplies are: • Appointments for birth control, including emergency contraception • Abortion • Tubal Ligation • Pregnancy testing and counseling • Vasectomy • Testing and treatment for sexually transmitted diseases
You can get more information about how to get these services by calling UHA Customer Care or your PCP. You can also call the Oregon Reproductive Health Program at (971) 673-0355. This program works with over 165 clinics all over the state to offer free or low-cost reproductive health services and birth control for women, men, and teens who need them. This program seeks to reduce unintended pregnancy in Oregon by giving access to information, services, and resources necessary to ensure that all pregnancies are healthy, well-timed, and intended.
OHP’s covered benefits and treatments are based off of a list of conditions and services. These are ranked by the Health Evidence Review Commission (HERC). This list is called the Prioritized List of Health Services. The HERC held many public meetings all over Oregon to find out what health issues were important to Oregonians. Covered benefits are based on where the conditions and treatments fall on the list. Not all medical care is covered. The Oregon Legislature did not fund conditions that ranked lower on the priority list. This means not all medical care is covered. The services that have been proven to help you are covered.
OHP also covers services to diagnose a condition, including conditions that are not on the list. This means we cover the office visit to find out what is wrong. Once the problem is diagnosed, UHA may not cover follow-up visits. If the condition or treatment is not funded on the Prioritized List of Health Services, we will not cover it.
OHP does not pay for the following services: • Treatment for conditions that get better on their own such as colds or flu. • Treatment for conditions for which home treatment works such as sprains, allergies, corns, calluses, or some skin conditions. • Cosmetic surgeries or treatments. • Treatments that are not normally effective. • Services to help you get pregnant. • Treatment rendered outside of Oregon that are not emergencies, urgent or planned care. • Services you got outside the United States, including Mexico and Canada.
If you have any questions about what is covered, please call UHA Customer Care at 541-229-4842.
Preventing health problems before they happen is important. UHA’s members are covered for preventative services to help them stay healthy. This includes check-ups and any tests to find out what is wrong. Your provider will suggest a schedule for check-ups and other services.
Other Preventative Services Include: • Well-child exams • Immunizations (shots) for children and adults (not for foreign travel or employment purposes) • Routine physicals • Women’s annual exams • Mammograms (breast x-rays) for women • Prostate screenings for men • Maternity and newborn care • Colorectal screening • Teeth cleaning • Fluoride treatment • Sealants • X-rays of teeth • Dental check-ups and fillings
Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) services are full and preventative health care services for children birth to under age 21. This benefit provides you with services that can prevent and detect if there are conditions or health concerns in early stages. It can reduce the risk of illness, disability or other medical/mental health care that may be needed. EPSDT stands for: • Early: Checking for and finding issues early. • Periodic: Checking health regularly. How often depends on the child’s age. • Screening: Providing tests to find possible issues for: Physical, Mental, Vision, Dental, Hearing, Development, and others. • Diagnosis: Performing tests to see if you have any health issues, so they can be treated. • Treatment: Correcting, controlling, or reducing health problems found.
When should a child have an EPSDT screening?
All children from birth to under age 21 and enrolled in Medicaid should have a yearly visit. Children who need EPSDT services should get them in a timely manner.
What is covered by the EPSDT program?
An EPSDT screening can be done at regular check-ups and is covered at no cost to you. It includes: A health and development screening. This includes: • Mental Development • Physical development • Screening for o Acute o Episodic o Chronic illness o Chronic conditions. • Assessment of nutritional status • Hearing and vision testing. Treatment for vision and hearing issues. This includes glasses and hearing aids. • General unclothed physical exam that includes an exam of teeth and gums. • Dental screenings and care as early as needed o For pain relief o Infections o Restoration of teeth o Maintenance of dental health o Referral to dentist who can provide the exam
• Immunizations that are recommended by the Advisory Committee on Immunization Practices. See links below for more information. o Child Immunization Schedule (birth to 18 years): https://www.cdc.gov/vaccines/schedules/hcp/imz/child-adolescent.html o Adult Immunization Schedule (19+): https://www.cdc.gov/vaccines/schedules/hcp/imz/adult.html • Health Education. This includes advice for member’s health as they grow. • Other lab tests. These tests include tests for anemia and sickle cell, as well as others. The testing that is done depends on age and risk. • Well-Child exams or screening tests for EPSDT members: o At every stage of member’s life o Testing from birth to under age 21 • Lead testing: o Children must have a blood lead test at age 12 months and 24 months. o Any child who is between ages 24 and 72 months with no record of a previous screening must have a test done. o Completing a risk survey does not meet the requirement for children under Medicaid. Any child with lead poisoning can have help through Case Management. • Health Education. This includes advice for member’s health as they grow. • Other lab tests. These tests include tests for anemia and sickle cell, as well as others. The testing that is done depends on age and risk. Well-Child exams or screening tests for EPSDT members: o At every stage of member’s life o Testing from birth to under age 21
EPSDT services will be provided as soon as the request for screening is received, generally within 6 months of the request. This timeframe includes the beginning of the EPSDT care.
For eligible EPSDT members, UHA has to give: • Regularly scheduled examinations and evaluations of the general physical and mental health, growth, development, and nutritional status of infants, children, and youth under the age of 21
If during the test an issue is discovered, and the member, member’s parent or member’s guardian agrees, a referral to a provider will be made for further care. These screenings become part of your health history. They also include information from other providers. The provider who does the screening must: • Explain why a referral is needed • Help find a provider who can treat the issue • Help make an appointment for care
If you need help getting EPSDT services: • Call Customer Care at 541-229-4842 or your health care provider. • Call Advantage Dental Services at 866-268-9631 to set up dental services or for more information. • Care Coordination is also available for EPSDT services, please see page 66 for more information. • For information on what we cover under EPSDT, including transportation and Care Coordination services, or for information or referral assistance for treatment and services not covered under EPSDT, call Customer Care
UHA covers visits for screenings. The kind of screenings that will be done depends on a member’s age. UHA follows the rules of the American Academy of Pediatrics and Bright Futures. Immunizations are covered as advised by the Advisory Committee on Immunization Practices (ACIP): • American Academy of Pediatrics schedule for Preventative Pediatric Health Care can be found here: downloads.aap.org/AAP/PDF/periodicity_schedule.pdf • The OHA’s EPSDT Fact Sheet can be found here: https://www.oregon.gov/oha/HSD/OHP/Pages/EPSDT.aspx EPSDT includes covered services on the Prioritized List.
WHERE DO I GO TO GET THESE SERVICES?
EPSDT screening services can be done by: • Medical Doctor (MD) • Doctor of Osteopathic Medicine (DO) • Physician Assistant (PA) • Nurse Practitioner (NP) • Any licensed care provider.
Any member who is signed up with a PCP can receive EPSDT services.
To find an EPSDT provider, you can: • Call your doctor • Look at the Provider Directory: https://portal.umpquahealth.com/ClientApp/providers • If you need help finding a doctor, call UHA Customer Care at 541-229-4842 • Call Advantage Dental at 866-268-9631 to set up dental services or for more information. o UHA or OHP will also help with Care Coordination, if needed.
DO YOU NEED A RIDE TO AN EPSDT APPOINTMENT?
Members are eligible to receive free rides through BCB. If you need help setting up a ride, call UHA Customer Care.
For more information on rides with BCB: • Call UHA Customer Care: 541-229-4842 o Toll-free: 1-866-672-1551 o TTY: 541-440-6304 • To schedule a ride: o Call BCB: 877-324-8109 o Or go online: http://bca-ride.com
Services not covered under EPSDT include but are not limited to Supplemental Nutrition Assistance Program (SNAP), education programs, and other Social Services programs. UHA will give referral help to members or their representatives who need help getting services not covered under EPSDT. If you need more information about any of these services, please contact UHA Customer Care at 541-229-4842.
For more information regarding EPSDT services, please go online: https://www.umpquahealth.com/wp-content/uploads/2022/11/epsdt-for-member-page-of-web.pdf
UHA does not cover everything. Some services are only available through OHP. These have no out-of-pocket costs to members. If you have any questions about these services and how to obtain them, please contact UHA Customer Care. You can also call OHP at 1-800-699-9075. OHP may be covering a service, UHA will still provide the Non-Emergent Medical Transportation (NEMT), see pages 130-132 for more details. Some of these services are: • Abortion and related services. • Hospice services for members who live in a skilled nursing facility (This is not covered for CAWEM Plus members). • Death with Dignity. • Administrative examinations requested or authorized by another government agency, CAF, SPD, AMH, OYA, SCF branch office or approved by the Health Systems Division in accordance with OAR 410-130-0230. • Services provided to Citizen Alien Waived Emergency Medical (CAWEM) recipients or CAWEM Plus-CHIP Prenatal Coverage for emergency medical services only. • School-based services that are covered services provided under the Individuals with Disabilities Education Act (IDEA).
The above services have care coordination provided by OHP, to reach the KEPRO Care Coordination team, call 1-800-562-4620 for more information.
There are some services that UHA does not cover and still provides care coordination and Non-Emergent Medical Transportation (NEMT), see pages 130-132 for more details. Some examples of these services include: • Long term care services and supports excluded from the CCO's payment as required by law (ORS 414.631). • Services which help to meet the needs of people with a chronic illness or disability who cannot care for themselves for a long period of time. Estate recovery applies, see Words to Know on pages 25-34. • Planned Community Birth services including prenatal and postpartum care for women who have a low-risk pregnancy who meet criteria defined in OAR 410-130-0240. • Family Connects Oregon, a free support program for families. o For more information on Family Connects Oregon, visit their website: www.familyconnectsoregon.org/for-parents • Assisting members in gaining access to certain behavioral health service. Examples of such services include, but are not limited to: o Certain drugs for some behavioral health conditions o Therapeutic group home reimbursement for members under 21 years of age o Long term psychiatric care for members 18 years of age and older o Personal care in adult foster homes for members 18 years of age and older
For more information on these certain Behavioral Health services, or for a complete list of services, call UHA Customer Care at 541-229-4842.
UHA does not have any known moral or religious objection to covering a service. You can contact OHP Client Service at 1-800-273-0557 to learn how to get the services covered by OHA listed above.
If you are a member of the Veterans Dental Program or COFA Dental Program, UHA only provides dental benefits and free rides to dental appointments. OHP and UHA do not provide access to physical health or behavioral health services or free rides for these services, which are non-covered services without care coordination.
If you have questions regarding coverage and what benefits are available contact UHA Customer Care at 541-229-4842
Health-Related Services (HRS) are extra services Umpqua Health Alliance (UHA) offers. These services are not covered by OHP but are offered by UHA as an addition to covered benefits. HRS help improve overall member and community health and well-being. HRS are flexible services for members and community benefit initiatives for members and the larger community. The UHA HRS program aids in the best use of funds to address social risks factors, like where you live, to improve community well-being. Learn more about health-related services at www.oregon.gov/oha/HPA/dsi-tc/Pages/Health-Related-Services.aspx.
