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Healthcare Coordination
Care coordination
Care coordination nurses work directly with facilities and providers. They facilitate preauthorization of scheduled procedures, inpatient stays and follow up care, and follow members during urgent emergent admissions. During the episode of care they may refer a member to a case management nurse if the member requires additional follow up and coordination of complex or catastrophic conditions.
Inpatient admission
Preauthorization is required for all non-emergent inpatient admissions, including acute care hospitals, inpatient rehabilitation and skilled nursing facilities. If the member is experiencing a serious illness or injury and requires post-hospital follow-up such as home-health or outpatient therapy, ODS care coordination nurses will work with the facility to coordinate discharge needs.
To obtain the required preauthorization, contact us by calling 503-243-4496 or toll free 800-258-2037 or fax a request to 503-243-5105 using the preauthorization form.Urgent/Emergent Admissions
"Emergency Medical Condition" means a medical condition that manifests itself by acute symptoms of sufficient severity, including severe pain, that a prudent lay person possessing an average knowledge of health and medicine would reasonably expect that failure to receive immediate medical attention would place the health of a person, or a fetus in the case of a pregnant woman, in serious jeopardy.
The hospital calls ODS to notify of all urgent/emergent hospital admission within 48 hours or as soon as reasonably possible.Outpatient services
Preauthorization is required for certain outpatient services. The Referral and Authorization Guidelines is a list of services that require preauthorization and may require a review for medical necessity. Please review the guidelines or obtain the required preauthorization by calling Medical Intake at 503-243-4496, or toll free at 800-258-2037. You may also fax a request to 503-243-5105 using the preauthorization form.
Authorization requirements for outpatient behavioral health services vary by plan. For further information, call ODS Behavioral Health at 503-624-9382 or 1-800-799-9391.
Case management
Case management is a voluntary service for members who are experiencing complex conditions or catastrophic events and need the assistance of a case management RN or behavioral health specialist. Case managers can help by working with members and their families as patient advocates to:
- Explain and maximize available benefits
- Communicate with providers
- Ensure discharge plans are in place following an admission
- Contact patients at home to ensure that their medical needs are being addressed
- Connect members with community resources as needed
To make a referral to case management, please call ODS Healthcare Services case management at 503-948-5561 or toll free at 800-592-8283], or fill out the referral form and fax it to 503-243-5105. A member can self-refer to case management or be referred by a family member, provider or facility staff. To make a referral, please provide the following information:
- Member name and ID number
- Contact name and number
- Reason for the referral
Once a referral is received, a case manager will evaluate the member’s situation and contact the member within five business days.