OAR 410-125-0140: Prior Authorization Does Not Guarantee Payment

(1) Prior authorization (PA) is valid for the date range approved only as long as the client remains eligible for services. For example, a client may become ineligible after the PA has been granted but before the actual date of service, or a client's hospital benefit days may be used prior to the time the claim for the prior authorized service is submitted to the Division of Medical Assistance Programs (Division) for payment. (2) All prior authorized treatment are subject to retrospective review. If the information provided to obtain PA cannot be validated in a retrospective review, payment shall be denied or recovered. (3) Hospitals should develop their own internal monitoring system to determine if the admitting physician has received PA for the service from the Division. (4) For the Plus Benefit Package PA information refer to the PA chart in the Hospital Services Program OAR 410-125-0080. (5) Hospitals may also verify PA requirements by calling the Division’s Provider Services Unit or the RN Benefit Hotline (contact phone numbers are located on the Division’s website).