Flexible Services Flexible services are support for items or services to help members become or stay healthy. UHA offers these flexible services: • Food supports, such as grocery delivery, food vouchers, or medically tailored meals. • Short-term housing supports, such as rental deposits to support moving costs, rent support for a short period of time, or utility set-up fees. • Temporary housing or shelter while recovering from hospitalization. • Items that support healthy behaviors, such as gym membership fees, athletic shoes, or clothing. • Mobile phones or devices for accessing telehealth or health apps. • Other items for your home that keep you healthy, such as an air conditioner, heater, or air filter.
How to get health-related services for you or family member
You can work with any provider, Traditional Healthcare Worker, Community Partner, or Case Manger to request these services. You can also call Customer Service at 541-229-4842 and have a request form sent to you in the language or format that fits your needs. This form is also on our website.
Flex requests can be faxed to 541-677-5881, emailed to flexspending@umpquahealth.com or dropped off or mailed to 3031 SE Stephens St. Roseburg, OR 97470, ATTN: Utilization Management – Flexible Spending. Any incomplete forms will not be reviewed. Below are examples of incomplete forms:
• Medical documentation is not attached with request. • Alternative resources have not been pursued first. • Request form does not contain enough information. • Request form is not signed by a provider. • The item/service is a covered benefit through UHA. • The member is not currently eligible on UHA. • If the request is for services being provided by independent vendor/provider, they must include a W9 to make the payment (if one is not already on file).
General flexible spending rules All flex requests must meet one of the following rules: • Improve your health outcomes or help you lower the barriers that may help you get better. • Prevent avoidable hospital readmissions through a comprehensive program for hospital discharge. • Keep you out of the hospital by our help through discharge planning • Improve your safety, reduce medical errors, and lower rates of bad outcomes. • Implement, promote, and increase wellness and health activities. • Create, promote and increase good health through services and items. • Social Determinates of Health and Equity (SDOH-E) (Services and supports to help you when the conditions in which you are born, grow, live, work and age effect your health. Also to help you be treated fairly).
They must also meet all of the following: • Likely improve health outcomes. • Lack billing and encounter codes. • Be health related. • Be consistent with a care/treatment plan. • Likely to be a cost-effective alternative. • Have no other community resources are available.
Decisions to approve or not approve flexible services requests are made on a case-by-case basis. If your flexible service request is not approved, you will get a letter. You can’t appeal a flexible service that was not approved, but you have the right to make a complaint. Learn more about appeals and complaints on pages 88-96
If you have OHP and have trouble getting care, please reach out to the OHA Ombuds Program. The Ombuds are advocates for OHP members and they will do their best to help you. Please email OHA.OmbudsOffice@dhsoha.state.or.us or leave a message at 877-642-0450. Another resource for supports and services in your community is 211 Info. Call 2-1-1 or go to the 211 Info website for help.
Each year, Umpqua Health Alliance supports projects and programs that further our community health improvement plan, or CHP. Examples of these community benefit initiatives are: • Community-based programs that help families access fresh fruits and veggies through farmers' markets. • Trainings on trauma informed practices. • Gardening opportunities for low income housing units. • Lifestyle Nutrition and Education classes. • And more!
For more information on UHA's community benefit initiatives and other community projects, you can visit our website at www.umpquahealth.com/ohp/community-advisory-council/.
What is ILOS? ILOS are services and settings that are sometimes offered as an option for member. These are options for services that are not usually covered by OHP but are needed by the member. ILOS can also be used to receive a service at a place that is not usually covered. They help you navigate the healthcare system and connect with services and resources. UHA currently offers 2 ILOS programs:
• Online Diabetes Self-Management o Online training, support, and help given by health coaches. You can schedule individual or group sessions or get help on your own time. These services aim to help you manage your diabetes and promote healthy habits.
• National Diabetes Prevention Program (National DPP) o A Centers for Disease Control (CDC) recognized online program offered by the National Diabetes Prevention Program (National DPP). Community organizations work together to help prevent or delay type 2 diabetes.
Deciding if an ILOS is right for you is a team effort. We work with your care team to make the best choice. The choice, however, is yours. You do not have to take part in these programs.
If you would like to receive ILOS, please contact UHA Customer Care at 541-229-4842 and tell us your needs. A team of health workers will look to see if there are programs able to help you.
If an ILOS is no longer going to be offered, UHA will let you know by mail at least 30 days before the change happens. Members have a right to file an appeal, or a grievance, for covered services that are fully or partially denied. For more information on appeals and grievances, please see page 88-96.
If you have any questions about any of the benefits or services above, call UHA Customer Care.
Umpqua Health Alliance (UHA) cares about you and your health. UHA and our providers will not stop you from filing a complaint, appeal or hearing. If you tell us your concerns, we will not punish you. We will not take away your coverage (disenrollment) or your provider. Your use of benefits, grievance, appeals, or hearings will not be denied or limited based on your need for another language, format or auxiliary aids. Our team will look into each of your concerns and keep it private. We will try to find a solution. You, your provider, or someone you choose, with your written consent, can also file a grievance (complaint), appeal, or hearing for you. You can ask for a copy of the paperwork used to make the decision at any time, free of charge.
We will provide you with help to complete forms and other steps needed to file a grievance (complaint), appeal, or hearing. This could be: • Help from a qualified community health worker (i.e., peer specialist or personal navigator) or care coordination services. • Interpreter services or auxiliary (added help or support) aids and services. • A letter in a different language or format. • Explaining the grievance (complaint), appeals, and hearings process or providing policies or documents.
Umpqua Health Alliance makes sure all members have access to a grievance system (complaints, appeals and hearings). We try to make it easy for members to file a complaint or appeal and get info on how to file a hearing with the Oregon Health Authority. The table below tells you how to reach us. We have copies of our forms in our administrative offices. You can also get them from our website or ask for them to be sent to you by email or by phone.
Let us know if you need help with any part of the complaint, appeal, and/or hearings process. We can also give you more information about how we handle complaints and appeals. Copies of our notice template are also available. If you need help or would like more information beyond what is in the handbook contact us at:
Call our Customer Care team Write or email Monday – Friday, 8:00AM – 5:00PM Umpqua Health Alliance Phone: 541-229-4842 Attn: Grievance and Appeals Toll free: 866-672-1551 TTY: 541-440-6304 Website: www.umpquahealth.com/ appeals-and-grievances/ 3031 NE Stephens St Roseburg, OR 97470 UHAGrievance@umpquahealth.com
If you are not happy with UHA, your healthcare services, or your provider, you can complain or file a grievance. You have a right to make a complaint if you are not satisfied with any part of your care. You can file a complaint about any matter other than a notice of denial (NOABD) and at any time orally or in writing.
We will try to make things better. Just call contact us at the information above. You may also find a complaint form at www.umpquahealth.com/ appeals-and-grievances/
Examples of reasons you may file a complaint or grievance are: • Problems making appointments or getting a ride • Problems finding a provider near where you live • Not feeling respected or understood by providers, provider staff, drivers or UHA • Care you were not sure about, but got anyway • Bills for services you did not agree to pay • Disputes on UHA extension proposals to make approval decisions • Driver or vehicle safety • Quality of the service you received
A representative or your provider may make (file) a complaint on your behalf, with your written permission to do so.
We will try to get all the facts about the issues. We will ask you to submit any information you have. We will also reach out to others that are a part of the complaint.
We will look into your complaint and let you know what can be done as quickly as your health requires. This will be done within 5 business days from the day we got your complaint.
If we need more time, we will send you a letter within 5 business days. We will tell you why we need more time. We will only ask for more time if it’s in your best interest. All letters will be written in your preferred language. We will send you a letter within 30 days of when we got the complaint explaining how we will address it. We will also try to reach you with the resolution by phone.
If you are unhappy with how we handled your complaint or grievance, you can share that with the Oregon Health Authority’s Client Services Unit at 1-800-273-0557 or please reach out to the OHA Ombuds Program. The Ombuds are advocates for OHP members and they will do their best to help you. Please email OHA.OmbudsOffice@dhsoha.state.or.us or leave a message at 877-642-0450.
UHA, its contractors, subcontractors, and participating providers cannot:
• Stop you from using any part of the grievance system process or take punitive action against a provider who ask for an expedited result or supports your appeal. • Encourage the withdrawal of a grievance, appeal, or hearing already filed; or • Use the filing or result of a grievance, appeal, or hearing as a reason to react against you or to request your disenrollment.
If we deny, stop, or reduce a medical, dental or behavioral health service, we will send you a denial letter that tells you about our decision. This denial letter is also called a Notice of Adverse Benefit Determination (NOABD). We will also let your provider know about our decision. If you disagree with our decision, you have the right to ask us to change it. This is called an appeal because you are appealing our decision.
Follow these steps if you do not agree with our decision
Step 1
Ask for an appeal. You must ask within 60 days of the date of the denial letter (NOABD). You can appeal orally or in writing. Call us at 541-229-4842 or use the Request to Review a Health Care Decision form. The form will be sent with the denial letter. You can also get it at bit.ly/request2review. You can also fax the form to 541-677-5881. If you have questions, you can email use at UHAGrievance@umpquahealth.com. Who can ask for an appeal? You or someone with written permission to speak for you. That could be your doctor or an authorized representative.
Step 2
Wait for our reply. Once we get your request, we will look at the original decision. A new doctor will look at your medical records and the service request to see if we followed the rules correctly. You can give us any more information you think would help us review the decision. How long do you get to review my appeal? We have 16 days to review your request and reply. If we need more time, we will send you a letter. We have up to 14 more days to reply. If we extend the timeframe, we will do our best to let you know orally. We will always send a written notice to let you know why we needed more time. You have a right to file a grievance if you disagree with the extension.
What if I need a faster reply? You can ask for a fast appeal. This is also called an expedited appeal. Call us or fax the request form. The form will be sent with the denial letter. You can also get it at bit.ly/request2review. Ask for a fast appeal if waiting for the regular appeal could put your life, health or ability to function in danger. We will call you and send you a letter, within one business day, to let you know we have received your request for a fast appeal. How long does a fast appeal take? If you get a fast appeal, we will make our decision as quickly as your health requires, no more than 72 hours from when the fast appeal request was received. We will do our best to reach you and your provider by phone to let you know our decision. You will also get a letter. At your request or if we need more time, we may extend the timeframe for up to 14 days. If a fast appeal is denied or more time is needed, we will call you and you will receive written notice within two days. A denied fast appeal request will become a standard appeal and needs to be resolved in 16 days or possibly be extended 14 more days.
Step 3
Read our decision. We will send you a letter with our appeal decision. This appeal decision letter is also called a Notice of Appeal Resolution (NOAR). If you agree with the decision, you do not have to do anything. Still don’t agree or we went beyond the required timeframes to make our decision? Ask for a hearing. It is your right to request a contested case hearing. You can ask the state to review the appeal decision. This is called asking for a hearing. We include a hearing request form when we send you the NOAR. You must ask for a hearing within 120 days of the date of the appeal decision letter (NOAR). What if I need a faster hearing? You can ask for a faster hearing. This is also called an expedited hearing. To ask for a normal hearing or a faster hearing, call the state at 800-273-0557 (TTY 711) or use the request form that will be sent with the denial letter. Get the form at bit.ly/request2review. You can send the form to: OHA Medical Hearings 500 Summer St NE E49 Salem, OR 97301 Fax: 503-945-6035 The state will decide if you can have a fast hearing 2 working days after getting your request. Who can ask for a hearing? You or someone with permission to speak for you. That could be your doctor or an authorized representative. We will need permission in writing. What happens at a hearing? At the hearing, you can tell the Oregon Administrative Law judge why you do not agree with our decision about your appeal. The judge will make the final decision.
