Or. Admin. Code § 410-147-0060

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

Section 410-147-0060 - Prior Authorization

(1) Most Oregon Health Plan (OHP) clients have prepaid health services, contracted for by the Oregon Health Authority (Authority) through enrollment in a Prepaid Health Plan (PHP). Client's who are not enrolled in a PHP, receive services on an "open card" or "fee-for-service" (FFS) basis.

(2) It is the responsibility of the Provider to verify whether a PHP or DMAP is responsible for reimbursement. Refer to OAR 410-120-1140 Verification of Eligibility.

(3) If a client is enrolled in a PHP there may be Prior Authorization (PA) requirements for some services that are provided through the PHP. It is the FQHC or RHC's responsibility to comply with the PHP's PA requirements or other policies necessary for reimbursement from the PHP before providing services to any OHP Client enrolled in a PHP. The FQHC or RHC needs to contact the client's PHP for specific instructions.

(4) Clients who are enrolled in a PHP can receive family planning services, human immunodeficiency virus (HIV) and acquired immune deficiency syndrome (AIDS) prevention services (excludes any treatment for HIV or AIDS) through an FQHC or RHC without PA from the PHP as provided under the terms of Oregon's Section 1115 (CMS) Waiver. If the FQHC or RHC does not have a contract or other arrangements with a PHP, and the PHP denies payment, the Division of Medical Assistance Programs (DMAP) will reimburse for these services per a clinic's encounter rate (see OAR 410-147-0120(12)(b)).

(5) If a client receives services on a "fee-for-service" basis, a PA may be required by DMAP for certain covered services or items before the service can be provided or before payment will be made. An FQHC or RHC assumes full financial risk in providing services to a "fee-for-service" client prior to receiving authorization, or in providing services that are not in compliance with Oregon Administrative Rules (OARs). See OAR 410-120-1320 Authorization of Payment and any applicable program rules.

(6) If the service or item is subject to Prior Authorization, the FQHC or RHC must follow and comply with PA requirements in these rules, the General Rules and applicable program rules, including but not limited to:

(a) The service is adequately documented (see OAR 410-120-1360, Requirements for Financial, Clinical and Other Records). Providers must 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; and

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

Or. Admin. Code § 410-147-0060

OMAP 19-1999, f. & cert. ef. 4-1-99; OMAP 35-1999, f. & cert. ef. 10-1-99; OMAP 20-2000, f. 9-28-00, cert. ef. 10-1-00; OMAP 21-2000, f. 9-28-00, cert. ef 10-1-00; OMAP 37-2001, f. 9-24-01, cert. ef. 10-1-01; OMAP 62-2002, f. & cert. ef. 10-1-02, Renumbered from 410-128-0640; OMAP 63-2002, f. & cert. ef. 10-1-02, Renumbered from 410-135-0080; OMAP 71-2003, f. 9-15-03, cert. ef. 10-1-03; OMAP 63-2004, f. 9-10-04, cert. ef. 10-1-04; OMAP 27-2006, f. 6-14-06, cert. ef. 7-1-06; DMAP 34-2008, f. 11-26-08, cert. ef. 12-1-08

Stat. Auth.: ORS 413.042

Stats. Implemented: ORS 414.025 & 414.065