OAR 410-125-0080: Inpatient Services

(1) Elective (not urgent or emergent) hospital admission: (a) Coordinated Care Organization (CCO) and Mental Health Organization (MHO) clients: Contact the client’s CCO, or MHO. The health plan may have different prior authorization (PA) requirements than the Division; (b) Medicare clients: The Division does not require PA for inpatient services provided to clients with Medicare Part A or B coverage; (c) Division clients: Oregon Health Plan (OHP) clients covered by the OHP Plus Benefit Package: (A) For a list of medical and surgical procedures that require PA, see the Division’s Medical-Surgical Services Program, rules OAR chapter 410, division 130, specifically OAR 410-130-0200, table 130-0200-1, unless they are urgent or emergent defined in OAR 410-125-0401; (B) For PA, contact the Division unless otherwise indicated in the Medical-Surgical Service program rules, specifically OAR 410-130-0200, Table 130-0200-1. (2) Transplant services: (a) Complete rules for transplant services are in the Division’s Transplant Services Program rules, OAR chapter 410, division 124; (b) Clients are eligible for transplants covered by the Oregon Health Evidence Review Commission’s Prioritized List of Health Services (Prioritized List). See the Transplant Services Program administrative rules for criteria. (3) Out-of-State non-contiguous hospitals: (a) All non-emergent and non-urgent services provided by hospitals more than 75 miles from the Oregon border require PA; (b) Contact the Division’s Medical Director’s office for authorization for clients not enrolled in a Prepaid Health Plan (PHP). For clients enrolled in a PHP, contact the plan. (4) Out-of-State contiguous hospitals: The Division prior authorizes services provided by contiguous-area hospitals, less than 75 miles from the Oregon border, following the same rules and procedures governing in-state providers. (5) Transfers to another hospital: (a) Transfers for the purpose of providing a service listed in the Medical-Surgical Services program rules, specifically OAR 410-130-0200, Table 130-0200-1, e.g., inpatient physical rehabilitation care, require PA. (b) For transfers to a skilled nursing facility, intermediate care facility, or swing bed, contact Aging and People with Disabilities (APD). APD reimburses nursing facilities and swing beds through contracts with the facilities. For CCO clients, transfers require authorization and payment (for first 20 days) from the CCO; (c) For transfers for the same or lesser level inpatient care to a general acute-care hospital, the Division shall cover transfers, including back transfers that are primarily for the purpose of locating the patient closer to home and family, when the transfer is expected to result in significant social or psychological benefit to the patient: (A) The assessment of significant benefit shall be based on the amount of continued care the patient is expected to need (at least seven days) and the extent to which the transfer locates the patient closer to familial support; (B) Payment for transfers not meeting these guidelines may be denied on the basis of post-payment review. (d) Exceptions: (A) Emergency transfers do not require PA; (B) In-state or contiguous non-emergency transfers for the purpose of providing care that is unavailable in the transferring hospital do not require PA unless the planned service is listed in the Medical-Surgical Service Program rules, specifically OAR 410-130-0200, Table 130-0200-1; (C) All non-urgent transfers to out-of-state, non-contiguous hospitals require PA. (6) Dental procedures provided in a hospital setting: (a) For prior authorization requirements, see the Division’s Dental Services Program rules; specifically OAR 410-123-1260 and 410-123-1490; (b) Emergency dental services do not require PA; (c) For prior authorization for fee-for-service clients, contact the Division’s Dental Services Program analyst. (See the Division’s Dental Services Program Supplemental information, http://www.oregon.gov/OHA/HSD/OHP/Pages/Policy-Dental.aspx); (d) For clients enrolled in a CCO, contact the client’s health plan. (7) Long-term acute care (LTAC) hospital services authorization requirements: (a) For an initial thirty-day stay: (A) LTAC provider must, before admitting the client, submit a request for prior authorization to the Division; (B) Include sufficient medical information to justify the requested initial stay; (C) Meet the clinical criteria outlined in the LTAC Hospital guide at: http:www.oregon.gov/OHA/HSD/OHP/Pages/Policy-Hospital.aspx . (b) Extension of stay: (A) Submit request for prior authorization to the Division; (B) Include sufficient medical justification for the extended stay.