What if I don’t get a denial letter? Can I still ask for an appeal? You have to get a denial letter before you can ask for an appeal. If your provider says that you cannot have a service or that you will have to pay for a service, you can ask us for a denial letter (NOABD). Once you have the denial letter, you can ask for an appeal.
What if UHA doesn’t meet the appeal timeline? If we take longer than 30 days to reply, you can ask the state for a review. This is called a hearing. To ask for a hearing, call the state at 800-273-0557 (TTY 711) or use the request form that was sent with the denial letter (NOABD). Get the form at bit.ly/request2review.
Can someone else represent me or help me in a hearing? You have the right to have another person of your choosing represent you in the hearing. This could be anyone, like a friend, family member, lawyer, or your provider. You also have the right to represent yourself if you choose. If you hire a lawyer, you must pay their fees. For advice and possible no-cost representation, call the Public Benefits Hotline at 1-800-520-5292; TTY 711. The hotline is a partnership between Legal Aid of Oregon and the Oregon Law Center. Information about free legal help can also be found at OregonLawHelp.com
Can I still get the benefit or service while I’m waiting for a decision? If you have been getting the benefit or service that was denied and we stopped providing it, you can ask us to continue it. You need to: • Ask for this within 10 days of the date of the denial letter (NOABD) or NOAR by the date this decision is effective, whichever is later. o You can ask for continued benefits in writing or orally by calling UHA Customer Care at 541-229-4842. • Use the Request to Review a Health Care Decision form. The form will be sent with the denial letter. You can also get it at bit.ly/request2review. • Answer “yes” to the question about continuing services on box 8 on page 4 on the Request to Review a Health Care Decision form. Do I have to pay for the continued service? If you choose to still get the denied benefit or service, you may have to pay for it. If we change our decision during the appeal, or if the judge agrees with you at the hearing, you will not have to pay. If we change our decision and you were not receiving the service or benefit, we will approve or provide the service or benefit as quickly as your health requires. We will take no more than 72 hours from the day we get notice that our decision was reversed.
What if I also have Medicare? Do I have more appeal rights? If you have both UHA and Medicare, you may have more appeal rights than those listed above. Call Customer Service at 541-229-482 (TTY 711) for more information. You can also call Medicare at 800-633-4227 to find out more on your appeal rights.
In some cases, if your provider asked UHA to cover a service or supply that was denied, they can ask for a peer- to-peer meeting. This means they can ask to talk to our Medical Director about the denial. If fitting, UHA will schedule a time to talk. You may still file an appeal while your doctor works on this.
There are times when requests for NEMT will be denied. Members have the right to file a grievance or appeal about anything related to their services. UHA follows the same process for NEMT grievances, appeals or reconsiderations with these differences.Before mailing out your NOABD, UHA must provide a second review by another employee when the first reviewer denies the ride. UHA will send out the NOABD within 72 hours of the denial. This letter will go out to you, and the provider or other third party you were scheduled to see.
We strongly urge you to call Customer Care at 541-229-4842 before you agree to pay a provider. • If your provider asks you to pay a copay, do not pay it! Ask the office staff to call UHA. • UHA pays for all covered services in accordance with the Prioritized List of Health Services, see page 35 and page 78. • For a brief list of benefits and services that are covered under your OHP benefits with UHA, who also covers case management and Care Coordination (see pages 71-77). If you have any questions about what is covered, you can ask your PCP or call UHA Customer Care. • No UHA in-network provider or someone working for them can bill a member, send a member’s bill to a collection agency, or maintain a civil action against a member to collect any money owed by UHA for services you are not responsible for. • Members are never charged for rides to covered appointments. See page 130-132. Members may ask to get reimbursements for driving to covered visits or get bus passes to use the bus to go to covered visits. • Protections from being billed usually only apply if the medical provider knew or should have known you had OHP. Also, they only apply to providers who work with OHP (but most providers do). • Sometimes, your provider does not fill out the paperwork correctly. When this happens, they might not get paid. That does not mean you have to pay. If you already got the service and we refuse to pay your provider, your provider still cannot bill you. • You may get a notice from us saying that we will not pay for the service. That notice does not mean you have to pay. The provider will write off the charges. • If UHA or your provider tell you that the service is not covered by OHP, you still have the right to challenge that decision by filing an appeal and asking for a hearing. See pages 88-96. • In the event of UHA closing, you are not responsible to pay for services we cover or provide.
OHP members do not pay bills for covered services. Your healthcare provider can send you a bill only if all of the following are true: 1. The service is something that UHA or OHP plans do not cover. 2. Before you got the service, you signed a valid Agreement to Pay, OHP form number 3165 & 3166 (also called a Waiver). 3. The form showed the estimated cost of the service. 4. The form said that OHP does not cover the service. 5. The form said you agree to pay the bill yourself.
This form usually only applies if the healthcare provider knew or should have known you had OHP. Always show your Umpqua Health Alliance ID card. These protections apply if the provider participates in the OHP program (most providers do). The completed form is only good if: • The estimated fee does not change • The service is planned within 30 days of signing, • The date on the form matches the date of service
Sometimes your provider does not do the paperwork correctly and will not get paid for that reason. That does not mean you have to pay. If you already got the service and we refuse to pay your healthcare provider, your provider still cannot bill you. You may get a notice from us saying that we will not pay for the service. That notice does not mean you have to pay. The provider can write-off the charges.
It is against the rules for provider who accepts OHP to bill a member for: • Missed appointments • Provider mistakes and billing errors • Balance Billing, or Surprise Billing—When a provider bills your insurance and sends you a bill for what is left • Send a member’s bill to a collection agency • Or maintain civil action against a member to collect money owed
If we or your provider tell you that the service is not covered by OHP, you still have the right to ask for an appeal and a hearing.
What Should I Do if I Get a Bill? Even if you do not have to pay, please do not ignore medical bills - call us right away. Many providers send unpaid bills to collection agencies and even sue in court to get paid. It is harder to fix the problem once that happens. As soon as you get a bill for a service that you got while you were on OHP, you should: 1. Call the provider, tell them that you were on OHP, and ask them to bill your CCO/UHA. 2. Call UHA Customer Care right away and say that a provider is billing you for an OHP service. We will help you get the bill cleared up. Do not wait until you get more bills. 3. If needed, you can appeal by sending UHA a letter (with a copy of the bill) saying that you disagree with the bill because you were on OHP at the time of the service. Keep a copy of the letter for your records. 4. Follow up to make sure we paid the bill. 5. If you get court papers, call us right away. You may also call an attorney or the Public Benefits Hotline at 800-520-5292 for legal advice and help. There are laws that can help you when you are wrongly billed while on OHP.
I was in the Hospital and my Plan Paid for That, but Now I am Getting Bills from Other Providers. What can I do? When you go to the hospital or the Emergency Room (ER), you may be treated by a provider who does not work for the hospital. For example, the ER doctors may have their own practice and provide services in the ER. They may send you a separate bill. If you have surgery in a hospital, there will be a separate bill for the hospital, the surgeon, maybe even the lab, the radiologist, and the anesthesiologist. Just because we paid the hospital bill, it does not mean that we paid the other providers. Do not ignore bills from people who treated you in the hospital. If you get other bills, call each provider and ask them to bill your CCO. You should follow steps 1-5 on page 98 for each bill you get.
Steps to take (if possible) to prevent getting a bill from an out of state provider: 1. Make sure you have your UHA member ID card with you when you travel out of state. 2. Present your card as soon as you can and ask if they are willing to bill UHA (Medicaid/OHP). 3. Contact UHA to let us know what happened and ask for advice on what to do. 4. Do not sign any forms until you know the provider is willing to bill UHA (Medicaid/OHP). 5. If at all possible, have UHA staff speak with the provider’s office regarding coverage while you are there.
When Will I Have to Pay for Healthcare Services on OHP? In times of emergency the steps above are not always possible. Being prepared and knowing what steps need to be taken during an emergency can resolve billing issues while at the provider’s office in that state. Taking these steps can avoid the added stress of getting bills for services that UHA will cover, when the provider will not bill UHA.
You may have to pay for services that are covered by OHP if you choose to see a provider that does not take OHP. Before you get medical care or go to a pharmacy, make sure that they are in network or a provider that accepts OHP. The provider's office should tell you up-front if a service or treatment is not covered and how much it costs. To be responsible to pay, you must first sign and date an Agreement to Pay form to say you will pay the bill for the non-covered service or treatment. Tell the provider’s office and your caseworker right away if you have other insurance, such as Medicare or private insurance.
Bring the ID Card for your other insurance to each appointment. Your provider must bill any other insurance before they can bill us for your services. We will only pay the provider after the other insurance has paid, except in some special cases.
You may also have to pay if you were not eligible on UHA or OHP when you received the service. Some hospitals and healthcare providers allow payment plans. Call their office to see what they offer. The phone number should be listed on your bill.
Some people have OHP (Medicaid) and Medicare at the same time. OHP covers some things that Medicare does not. If you have both, Medicare is your main health coverage. OHP can pay for things like medications that Medicare does not cover. If you have both, you are not responsible for: • Co-pays • Deductibles or • Co-insurance charges for Medicare services, those charges are covered by OHP.
You may need to pay a co-pay for some prescription costs.
There are times you may have to pay deductibles, co-insurance or co-pays if you choose to see a provider outside of the network. Contact your local Aging and People with Disabilities (APD) or Area Agency on Aging (AAA) office. They will help you learn more about how to use your benefits. Call the Aging and Disability Resource Connection (ADRC) at 855-673-2372 to get your local APD or AA office phone number.
Call UHA Customer Care to learn more about which benefits are paid for by Medicare and OHP (Medicaid), or to get help finding a provider and how to get services.
Providers will bill your Medicare and UHA. UHA works with Medicare and has an agreement that all claims will be sent so we can pay. • Give the provider your OHP ID number and tell them you’re covered by UHA. If they still say you owe money, Call Customer Care at 541-229-4842. We can help you. • Learn about the few times a provider can send you a bill below.
Members with Medicare can change or leave the CCO they use for physical care at any time. However, members with Medicare must use a CCO for dental and behavioral health care.
Some services need approval before you get the service. This is known as a “prior authorization (PA)” or “preapproval”. Your provider works with UHA to ask for preapproval for a service. If you have any questions about preapproval of a service, contact UHA Customer Care at 541-229-4842. You can also email any questions to priorauthorizations@umpquahealth.com
You might not get the service if it is not approved. We review PA requests as quickly as your health condition requires. Most decisions are made within 14 days. Sometimes a decision may take up to 28 days. This only happens when we are waiting for more information. If you or your provider feel following the standard time frame puts your life, health or ability to function in danger, we can make an “expedited service authorization” decision. Expeditated service decisions are typically made within 72 hrs. but there may be a 14-day extension. (Please see pages 94-96 if you disagree with the extension decision or denial letter).
