OAR 410-127-0080: Prior Authorization

(1) Home health providers must obtain prior authorization (PA) for services as specified in rule. (2) Providers must request PA as follows (see the Home Health Supplemental Information booklet for contact information) and include the documentation requirements from the supplemental (e.g., face-to-face encounter, plan of care, primary diagnosis, initial assessment, evaluation, etc.): (a) For clients enrolled in a Coordinated Care Organization (CCO) or a Prepaid Health Plan (PHP), from the CCO or the PHP; (b) For all other clients, from the Division. (3) For services requiring authorization, providers must 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. The provider shall obtain payment authorization. Authorization shall be given based on medical appropriateness and appropriate level of care, cost, and effectiveness as supported by submitted documentation. The plan of care submitted must include the client’s condition, the rationale for the care plan including justification for the required skill level of care, and the summary of care for additional certification periods. (4) Payment authorization does not guarantee reimbursement (e.g., eligibility changes, incorrect identification number, provider contract ends). (5) For rules related to authorization of payment including retroactive eligibility, see General Rules OAR 410-120-1320.