Or. Admin. Code § 410-129-0080

Current through Register Vol. 63, No. 12, December 1, 2024

Section 410-129-0080 - Prepayment Review (PPR) and Prior Authorization (PA) for payment

(1) Speech-language pathology, audiology, and hearing aid providers are subject to PPR or shall obtain PA for services exceeding 30 habilitative and 30 rehabilitative visits in a calendar year.

(2) Providers shall request PA as follows (see the SLP, Audiology and Hearing Aid Services Program Supplemental Information booklet for contact information):

(a) For Medically Fragile Children's Unit (MFCU) clients, from the Authority's MFCU;

(b) For clients enrolled in the fee-for-service Medical Case Management program, from the Medical Case Management contractor;

(c) For clients enrolled in an MCE, from the MCE;

(d) For clients requiring visits in excess of 30 habilitative visits and 30 rehabilitative visits per calendar year.

(3) For services requiring PA, providers shall contact the responsible unit for authorization within five working days following initiation or continuation of services. The FAX or postmark date on the request shall be honored as the request date. It is the provider's responsibility to obtain PA.

(4) For services subject to PPR and to ensure reimbursement of SLP services, beyond the initial evaluation, the SLP provider must submit all required supporting documentation:

(a) Upon submission of the first claim in a series of claims in each therapy plan of care as established by prescribing practitioner per OAR 410-129-0020 for claims subject to PPR;

(b) Request a PA within five working days following 30 rehabilitative or 30 habilitative visits within a calendar year if additional visits are necessary:

(A) PA requests dated within five working days may be approved retroactively to include services provided within five days prior to the date of the PA request;

(B) PA requests dated beyond five working days may not be authorized retroactively and if authorized shall be effective the date of the PA request. The Division recognizes the facsimile or postmark as the PA date of request.

(c) All claims subject to PPR or that requires PA must include a therapy plan of care; and

(d) A PA is not required for Medicare-covered SLP services provided to dual-eligible clients (Medicare clients who are also Medicaid-eligible).

(5) If the service or item is subject to PPR or requiring PA, the provider shall follow and comply with PPR or PA requirements in these rules and the General Rules (OAR chapter 410, division 120) including but not limited to:

(a) The service is adequately documented (see OAR 410-120-1360 Requirements for Financial, Clinical and Other Records). Providers shall maintain documentation in the provider's files to adequately determine the type, medical appropriateness, or quantity of services provided;

(b) The services provided are consistent with the information submitted when authorization was requested;

(c) The services billed are consistent with those services provided;

(d) The services are provided within the timeframe specified on the authorization of payment document; and

(e) Includes the PA number on all claims for services that require PA, or the Division shall deny the claim.

Or. Admin. Code § 410-129-0080

AFS 14-1982, f. 2-16-82, ef. 3-1-82; AFS 49-1982, f. 4-30-82, ef. 5-1-82; AFS 52-1982, f. 5-28-82, ef. 6-30-82; AFS 14-1984(Temp), f. & ef. 4-2-84; AFS 22-1984(Temp), f. & ef. 5-1-84; AFS 40-1984, f. 9-18-84, ef. 10-1-84; AFS 67-1985, f. 11-19-85, ef. 12-1-85; AFS 7-1988, f. & cert. ef. 2-1-88; HR 5-1991, f. 1-18-91, cert. ef. 2-1-91, Renumbered from 461-021-0310; HR 11-1992, f. & cert. ef. 4-1-92; HR 27-1993, f. & cert. ef. 10-1-93; OMAP 36-1999, f. & cert. ef. 10-1-99; OMAP 38-2000, f. 9-29-00, cert. ef. 10-1-00; OMAP 39-2001, f. 9-24-01, cert. ef. 10-1-01; OMAP 85-2003, f. 11-25-03 cert. ef. 12-1-03; OMAP 57-2004, f. 9-10-04, cert. ef. 10-1-04; OMAP 40-2006, f. 12-15-06, cert. ef. 1-1-07; DMAP 34-2008, f. 11-26-08, cert. ef. 12-1-08; DMAP 49-2016, f. 7-26-16, cert. ef. 8-1-16; DMAP 100-2018, amend filed 11/06/2018, effective 11/06/2018; DMAP 102-2018, amend filed 12/13/2018, effective 12/13/2018; DMAP 18-2019, temporary amend filed 06/18/2019, effective 7/1/2019 through 12/27/2019; DMAP 44-2019, amend filed 11/06/2019, effective 11/14/2019

Publications referenced are available from the agency.

Statutory/Other Authority: ORS 413.042

Statutes/Other Implemented: ORS 414.025 & ORS 414.065