You do not need approval for emergency or urgent services or for emergency aftercare services. See pages 106-109.
How do I get a prior authorization (PA)? Your provider will submit a PA to us. In-network providers must submit a PA through our provider portal. If the provider is out-of-network, they can fax the request on our PA Form with medical notes to support the need for the service. This form is available on our website at www.umpquahealth.com/prior_authorizations/. The provider can call us if they need help getting one. UHA’s PA/Referral Policies are on our website at www.umpquahealth.com/provider-trainings/. You can also contact UHA Customer Care at 541-229-4842. We can mail you a copy, free of charge, within five business days.
An approved PA is not a guarantee of payment. Payment is based on benefits in effect at the time of service, member eligibility, and medical necessity.
How long does it take to get a PA? UHA follows all state rules when making a decision on requests for services. Some services need to be reviewed quicker than others per the state rules. Below is how long it can take for some services to be authorized. • 24 hours - Prescription Drugs • 2 business days - Substance Use Disorder (SUD) detoxification and residential treatment and skilled nursing facility • 72 hours - Behavioral health inpatient and residential services and fast (expedited) requests (if waiting for the regular appeal could put your life, health, or ability to function in danger) • 14 days – Standard requests for all other services
To get some services, you will need to have a referral from your primary care provider (PCP). A referral is a written order from your provider noting the need for a service.
If your PCP cannot give you services you need, they can refer you to a specialist. If there is not a specialist close to where you live or who works with UHA (also called in-network), they may have to work with the Care Coordination team to find you care out-of-network. There is no extra cost if this happens.
A lot of times your PCP can perform the services you need. If you think you might need a referral to a health care specialist, ask your PCP. You do not need a referral if you are having an emergency and cannot reach your PCP. Some services do not require a referral from your provider. This is called a self-referral. A self-referral means you can look in the provider directory to find the type of provider you would like to see. You can call that provider to set up a visit without a referral from your provider. Learn more about the Provider Directory on page 65.
Whether you can self-refer or need a referral to see a specialist, you may still need preapproval (PA) for the service. Talk with your PCP or contact Customer Service if you have questions about if you need a preapproval to get a service. If you see provider not in our network, and you do not have a PA, you may have to pay for the services.
UHA covers some services without a referral. You can self-refer to in and out-of-network specialists who offer the care below. You can do this by finding a provider in our network, calling them, and setting up an appointment. You do not need a PA.
Below is a list of some services that require a PA. Our full list of requirements is on our PA Grid at www.umpquahealth.com/prior_authorizations/. Below is not a full list of services that need preapproval. If you have questions about preapprovals, please call UHA Customer Service at 541-229-4842.
Direct Access You have “direct access” to providers when you do not need a referral or preapproval for a service. You always have direct access to emergency and urgent services. See the charts below for services that are direct access and do not need a referral or preapproval.
You have a right to get a second opinion for no cost to you about your condition or treatment. Second opinions are free. If you want a second opinion, call UHA Customer Care and tell us you want to see another provider.
If there is not a qualified provider within our network and you want to see a provider outside of our network for your second opinion, contact UHA Customer Care for help. We will have our Care Coordination team help you arrange the second opinion for free.
What is telemedicine/telehealth? Telemedicine or telehealth services are health care services provided to patients using secure electronic communications. UHA members can choose telemedicine, telehealth modalities, or in-person visits. UHA and our contracted providers will comply with HIPAA and the Authority’s Confidentiality and Privacy Rules and security protections in regards to telemedicine communication and related records as per OAR 410-130-0610(7)(a-e) and OAR 410-141-3566. Examples of telehealth are: • Secure email • Patient portals • Online audio/video conferencing • E-visits
Telehealth allows you to get the care you need in a way the fits your needs. It can be used for physical, behavioral, or oral health needs. It also allows you to avoid clinical and public places. Some examples of when it is a good choice to use telehealth are: • Routine health care • Wellness visits • Medication consultation • Eye exams • Mental health counseling
Also, there are some times when telehealth will not work. For example: • Care that requires a hands on physical • When the provider needs to do an in-person exam or test
To schedule a telehealth visit, call your providers office and ask if it is an option. Most health providers have telehealth visits available. UHA allows any telehealth services that can be done virtually on any platform, covered by the Oregon Administrative Rules (OAR). To get these services, you will need to use a device that supports the technology. UHA members still qualify for interpreter services, even with Telehealth. If you would like to know more, please see pages 46-47 for more information.
To use telehealth services, you will need a smartphone, tablet, or computer/laptop with internet access. You will need to supply your own device. UHA does not provide or support these technologies. This service is provided by our contracted providers. If you need technical assistance, please contact your telehealth provider.
Do you need help finding a provider that offers telehealth? Below is a list of community health centers that can provide services that meet your needs. Also, you can look on-line in the Provider Directory at www.umpquahealth.com/ohp/ or you can request that a copy be mailed to you, free of charge, at any time.
• Evergreen Family Medicine: Has telehealth available through video call and phone call. o What services are offered as telehealth? All established patient visits. If a patient feels more at ease, they can schedule their follow-up via telehealth. New patients are required to be seen in-person for first visit.
• Aviva Health: Has telehealth available through video call and phone call. o What services are offered as telehealth? All services available (such as wellness visits, medication refills, behavioral health). New patients are required to be seen in-person for first visit.
• Cow Creek: Has telehealth available for over the phone visits only. o What services are offered as telehealth? Behavioral health therapy, psychiatry, medical nutrition therapy (dietician services in general and Diabetes Prevention Program (DPP), and primary care visits (clinician approved, as needed).
• Umpqua Health Newton Creek: Has telehealth available through video call and phone call. o What services are offered as telehealth? Mental health visits only. Most physical health visits are done in person. It is up to the provider if they will see a member via telehealth. If the visit is for a physical exam (i.e. back pain) it is asked that members be seen in person.
• Adapt Primary Care: Has telehealth available through a website called doxy.me. o What services are offered as telehealth? All services available (such as wellness visits, medication refills, behavioral health). To access this service for free, please go here: doxy.me/sign-in. This may not work in all browsers.
As a CCO, UHA is required to make sure our contracted providers have telehealth services available and do not limit anyone to only allow telehealth visits, except during a declared state of emergency and/or when a facility has implemented its disaster plan. Telehealth services still must meet your needs and be culturally and linguistically appropriate as if you had an in-person visit. Do you need an interpreter or help in another language or format? Tell your provider’s office when you make the telehealth appointment. If you need more help finding a telehealth provider, call UHA Customer Care at 541-229-4842.
Call your provider’s office as soon as you know you can’t make your appointment. This will allow them to reschedule you at that time. Ask your provider’s office about their policy for missed appointments.
After-hours, Weekends, Holidays: If you have an emergency and need help right away, the contact information for the Hospitals and Urgent Care services is listed below. Your PCP also can provide care 24-hours a day, seven days a week. Even if your PCP’s office is closed, call their office number. You can also call UHA's 24-Hour Nurse hotline for help anytime of the day or night. This phone number is 888-516-6166 and they will take after hour calls that are urgent or an emergency. If you made a call that is urgent or emergent, you will receive a call back within 30 minutes. If the information provided does not determine it to be urgent, your call will be returned within 60 minutes to gather more information. You or your representative will get a call back as soon as possible for any urgent or emergent calls. If you do not have an emergency and need to contact UHA when we are closed, you can call us at our regular number and leave a message. We will return your call on the next business day.
Urgent Care: If you can’t reach your PCP’s office about an urgent problem, or they can’t see you soon enough, you can go to the Urgent Care without an appointment. • Evergreen Urgent Care is open Monday through Friday from 7:00 am to 7:00 pm, and Saturday and Sunday from 9:00 am to 5:00 pm. Their phone number is 541-677-7200. Their address is 2570 NW Edenbower Blvd, Roseburg OR 97471. • Umpqua Health Newton Creek is open 7 days a week, 7:00 am to 7:00 pm. Their phone number is 541-229-7038. Their address is 3031 NE Stephens St, Roseburg OR 97470.
Urgent care does not require pre-approval and is covered for in network and out of network within the United States. Urgent problems are things like severe infections, sprains, and strong pain. If you do not know how urgent the problem is, call your PCP.
Dental: Contact your Primary Care Dentist (PCD) for tooth pain. If you do not know who your PCD is, call the Dental Care Group (DCG) listed on your Member ID card. • Advantage Dental customer service is open Monday through Thursday, 8:00 am to 6:00 pm, Friday from 8:00 am to 5:00 pm. They also provide 24 Hour Afterhours Call system. Their phone number is 1-866-268-9631.
Emergency Services: An emergency medical condition means you believe your health will be in serious danger if you do not get help right away. This includes your unborn baby, if you are pregnant. An emergency might be, but is not limited to: • Chest pain • Trouble breathing • Bleeding that will not stop • Broken bones • Mental health emergency
If you believe you have an emergency, call 9-1-1 or go directly to the emergency room (ER). You do not need prior approval to get care in an emergency. You can go to any hospital or ER within the United States. • Mercy Medical Center has a 24-hour emergency room. They are located at 2700 NW Stewart Parkway, Roseburg OR, 97471. Their phone number is 541-673-0611.
Crisis Services: A mental health emergency is the feeling of being out of control, or being in a situation that might harm you or someone else. Get help right away. Do not wait until there is real danger. Call the Crisis Hotline at 1-800-866-9780. They are open 24-hours a day, 7 days a week. You can also call 911, or go to the ER. The Crisis Hotline is ran by Adapt Integrated Health Care. They offer mental health evaluations and interventions, treatment determinations, client protective service investigations, Intensive In-Home Behavioral Health Treatment (IIBHT) for children and have a mobile community crisis response team. Adapt Integrated Health’s mobile crisis team works closely with the Roseburg Police Department. On this team is two qualified mental health professionals. They respond along with police. They are available 7 days a week during high risk times. They respond to calls in, and around the City of Roseburg. The mental health workers will provide acute mental health stabilization and assessment. They also connect people with proper mental health treatment. This helps stop needless trips to the hospital or jail time for people going through a mental health crisis. If you are getting Intensive In-Home Behavioral Health Treatment (IIBHT), there are crisis response services available 24 hours a day.
Important! You do not need a referral or prior approval from UHA or your provider to call the crisis line or to get emergency services. You can use those services at any time you feel you are having an emergency. Ask your PCP, counselor, therapist, or mental health doctor to make a crisis plan for you. This plan will help you avoid crisis and know what to do in a crisis. Do not use the ER for Routine Care. Examples of routine care are: • Colds • Back pain • Constipation • Toothache • Diaper rash
You should not wait until after office hours to contact your PCP or PCD for routine care.
