Health Share of Oregon is the OHP coordinated care organization for Clackamas, Multnomah and Washington counties. Its specialty behavioral health benefit, ABA included, is administered by CareOregon: CareOregon’s Behavioral Health Utilization Management Procedure Handbook (July 2026) covers "members of Health Share of Oregon," and its Metro Area provider manual governs claims for Health Share behavioral health services.
Health Share’s partner site points behavioral health providers to CareOregon’s guidelines, which "provide guidance for serving CareOregon/Health Share members." CareOregon’s Metro Area Behavioral Health Provider Manual (April 2026) lists Applied Behavioral Analysis among services that require a prior authorization from CareOregon, and since October 1, 2025 non-contracted providers also need one to start or continue ABA. Authorizations, eligibility and claims for Health Share behavioral health run through CareOregon Connect.[4][3][2]
CareOregon uses its practice guidelines with Guideline Note 75. ABA requires a diagnosis of ASD or Stereotypic Movement Disorder "by an MD, DO, PhD, or PsyD" using the ADOS, the CARS-2, or "An educational diagnosis conducted by an MD, DO, PhD, or PsyD"; other diagnoses need secondary review. "Authorization requests for members age 13 or older, or requests exceeding 25 treatment hours of service per week, require secondary review by a CareOregon Medical Director." Assessment requests carry the diagnosis and tool. Treatment requests must include a comprehensive plan: measurable goals with baseline data and dates, graphs, medical concerns, family and custody information, language and interpreter needs, barriers to treatment, the diagnosing clinician’s credentials and date of diagnosis, school and Early Intervention services, at least two measurable caregiver goals, prior ABA providers, all assessment data, and units for the full six-month authorization by CPT code. CareOregon decides standard requests within 7 calendar days and expedited ones within 72 hours. BH UM: 503-416-3404.[2]
CareOregon requires valid behavioral health claims "within 120 calendar days of the date of service," with exceptions for retroactive eligibility and when Medicare or another third party is primary. Medicaid is the payer of last resort: providers "must bill all other insurance resources before billing Medicaid." The OHP rates and licensure rules in the Oregon Health Plan guide apply; Health Share and CareOregon contract their own rates.[1][3][1]
OAR 410-141-3565 adds two rules every CCO must follow: a timely claim that needs correction or resubmission gets "a minimum of 180 days after the initial adjudication date," and the CCO "shall pay or deny at least 90 percent of valid claims within 30 days of receipt and at least 99 percent of valid claims within 90 days of receipt." No weekly payment cycle or submission cutoff is published.[1][3][1]
The questions that decide whether a family can start with Health Share of Oregon, and what they have to bring. Each maps onto something intake should ask on the first call.
No age cap, but requests for members 13 or older require CareOregon Medical Director review. OHP rules require ABA beyond Guideline Note 75 when medically appropriate "including individuals age 13 and older," and under 21 EPSDT bars age-group-wide denials.[2][7][15]
No recency rule; the treatment plan must give the diagnosing clinician’s credentials and the date of diagnosis for every listed diagnosis. The OHP rule dates only the physical exam and hearing test (OAR 410-172-0770).[2][7]
An MD, DO, PhD or PsyD.[2]
ADOS or CARS-2 (or an educational diagnosis by an MD, DO, PhD or PsyD).[2]
CareOregon’s handbook adds no referral rule of its own, so the OHP rule applies. Yes. Before services, OAR 410-172-0770(1)(k) requires "A referral for ABA treatment with or without specification of hours or intensity" that includes the diagnosis and a copy of the evaluation, from a physician, psychologist, or nurse practitioner or physician associate specializing in developmental medicine who has experience diagnosing and treating autism (OAR 410-172-0760(1)).[2][7][6]
CareOregon’s ABA guidance publishes no telehealth rule of its own. The state rule applies: "For purposes of behavioral health services, the Authority shall provide coverage for telemedicine services to the same extent that the services would be covered if they were provided in person" (OAR 410-172-0850(5)), using synchronous two-way video (telephone and e-mail only where HERC guidelines allow). OHA’s behavioral health fee schedule lists modifier GT ("Via Interactive Simultaneous Audio and Video Telecommunication Systems") as an allowable modifier on every ABA code it prices, 97151 through 97157, including the 97151 assessment and 97155 protocol modification.[2][9][10]
Coverage decides whether Health Share of Oregon pays. These decide whether the claim survives: how sessions must be staffed and supervised, what may be billed concurrently, the per-day ceilings, who signs the note, where the service is payable, and whose NPI the claim goes out under.
CareOregon’s handbook and manual publish no ABA supervision ratio of their own, so the state rule applies. OHA does not pay assistant behavior analysts or registered behavior analysis interventionists directly (OAR 410-172-0760(4)); they work under a directly payable Licensed Behavior Analyst, licensed health care professional or declarant. The licensing rule sets the interventionist supervision floor: direct and indirect supervision "for at least 5 percent of the interventionist’s service hours," including direct supervision at least once per calendar month, by a licensed behavior analyst, licensed assistant behavior analyst or licensed health care professional (OAR 824-040-0010). Direct supervision may be remote if it is synchronous audio and video (OAR 824-010-0005).[2][6][13][17]
No numeric cap, but requests "exceeding 25 treatment hours of service per week" require CareOregon Medical Director review, and units are requested for the whole six-month authorization by CPT code.[2]
CareOregon publishes no ABA rendering-provider rule. The OHP rule applies: only a Licensed Behavior Analyst, licensed health care professional or declarant is eligible for direct payment; assistant behavior analysts and interventionists are not (OAR 410-172-0760(3)–(4)).[2][6]
CareOregon says documentation standards for its provider types are "available upon request" from cqssupport@careoregon.org. The OHP floor is OAR 410-172-0620(4): each service note "signed or initialed by the individual providing the service."[3][8]
Blocked on: E-mail cqssupport@careoregon.org for CareOregon’s documentation standards for ABA providers.
Not addressed in CareOregon’s BH UM handbook or Metro BH provider manual; OHA publishes no rule either.[2][3]
Ask the plan: CareOregon Provider Customer Service, 800-224-4840 (option 3), or your CareOregon provider agreement.
Not addressed in CareOregon’s ABA guidance; the treatment plan must list school and Early Intervention services, but no setting rule is stated.[2]
Ask the plan: CareOregon BH UM, 503-416-3404: ask which settings and place-of-service codes it pays for ABA.
CareOregon’s behavioral health utilization management team, through CareOregon Connect or fax (BH UM 503-416-3404).
Yes. Submit the diagnosis and the ADOS or CARS-2 results; for Health Share members the request may list "TBD Behavioral Health Provider" as the rendering provider.
When the member is 13 or older, when more than 25 hours a week are requested, or when the diagnosis is something other than ASD or Stereotypic Movement Disorder.
120 calendar days from the date of service, with exceptions for retroactive eligibility and when another payer is primary.
Payer policies change frequently and vary by plan, state, and funding type. This guide was compiled from the sources above and last reviewed October 2026; it is general information, not billing, legal, or clinical advice. Always verify current requirements against the payer's live policy and a benefits check for the specific member.
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