Out-of-Town Emergencies: If you have a real emergency when you are away from home, call 911 or go to the nearest ER. Some examples of emergencies are: • Chest pain • Vomiting blood • Severe burns or cuts • High fevers • Seizures • Numbness in legs, arms, or face
For a helpful diagram with some examples of the difference between emergency, urgent, and routine care is, please see page 139 in this handbook. Your care will be covered until you are stable. For follow-up care after the emergency, call your PCP.
Planned care out-of-state: UHA will help you locate an out of state provider and pay for a covered service when: • You need a service that is not available in Oregon • If the service is cost effective
Traveling Out-of-State: Emergency and urgent care are covered anywhere in the United States. Be aware that even though UHA covers an ER visit in another state, this does not mean that they are willing to bill us. You could get a bill for these services. Do not ignore bills that you may get from your visit.
If you get a bill for out-of-town or out-of-state emergencies, UHA will try to help you resolve the issue. Call UHA Customer Care right away at 541-229-4842 if you receive a bill from out-of-state or out-of-town services. For more information on what to do if you receive a bill, see page 98.
Traveling Out-of-the Country: OHP does not cover any care outside of the US. This means OHP will not pay for any care you get in Mexico or Canada. Shots required for foreign travel are also not covered.
Filling your Prescriptions. You must use a participating network pharmacy when filling your drugs. An in-network pharmacy is a pharmacy that has agreed to work with our members. To check if your pharmacy is in our network, you can use the “Find A Pharmacy” tool on our website, www.umpquahealth.com. Most drugs have a 90-day supply option at a participating network pharmacy, except for specialty medications. Other limitations may apply for specialty medications. For more information about specialty medications and UHA’s Formulary list of covered medications, see pages 110-111).
Do not go to a pharmacy that is not listed in the Provider Directory or to an ER to get your prescriptions filled. UHA may only pay for medications from pharmacies/providers that are enrolled with the Oregon Health Plan (OHP). Many of these pharmacies have extended hours for you to have your prescriptions filled in the evenings or on weekends.
UHA does not pay for medications without a prescription. We also do not cover over-the-counter drugs. Certain medications may require pre-approval for UHA coverage. If you have been prescribed a medication that is one of these or is not on our formulary (see UHA Medication Formulary section), your doctor may submit a request for approval. This does not verify coverage. UHA will notify you, the pharmacy, and doctor if the request has been approved or denied. If the request is denied you may appeal the denial. Or you may choose to pay for this medicine out of pocket. The cost may not be repaid in this case. To get non-formulary drugs or over-the-counter drugs, you will need to pay out of pocket as UHA does not cover these.
For medication delivery, call the pharmacy and ask about delivery. Some pharmacies may deliver to your home. They will let you know what you need to do to set this up.
Mail order. UHA has two mail order pharmacies in-network available to all our members, so that you can get your prescriptions through the mail.
Formulary. UHA has a list of covered drugs called a formulary. Pharmacists and doctors decide which drugs should be in the formulary. You can find the formulary on our website at www.umpquahealth.com/ohp/. It is located in the Member Forms/Notices section. It is called “UHA Formulary”.
The drugs on the formulary can have additional requirements or limits on coverage that include: • The use of generic drugs when available • Prior authorization (pre-approval) • Step therapy (trying other drugs first) • Age restrictions • Quantity limits
Which Medications are not Covered? • Medications not listed in the formulary or drugs removed from the formulary. • Medications that do not have an FDA approved use. • Medications used to treat conditions that are not covered by the Oregon Health Plan (examples are fibromyalgia, allergic rhinitis and acne). • Medications that are not medically necessary. • Medications that are not approved by the FDA. • Medications listed as less than effective by the FDA (DESI drugs). • Experimental or investigational medications. • Medications to help you get pregnant. • Medications used for sexual dysfunction (including impotence). • Medications used for weight loss. • Cosmetic or hair-growth medications. • Some medications you can buy without a prescription (sometimes called over-the-counter medications). • Medications covered by Medicare Part D for dual eligible members. • Fluoride for members over 18 years old.
Mental Health Prescriptions. Most medications that people take for mental illness are paid directly by the Oregon Health Authority (OHA). Please show your pharmacist your Oregon Health ID and your Umpqua Health Alliance medical ID card. The pharmacy will know where to send the bill.
Medication Management. If you need help with filling your medications or having any medication related questions or issues, our Medication Management program may help you. Our UHA Clinical Pharmacy team provides medication management services to help you get the most benefit from your medications as possible. If the pharmacy team or your provider thinks you would benefit from this program, you may be contacted by phone or mail. You may request medication management services if you have a concern with one or more of your medications. To sign up, you may fill out the Medication Management referral form located on the www.umpquahealth.com/pharmacy-services/ webpage or call 541-229-7007
If you have questions or need help getting a medication, please call UHA Customer Care. A copy of the Provider Directory can be requested by calling UHA Customer Care at any time, at no cost to you. We will mail it to you within 5 business days.
UHA has limited vision services. Routine vision exams and glasses are covered for members who are pregnant or younger than 21. Members age 20 and younger can have an eye exam and new glasses (lenses and frames) every 12 months. Pregnant women (21 or older) can have an eye exam and new glasses (lenses and frames) every 24 months. Also, routine vision services are covered for 12 months after your pregnancy ends (postpartum period). For members 21 or older not on the pregnancy tier, you can have an exam once every 24 months
UHA has eye doctors (optometrists and ophthalmologists) available for vision care. Please call UHA Customer Care at 541-229-4842 if you need help finding an eye doctor.
Dental services are part of your benefits. We will assign you to a Dental Care Group (DCG). They will send you information to help you get dental care and tell you who your dentist is going to be
Basic Dental Coverage Includes: • 24-hour emergency care • Crowns: Not covered for non-pregnant adults over 21, some upper and lower front teeth, limited to 4 crowns every 7 years for pregnant adults and those under 21 • Dentures: Full dentures every 10 years, partial dentures every 5 years • Preventative services including cleanings, fluoride, varnish, sealants for children • Root canals on back teeth for children, pregnant women, and adults age 18 to 20 • Routine services (check-ups, fillings, x-rays, and tooth removal) • Specialist care • Orthodontics for handicapping malocclusion and to treat cleft palate in children under 21. It is required to have approval from your dentist and to not have any cavities or gum disease.
Contact Advantage Dental Services, LLC today for help finding a dental provider! • Phone number: 1-866-268-9631 • Website: www.advantagedentalservices.com
How to Get Dental Care You get to choose a Primary Care Dentist (PCD) from your DCG’s network. If you do not choose a PCD, your DCG will assign you to one. Your DCG can help you change PCDs too. Call your PCD during normal business hours to schedule to make a dental appointment for you or your family. Your PCD will take care of most of your dental needs. If you need to see a dental specialist, your PCD will refer you to one. They are available 24 hours a day, seven days a week. PCDs will take care of most of your dental care. If you need to see a specialist, your PCD will refer you. If you need to see your dentist, please try calling during normal business hours. If you call after hours, there will be a message telling you where to call for urgent or emergency services. The on-call Customer Service Representative will call your PCD and arrange a time for them to call you back. The on-call Dentist may be the one returning your call. Even though they are not your PCD, let them guide you in taking care of your needs.
Dental Prevention: Routine dental care is very important to your health. You can get this care from your PCD. This includes regular checkups and cleanings. You can discuss your care with your PCD and schedule the needed appointments for your care. Having dental routine care will help avoid tooth problems in the future.
Care Away from Home: Umpqua Health Alliance and your Dental Care Group (DCG) do not pay for routine or follow-up care if you are outside of the coverage area. If you decide to get routine dental care while you are away from home, you may have to pay the bill.
Your DCG will cover most of your dental services. The table on pages 113-114 will help you with how your dental coverage works. All covered services are provided to you with no charge. These are covered as long as your provider says you need the services. They are only covered if you have them as often as is allowed on the plan. Some items require a pre-authorization (pre-auth) or a referral. Some items, like prescriptions and hospital visits for dental reasons, are covered by your medical plan. Post-Emergency stabilization services are included with Emergency Stabilization.
Benefits UHA (for pregnant women and members under 21) UHA (for all other adults)
EMERGENCY SERVICES
Emergency Stabilization (in or out of the service area) Examples: • Extreme pain or infection • Bleeding or swelling • Injuries to the teeth or gum No limits No limits
PREVENTATIVE SERVICES
Exams *Twice a year *Once a year Cleaning *Twice a year *Once a year Fluoride Treatment *Twice a year *Once a year X-rays *Once a year *Once a year Sealants (Age 15 and Younger) *Under age 16, adult back teeth once every 5 years Not Covered
RESTORATIVE SERVICES
Fillings *As needed *As needed Partial Dentures *Once every 5 years *Once every 5 years Complete Dentures *Once every 10 years *Once every 10 years Crowns *Some upper and Lower Front Teeth. 4 crowns every 7 years Not covered
ORAL SURGERY AND ENDODONTICS
Extractions *As needed *As needed Root Canal Therapy *Not covered on Third Molars (Wisdom Teeth) *Only on Front Teeth and Pre-Molars
Please note that the above services are not covered for everyone. Covered services depends on the dentist’s diagnosis and treatment plan.
Interpreter Services: If you need an interpreter for your dental visit, please contact your DCG’s Customer Care. Interpreter services are available either by phone or in person. They will also be able to provide informational materials in an alternate format if you need it.
If you are Unable to Keep Your Appointment, make sure to call the provider’s office at least one day before your appointment. If you need a ride, please call UHA Customer Care, or call BCB at 877-324-8109.
If you miss three appointments without canceling, your PCD may no longer want to provide care for you or your family members.
Intensive Care Coordination: The Intensive Care Coordination program helps members that are 65 and over or who have Special Health Care Needs. They help you get the dental care you need. If you have special supply needs, or want support services, please call your DCG and ask for an Intensive Care Manager.
What if I Have a Dental Emergency? Emergency care is available 24 hours a day, seven days a week. Prior approval is not required for a dental emergency. Call your PCD, if you are unable to reach your PCD, call your DCG. They can help you find a dentist who will see you. If you are unable to reach your PCD or DCG, call 911 or go to the ER. Tell the ER staff the name of your PCD.
Follow-up care is NOT an emergency. Call your PCD for follow-up care if needed.
How to Tell If You Have a Dental Emergency: An emergency is when a service is needed right away because of an injury or sudden illness. Examples of emergencies are heavy bleeding that does not stop, a tooth that has been knocked out, or an infection that makes it hard to breathe.
Issues like cavities, broken teeth, and typical routine care are not considered emergencies.
We proudly support members getting oral health services in community settings. Dental hygienists with a special permit go to schools, Women Infants Children (WIC), Head Start, Medical offices, long-term care facilities and other community locations to complete assessments. They also do some preventive services while they are there, like fluoride or silver fluoride and help people understand how to take care of their teeth.
In places where we don’t have a hygienist to do this, we work with other organizations. Services you have in the community should be free to you if they are covered on your plan. If you aren’t sure, you can ask the person who is doing the services or you can call UHA Customer Care.
Treatment for alcohol and drug use, including tobacco, are part of the basic benefit plan for all Oregon Health Plan Members. See below for a list of substance use treatment benefits that are available to you at no cost. UHA will coordinate services for free if you need help. If you need help understanding your options for substance use disorder treatment, please call UHA Customer Care at 541-229-4842 and ask for a behavioral health coordinator.
You do not need a referral for outpatient substance use treatment services. If you have questions about preapprovals, please call UHA Customer Care or contact your PCP to find a treatment center that is in-network.
Service Referral or preapproval required CCO Benefit Plan Assertive Community Treatment and Wraparound Services Direct access (Referral or approval is provided by Adapt) CCOA CCOB CCOG Behavioral Health Services Applied Behavioral Analysis PA required for in-network and out-of-network providers CCOA CCOB CCOG Electroconvulsive Therapy (ECT) PA required for in-network and out-of-network providers CCOA CCOB CCOG Intensive In-Home Behavioral Health Treatment (IIBHT) PA required for in-network and out-of-network providers CCOA CCOB CCOG Inpatient Substance Use Disorder Residential and Detox services Requires approval CCOA CCOB Medication Assisted Treatment (MAT) for Substance Use Disorder (SUD) No preapproval required for first 30 days of treatment. May require a referral. CCOA CCOB Neuropsychological Evaluations PA required for in-network and out-of-network providers CCOA CCOB CCOG Transcranial Magnetic Stimulation (TMS) PA required for in-network and out-of-network providers CCOA CCOB CCOG Substance Use Disorder (SUD) services No PA required for in-network, all out-of-network requests require a PA No PA required for first 30 days for out-of-network Medication Assisted Treatment For more information on these services, please see pages 115-117. CCOA CCOB
Above is not a full list of services that need preapproval. If you have questions about preapprovals, please call UHA Customer Care.
MENTAL HEALTH CARE BENEFITS UHA partners with Adapt Integrated Health Care, the Community Mental Health Program for Douglas County to provide community access to mental health care benefits that are available to you at no cost. Adapt provides crisis services, adult mental health services, youth and family mental health services, and mental health support services. UHA will coordinate services for free if you need help. For more information, please contact your PCP or Adapt at (541) 672-2691. You can also check out their website at www.adaptoregon.org.
See below for a list of behavioral health benefits that are available at no cost to you. This is not a full list. If you have questions about what is covered, please contact UHA Customer Care at 541-229-4842.
Service Referral or preapproval required? Assertive Community Treatment and Wraparound Services Direct access (No referral or approval is required) Behavioral Health Assessment and Evaluation Services Direct access (No referral or approval is required) Behavioral Health Psychiatric Residential Treatment Services (PRTS) No PA required for in-network PA required for out-of-network services Outpatient and peer delivered behavioral health services from an in-network provider Direct access (No referral or approval is required) Prescription Medication (Behavioral Health Specific) Please refer to UHA’s Medication Formulary. Please see page 110-111 for more information. Specialist Services For those with special health care needs receiving ICC or LTSS: No referral is required. May need preapproval.
A behavioral health emergency is when you need help right away to feel or be safe. It is when you or other people are in danger. An example is feeling out of control. You might feel like your safety is at risk or have thoughts of hurting yourself or others.
Call 911 or 988 or go to the emergency room if you are in danger.
Behavioral health emergency services do not need a referral or preapproval. UHA offers members crisis help and services after an emergency.
A behavioral health provider can support you in getting services for improving and stabilizing mental health. We will try to help and support you after a crisis.
A behavioral health crisis is when you need help quickly. If not treated, the condition can become an emergency. Please call one of the 24-hour local crisis lines below if you are experiencing any of the following or are unsure if it is a crisis. We want to help and support you in preventing an emergency.
24-hour crisis line: Toll-free: 1-800-866-9780 You can also dial 988 or 911 or go the ER.
Examples of things to look for if you or a family member is having a behavioral health emergency or crisis: • Considering suicide • Hearing voices that are telling you to hurt yourself or another person. • Hurting other people, animals, or property. • Dangerous or very disruptive behaviors at school, work, or with friends or family.
Here are some things available through UHA in our community to support stabilization: • Call the 24-hour 7day a week crisis hotline - 1-800-866-9780 • Mobile crisis team that will come to a member who needs help. • Open Access and walk-in services • Post stabilization services and urgent care services. This care is available 24 hours a day and 7 days a week. o Post Stabilization care services are covered services, related to a medical or behavioral health emergency, that are provided after the emergency is stabilized and to maintain stabilization or resolve the condition. • Crisis response services for members receiving intensive in-home behavioral health treatment 24 hours a day.
SIGNS OF DEPRESSION
What are some of the symptoms of Depression? If you are depressed, you may feel: • Sad • Empty • Anxious • Hopeless • Worthless • Restless • Helpless • Irritable
If I’m depressed, how do I help myself get better? To help yourself feel better: • Spend time with family and friends • Engage in physical activities • Don’t take on everything all at once; break things down into smaller, manageable projects
For more information or if you need help, please do not wait. Call or Text the info below: • Teen Support o oregonyouthline.org/ o Text: teen2teen to 839863 • Suicide Prevention Lifeline o 1-800-273-TALK (8255) o 1-888-628-9454 (Spanish) • 24 Hour Crisis Line
Mental health services are covered to all OHP members. You can get help with depression, anxiety, family problems, and difficult behaviors, to name a few. We cover mental health assessments to find out what kind of help you need. This is to help you with case management, therapy, and care in a psychiatric hospital.
Important: You do not need a referral to get mental health services from a network provider. Please go to our on-line Provider Directory at www.umpquahealth.com/ohp/. Click on “Find A Provider” under the OHP MEMBER drop down menu.
Our mental health providers can help with lots of services. This includes mental health assessments and evaluations, crisis intervention, and outpatient treatment for all ages. Also, they provide services that meet the needs of people who need special services.
Other mental health services that are covered: • Programs that teach you how to live on your own • Services to make sure you are taking your medications right • Services needed in an emergency or that are medically needed • Visits with a psychiatrist or other provide who can prescribe drug for mental illness • Programs that teach you how to get along with other people • Hospital care for a mental illness • Programs that teach you how to get and keep a job • Programs that teach you how to manage your mental condition • Programs that help promote and keep you in good mental health
If you are having a Crisis, please contact our 24 Hour Crisis Line at 800-866-9780.
Adult Mental Health Services: Choice Model Services coordinates care for adults with serious mental illness when they leave the Oregon State Hospital. This program helps discharged members get the community services they need to live. This could be outpatient or residential treatment, adult foster care, or living in a supported apartment. The goal is to avoid going back to the state hospital.
Children’s Mental Health Services: Children with behavioral needs are served through Wraparound or intensive care coordination. Intensive care coordination services meet the child and family’s needs. System of Care and Wraparound planning involves everyone in the child’s life. This includes schools, local programs, doctors, the criminal justice system, and others. This forms a team around the child and family to plan support services.
Tobacco cessation products are covered by UHA. The best thing you can do for your health and your family’s health is to stop using tobacco. If you want to quit smoking or chewing tobacco, please call UHA Customer Care. We have resources to help you quit.
Did you know? • Within 12 hours of quitting, the carbon monoxide levels in your blood return to normal. • 1 Year after you quit, your risk of heart disease is cut in half. • 5 Years after you quit smoking, your risk of having a stroke is the same as a non-smoker.
Adapt has a patient-centered care approach geared towards helping people with their nicotine use. They offer: • Assessment for tobacco use • One on one counseling • Custom treatment plans • Services for youth and adults • Information about stop smoking medications • Mayo Clinic’s quit guide “My Path to a Smoke Free Future” • Relapse prevention and education • Referrals to additional support services when needed
Contact Adapt today to get started on your road to a tobacco free life! • Phone: 541-492-0152 • Online: www.adaptoregon.org • Address: 621 W Madrone St, 2nd Floor Roseburg, OR 97470
Stop Smoking Programs • Oregon Quit Line: • English: 1-800-QUIT-NOW (1-800-784-8669) • Español: 1-855-DEJELO-YA • TTY: 1-877-777-6534 • Online: www.quitnow.net/oregon
Other Sources to Consider to Help Stop Smoking: • Smoke Free: smokefree.gov/ • Teen: teen.smokefree.gov/ • VA: smokefree.gov/tools-tips-vet/smokefreevet
Freedom from Smoking: • Online: www.freedomfromsmoking.org/ • Toll Free: 800-586-4872
Nicotine Anonymous: • Online: nicotine-anonymous.org/
Mercy Medical Center is your primary hospital. It is located at: • 2700 Stewart Parkway Roseburg, OR 97471 • 541-673-0611, TTY 541-677-2143 • chimercyhealth.com/
If you need a service which they are not able to provide, you will be referred to a different hospital.
UHA is also contracted with the following hospitals outside of Douglas County: • Sacred Heart University District Hospital Eugene o 1255 Hillyard St. Eugene, OR 97401 o 541-686-7300 o www.peacehealth.org/hospitals/sacred-heart-university-district
• Sacred Heart Riverbend o 3333 Riverbend Dr. Springfield, OR 97477 o 541-222-7300 o www.peacehealth.org/hospitals/sacred-heart-medical-center-riverbend
If you are unsure if you should use an ambulance, call your PCP. Ambulance services are only covered for emergencies. If you use the ambulance for something that is not a real emergency, you may have to pay the bill. Call 911 for ambulance service.
Emergency care is covered until you are stable. Call your PCP, PCD, or mental health provider for follow-up care. Follow-up care once you are stable is covered but is not an emergency. Please get follow-up care from your PCP or regular doctor.
We offer a program called Care Transitions to help you when you are being discharged from the hospital or a Skilled Nursing Facility (SNF). The Care Transition team can: • Answer any questions you may have about the discharge instructions you were given. • Answer questions about the drugs your doctor gives you. • Provide information about new or ongoing medical problems. • Help arrange your doctor visits. • Help arrange rides to appointments. • Help set up support for you or your family members if needed.
Also, if you need help going home from after you leave a facility, please call UHA Customer Care at 541-229-4842 and we may be able to help. You can reach a member of the Care Transition team at 541-229-7051.
Post-stabilization care is the care you get after an emergency and until your condition is stable. Post-Stabilization Services are available at any hospital and are provided without preauthorization. For more information about our hospitals, please see the Hospital Services section. If you get emergency care at a hospital that is out-of-network and are needing care after your condition is stable: • You must return to an in-network hospital to get your care covered, or • You must get approval in advance to get your care covered. After you get emergency treatment, call your PCP or mental health provider to arrange for more follow-up care if you need it.
Post stabilization and emergency services never require an authorization. Providers of long-term care facilities that wish to request authorization can call 541-229-4842 during normal business hours. The call will be answered by UHA Customer Care. If calling after normal business hours, you can leave a message or speak with UHA’s Nurse Triage line.
If you are pregnant, OHP providers extra services to help keep you and your baby healthy. When you are pregnant, UHA can help you get the care you need. It can also cover your delivery and your care for one year after your pregnancy.
Here’s what you need to do before you deliver: • Tell OHP that you’re pregnant as soon as you know. Call 800-699-9075 (TTY 711) or login to your online account at one.Oregon.gov. • Tell OHP your due date. You do not have to know the exact date right now. If you are ready to deliver, call us right away. • Ask us about your pregnancy benefits. UHA offers New Day and New Beginnings programs for pregnant women and their children. For more information about these programs, please see pages 125-127.
After you deliver: • Call OHP or ask the hospital to send a newborn notification to OHP. • OHP will cover your baby from birth. Your baby will also have UHA.
About New Day: New Day is a service of Umpqua Health Alliance for moms in Douglas County on the Oregon Health Plan. We help pregnant women struggling with substance abuse or other challenges. We work together with you, your OB doctor, and other community providers and agencies to offer support and resources.
The New Day staff can help with: • Evaluating your needs • Emotional support • Counseling • Buprenorphine Medication Assisted Therapy (MAT) • Methadone/Suboxone plan • Drug treatment options • Stop smoking • Making and keeping your appointments • Finding resources
Are you Pregnant and Unsure What to do Next? Most importantly, see a doctor. You can: • Call your OB/Gyn to make an appointment • Call your PCP and get a referral • Call UHA Customer Care at 541-229-4842 and ask for help. • Ask your counselor, case manager, or any community partner for help • Call New Day to make a self-referral.
Arrangements can also be made for a meeting place in the community. • Visit us on the web at www.umpquahealth.com/new-day/ • Phone: 541-229-704 • Fax Line: 541-459-5741
Substance Use During Pregnancy: Lots of things can cause problems for babies before and after they are born. Sometimes those problems last a lifetime. Smoking, alcohol, substance abuse, marijuana, unsafe housing, poor nutrition, domestic violence, and stress are harmful to pregnant women and their children. The New Day program can help you deal with these things. Even small changes can make a BIG difference. We can help.
If you are currently using opiates like heroin or pain pills, or in a methadone or Suboxone program, we can work with a doctor who specializes in MAT to help you get through your pregnancy safely. You want a healthy baby and we want to help get you there.
Our Staff: The New Day program is led by Mandy Rigsby, BA, NCAC II, CADC II, CGAC I Behavioral Support in Pregnancy.
Referrals To make a referral to New Day, contact your provider and request they send it to Mandy Rigsby. Referrals can also be sent by phone, email or fax. • Office: 541-229-7049 • Email: mrigsby@umpquahealth.com • Referral Fax: 541-229-8180
About New Beginnings: New Beginnings is a program offered by Umpqua Health Alliance for Oregon Health Plan members in Douglas County. We focus on children birth to age five. We work with the child, family, care providers, and community partners to offer support and resources. The New Beginnings staff create and strengthen partnerships so you can use community resources. This includes: • Counseling • Primary care physicians • Family development centers • Child Advocates • Abuse prevention services • Early Intervention Specialists • Schools and childcare services • Hospitals • Housing and food assistance programs • Women, Infants and Children (WIC) • Dentists • Transportation needs
The Early Years: The first few years of a child’s life are important for the physical and social development of that child. Children in poverty or who lack stable housing and healthy foods can have a hard time coping.
Every parent wants what is best for their child, and that’s where New Beginnings can help. Together, through coordinated care, each child’s unique needs will be identified and addressed. New Beginnings will also help parents create a solid foundation for Douglas County children to grow and thrive.
Do you have a young child? Most importantly, go to well child visits. You can also: • Call your child’s doctor to make an appointment • Call UHA Customer Care at 541-229-4842 • Ask your counselor, case manager or any community partner for help • Call New Beginnings
Referrals To make a referral to New Beginnings program, please contact New Beginnings staff at one of the following: • Office: (541) 673-1462 • Email: CaseManagement@umpquahealth.com • Fax: (541) 229-8180
Copy of Your Records: You can have a copy of your medical records. Your doctor’s office has most of your records, so you can ask them for a copy. They may charge a reasonable fee for copies. You can ask us for a copy of the records we have. We may charge you a reasonable fee for the copies. You can have a copy of your mental health records unless your provider thinks this could cause serious problems.
Right to Change Your Records: If you believe that medical information is missing from your records or is not accurate, you may ask your provider to make changes. To make changes to your records, you will need to send your provider a letter telling them what you would like to have changed and why you want the change.
They may deny your request to change your records due to the following reasons: • They believe that the information is accurate and/or complete. • You haven’t given them your request in writing. • The information was not created by your provider. If your provider does not make the change, you have the right to appeal this decision. Please contact UHA Customer Care to start that appeal.
Physician Incentives: We pay a bonus or reward our providers for keeping you healthy. We do not pay or reward our providers for limiting services and referrals. We will send you more information about provider payments upon your request. We will mail it out to you, free of charge, within 5 business days.
Involvement in CCO Activities: Umpqua Health Alliance has a Community Advisory Council (CAC). We invite you to apply to serve on the Council. Most of the Council includes members that are Oregon Health Plan Members. Other members are from government agencies and groups that provide OHP services. If you are interested in being a member of the CAC, please call UHA Customer Care at 541-229-4842. You can ask for an application.
Structure and Operation: At your request, UHA will provide information on the structure and operation of UHA’s organization. We will mail it out to you, free of charge, within 5 business days.
Disease Management & Prevention Programs: UHA providers have access to health education programs, including self-care, prevention, and disease self-management materials, in easy-to-read formats and in Spanish. You can always ask your provider to print these materials for you, to help you be more involved in your health care and give ideas on things you can do that will make you healthier. More prevention ideas and resources are listed on our website and in our Member Newsletter at: www.umpquahealth.com/ohp/.
Fraud and Abuse: Misuse of UHA and/or OHP costs all of us. The following actions are forms of misuse: • A person makes false statements regarding resources or income to eligibility workers. • A provider bills Medicaid for services that the recipient never got. • A person uses doctors or hospitals for social purposes rather than for needed health care. • A person manipulates the program to acquire drugs or supplies for ineligible persons, or for personal gain. • A person abuses narcotics purchased through the program.
If you believe there is fraud or abuse happening, please contact UHA Customer Care, or UHA’s Appeals and Grievances team (their contact information is located on page 2, page 89, page 134, and page 138 of this handbook).
Third Party Recovery: If you have been in an accident (Motor Vehicle or Workman's Comp) please go to www.umpquahealth.com/third-party-recovery/ and fill out the Accident/Injury/Information form.
Other Insurance: If you get or lose other health insurance, call OHP Customer Service at 1-800-699-9075, TTY 711 and tell them. You can also let UHA Customer Care know. They can be reached at 541-229-4842 or TPR@umpquahealth.com. You are also required to help find any other insurance to which you are entitled. Be sure to bring the ID Card for all of your insurances to each appointment with you. Your provider must bill any other insurance first. We will only pay the bill after all other insurances have paid, except in some special cases. If you get payments as a result of an accident or an injury, you must return the amount of benefits you got to UHA.
Guidebook & Policies: For more information or to request a copy of our policies and/or procedures regarding Third Party Liability and Recovery claims, please call Customer Care or email TPR and request a copy of our guidebook.
Hardship Waivers: Any person getting money or valuables after a UHA member dies may ask OHA to waive Estate Recovery. The person must meet the requirements of a hardship waiver. There are important deadlines for hardship waivers. Please contact the Estate Administration Unit right away
To learn more about Estate Recoveries: • Read the Estate Recovery Program brochure (MSC 9093) at apps.state.or.us/Forms/Served/me9093.pdf. • Also see Oregon Administration Rules 461-135-0832 to 461-135-0847.
If you still have questions, contact: • DHS Estate Administration Unit PO BOX 14021, Salem, OR 97301 • 1-800-826-5675 (toll-free inside Oregon) • 503-378-2884 / TTY: 711 • Fax: 503-78-3137
Scheduling a ride: You or your representative can call Bay Cities Brokerage (BCB) at 877-324-8109 to schedule your ride. Their call center is open Monday through Friday, from 8 am—5 pm. If calling after hours, there is a 24-hour hotline available.
You can also go on their website: http://bca-ride.com.
Medical trips are covered and provided 24 hours a day, 365 days a year. In accordance with OAR 410-141-3920: • Same day for Non-Emergent Medical Transportation (NEMT) Services, • Up to 90 days in advance, • Multiple NEMT services at one time for multiple appointments up to 90 days in advance. • After hours, weekends, or holidays may be more difficult to arrange. If you have an appointment during that time, please make sure to call BCB ahead of time. They will need to arrange a ride for you.
When to be Ready: It’s very important to make sure you are ready for your appointment. When you schedule your ride, the representative will give you the time when your driver will arrive. The transportation driver may arrive 15 minutes before, or 15 minutes after your scheduled pick-up time. Please make sure to give yourself enough time when scheduling to allow for this extra time. If your driver does not arrive in that timeframe, please call BCB right away.
Your driver will make sure you get to your appointment at your pre-arranged time and will pick you up at the pre-arranged time for the return leg of your trip. For return trips with no pre-arranged pick-up time, please call the driver to let them know you’re ready to be picked up. They will meet you within one (1) hour. If they do not pick you up in that timeframe, please call BCB right away.
If you miss your scheduled ride, you MUST call BCB at 877-324-8109. Do NOT call the transportation driver to reschedule.
If you are not ready when the driver arrives, they will wait 15 minutes. After 15 minutes, the driver may go to their next scheduled pickup and you will need to reschedule with BCB.
If your driver arrives before your scheduled pickup, you do not have to leave early. The 15 minutes will start at the scheduled pickup time.
BCB will drop you off for your appointment at least 15 minutes before it starts
First appointment of the day: BCB will drop you off no more than 15 minutes before the office opens. Last appointment of the day: BCB will pick you up no later than 15 minutes after the office closes, unless the appointment is not expected to end within 15 minutes after closing. Asking for more time: You must ask to be picked up earlier or dropped off later than these times. Your representative, parent, or guardian can also ask BCB. Call if you don’t have a pickup time: If there is no scheduled pickup time for your return trip, call BCB when you are ready. Your driver will be there within 1 hour after your call.
BCB Contact Information: Toll-Free Phone: 877-324-8109 TTY: 711 Website: http://bca-ride.com
Mailing address: Bay Cities Brokerage 3505 Ocean Blvd SE Coos Bay, OR 97420
Local Address: Umpqua Valley Ambulance 1290 NE Cedar St Roseburg, OR 97470
Riders Guide: The Riders Guide and BCB policies and procedures are available on their website or you can request a copy be sent to you by calling Customer Care at 541-229-4842 or contact BCB at 877-324-8109. The Rider’s Guide is available on our website at: www.umpquahealth.com/ohp/ • You can find it by scrolling down under Member Forms/Notices
Mileage reimbursement: You can contact BCB to request a copy of Rider’s Guide and get reimbursement forms. The reimbursement amounts are as follows: • Mileage: $0.25/mile. • Meal Reimbursements - Travel must be a minimum of (4) four hours outside of your local area. Members do not need to submit receipts for meals. o Breakfast: $3.00 - Travel must begin before 6:00 am. o Lunch: $3.50 - You must be gone the entire period from 11:30 am to 1:30 pm. o Dinner: $5.50 - Travel ends after 6:00 pm. • Lodging reimbursement is available if the travel begins before 5:00 am in order to reach a scheduled appointment or if travel from a scheduled appointment would end after 9:00 pm. Lodging is not reimbursed if the trip can be completed in one day or for multiple appointments on different days when they can be scheduled the same day. o Lodging Amount: $40.00 per night.
Passenger Rights and Responsibilities When you use NEMT services, you have the right to: • Get the transportation you need. • Request interpreter services if needed (during the ride or when scheduling). • Request written materials about NEMT in a language or format that meets your needs. • Report concerns or complaints to UHA. See pages 88-92 for more information on how to file a complaint. • Ask for an appeal, ask for a hearing, or ask if both if you feel you have been denied a ride service unfairly. See pages 91-96 for more information.
Also, when you are using NEMT services, you are responsible to: • Treat the driver and other passengers with respect. • Call to schedule, make a change, or cancel your ride as soon you possibly can. • Follow the laws and wear your seatbelt. • Ask for additional stops, like the pharmacy, in advance.
OHP members have many rights, please see pages 57-61 for more information on member rights.
Someday you may get so sick or injured that you can’t tell your providers if you want certain care or not. Adults ages 18 years and older can make decisions about their own care, including refusing care. If you don’t want certain kinds of care, like a breathing machine or feeding tube, you can write that down in an Advance Directive (also called a Living Will). It lets you decide what care you want before you need it. This is in case you are unable to tell them yourself (such as if you are in a coma). If you are awake and alert your providers will always listen to what you want.
An Advance Directive allows you to choose a person to make your health care decisions if you could not make them for yourself. This person is called your health care representative and they must agree to act in this role.
If you have written an Advance Directive your providers may follow your wishes. Some providers may not follow them. Ask your providers if they will follow yours. If you don’t have an Advance Directive, they may ask your family what to do. If your family can’t or will not decide, your providers will take the usual steps in caring for you.
You can get an Advance Directive form at https://www.oregon.gov/oha/ph/about/pages/adac-forms.aspx. Most hospitals and providers have them as well. You can also contact UHA Customer Care at 541-229-4842 for a copy of the Advanced Directive at no cost to you. If you write one, be sure to talk to your PCP, Mental Health Provider, and your family about it. You also should give them copies. They can only follow your plans if they have them. Some providers and hospitals will not follow them for religious or moral reasons. You should ask them about this.
If you change your mind, you can cancel your Advance Directive anytime. To cancel it, ask for the copies back and tear them up. You can also write CANCELLED in large letters, sign, and date them.
You will not be treated differently for not having an Advance Directive. UHA does not limit the use of them. For questions or more information contact Oregon Health Decisions at 800-422-4805 or 503-692-0894, TTY 711.
If your provider does not follow your wishes in your Advance Directive, you can complain. You can file a grievance through UHA. Please see the Grievance section of this handbook on pages 88-92. If you think UHA did not follow Advance Directive requirements (meaning UHA or subcontractors did not inform you about your rights regarding an Advance Directive), you can file a complaint with OHP.
You can do this by calling their Customer Service at 800-699-9075. You can also file through the Health Care Regulation and Quality Improvement office. You can get a complaint form here: www.oregon.gov/oha/PH/PROVIDERPARTNERRESOURCES/HEALTHCAREPROVIDERSFACILITIES/HEALTHCAREHEALTHCAREREGULATIONQUALITYIMPROVEMENT/Documents/ALLFACILITIESComplaintIntakeForm.pdf
You can send your complaint form to: • Health Licensing Office • 503-370-9216 (TTY users, please call 711) • Hours: Monday through Friday, 8 a.m. to 5 p.m. PT • Mail a complaint to: • 1430 Tandem Ave NE, Suite 180 • Salem, OR 97301 • Email: hlo.info@odhsoha.oregon.gov
OR
• Umpqua Health Alliance • Attn: Grievance and Appeals • 3031 NE Stephens St • Roseburg, OR 97470 • Email: UHAGrievance@umpquahealth.com • Fax: 541-677-6038 • Phone: 541-229-4842 • Toll-Free: 1-866-672-1551, TTY 711
UHA follows the State and Federal laws regarding advance directives. Oregon law allows UHA or any provider to object to following it as a matter of conscience. Also, we are not required to provide any care the conflicts with the Advanced Directive.
We are required to update this handbook within 90 days from the date of any change in state law that affects the information in this handbook about Advance Directives. If you would like a copy of our Advance Directives Policy or Advance Directive form, please call UHA Customer Care at 541-229-4842. We will mail you a copy free of charge.
If you need more information regarding UHA’s policies and procedures about Advanced Directives, go online: https://www.umpquahealth.com/?wpdmdl=11874%27%3EAdvance%20Directives/Declaration%20of%20Mental%20Health%20Treatment%3C/a%3E
A POLST is a medical form that you can use to make sure your wishes for treatment near the end of life are followed by medical providers. You are never required to fill out a POLST, but if you have serious illnesses or other reasons why you would not want all types of medical treatment, you can learn more about this form. The POLST is different from an Advance Directive:
Advance Directive POLST What is it? Legal document Medical order Who can get it? For all adults over the age of 18 Anyone of any age with a serious illness Does my provider need to approve/sign? Does not require provider approval Needs to be signed and approved by healthcare provider When is it used? Future care or condition Current care and condition
To learn more, visit: oregonpolst.org Email: polst@ohsue.edu or call Oregon POLST at 503-494-3965
Do you need help creating an Advance Care Plan? Iris is our partner for providing Advance Care Planning. They provide help to members dealing with serious illness. Their health experts help members talk to their loved ones or care givers to create a plan for member’s care. This service is offered by phone or video.
The Iris Premier program is a free Advance Care Planning service. Members will meet with a licensed health care expert by phone or video. These trained experts meet with each member and their loved ones. They help members in making a care plan that is specific to each member’s needs. They help by listening to member’s needs and providing advice. The plans that are created are given to the member’s provider and care teams for future use. Members can receive two years of support through this program.
Iris Empower is a free Advance Care planning tool for people in Douglas County. Empower is a way to make care plans online. It helps users with: • Making healthcare choices • Making advance directives • Sharing plans with family members • Sharing plans with care teams
If you would like to make an advance care plan: • Follow the link on UHA’s website: www.umpquahealth.com/advanced-care-planning-empower/ • Contact UHA Customer Care
If you would like to contact Iris Health Care: • Phone: 512-895-9544 or • (Toll-Free) 1-800-845-2081 • Email: getinfo@irishealthcare.com • Online: www.irishealthcare.com
Oregon has a form for writing down your wishes for mental health care. This form is for if you have a mental health crisis, or if you can’t make decisions about your mental health care. It is called the Declaration for Mental Health Treatment. You should complete it while you can understand and make decisions about your care. This form tells your providers what kind of care you want if you are not able tell them. Only a court or two doctors can decide if you are not able to make decisions about your mental health care.
This form allows you to make choices about the kinds of care you want. It can be used to name an adult to make decisions about your care. The person you name must agree to speak for you and follow your wishes. If your wishes are not in writing, this person will decide what you would want.
This form is only good for three years. If you are not able to make decisions in those three years, it will be in place until you can again. You may change or cancel the form when you can understand and make choices about your care. You must give your form to your PCP or Mental Health Provider and the person you name to make decisions for you.
For more information on the Declaration for Mental Health Treatment, call UHA Customer Care at 541-229-4842. You can also go to the State of Oregon website at: aix-xweb1p.state.or.us/es_xweb/DHSforms/Served/le9550.pdf.
If you don't think we followed regulation about sharing information with you on Declaration for Mental Health Treatment, you can complain. You can file a grievance through UHA. Please see Grievance section of this handbook on pages 88-92. You can file a complaint with OHP by calling their Customer Service at 1-800-699-9075. You can also file through the Health Care Regulation and Quality Improvement office.
To find the complaint form for the Quality Improvement office, please follow this link: www.oregon.gov/oha/PH/PROVIDERPARTNERRESOURCES/HEALTHCAREPROVIDERSFACILITIES/HEALTHCAREHEALTHCAREREGULATIONQUALITYIMPROVEMENT/Documents/ALLFACILITIESComplaintIntakeForm.pdf
You can send your complaint form to: • Mark clearly on the envelope *CONFIDENTIAL* and send to Health Facility Licensing and Certification Program 800 NE Oregon Suite 465 Portland, OR 97232 • Email: mailbox.hclc@odhsoha.oregon.gov • Fax: 971-673-0556 • Phone: 971-673-0540; TTY: 971-673-0372
OR
• Umpqua Health Alliance Attn: Grievance and Appeals 3031 NE Stephens St Roseburg, OR 97470 • Email: UHAGrievance@umpquahealth.com • Fax: 541-677-6038 • Phone: 541-229-4842 • Toll-Free: 1-866-672-1551, TTY 711
This service is for current Umpqua Health Alliance members only. This is not for emergencies. If you have an emergency, call 911.
What is the Nurse Advice Line? It’s a benefit that UHA provides for our members. They can speak with trained nurses at any time. These nurses are here for you to speak with about symptoms you may be having. They will help you with your next steps in care. This service is available any time of day or night, 7 days a week.
What do they do? Tell the nurse your problem or concerns. They will quickly help you decide on the best care.
What information do I need before I call? • Caller’s Name • Patient’s Name • Patient’s Date of Birth • Patient’s Gender • Callers Relationship to Patient • Return Phone Number • Member ID Number
GO TO THE EMERGENCY ROOM OR CALL 911
Emergency rooms should be used for very serious or life-threatening problems, when you need medical care now and cannot wait. Examples include, but are not limited to: • Chest pain • Vomiting blood • Severe burns and cuts • High fevers • Seizures • Numbness in leg, arm, or face • Thoughts of hurting yourself or others
GO TO URGENT CARE
Urgent care clinics should be used for common illnesses and minor injuries. This is for when you need care today but cannot get in to see your PCP. Check with your PCP first to see if they can see you. Examples include, but are not limited to: • Flu-like symptoms • Earaches • Sprains and minor broken bones • Minor cuts or burns • Back and body pain • Migraines
CALL OR SEE YOUR PRIMARY CARE PROVIDER
For most of your health problems, you should schedule an appointment with your Primary Care Provider (PCP). They know your health history and can care for most medical needs. Examples include, but are not limited to: • Medication refills • Regular physicals • Vaccinations • Medical screenings • Advice on a new or worsening health problem
• Evergreen Family Medicine 2570 NW Edenbower Blvd. o Monday - Friday 7AM - 7PM o Saturday- Sunday 9AM - 5PM o (541) 957-1111 • Umpqua Health Newton Creek 3031 NE Stephens St. o Daily 7AM - 7PM o (541) 229-7038 • Adapt: Douglas County Open Access to Mental Health Services o 24 hour crisis line: 800- 866-9780 o Youth & Family: Mon-Thur, 9 am-3 pm, except major holidays, 541- 229-8934 o Adults: Mon- Fri, Same day walk in access to mental health care, 541-440-3532
The right care, at the right place, at the right time.