OAR 410-130-0200: Prior Authorization

(1) For fee-for-service (FFS) clients, Prior Authorization (PA) is required for all procedure codes listed in Table 130-0200-1. PA is required in all settings unless otherwise indicated. See indicators in table heading. For details on where to obtain PA, download a copy of the Prior Authorization Handbook at: http://www.oregon.gov/oha/HSD/OHP/Tools/Prior%20Authorization%20Handbook.pdf . (2) Providers must obtain PA from the OHP payer, either FFS or CCO; that shall be responsible for payment at the time the service is delivered. (3) The Division shall authorize for the level of care or type of service that meets the client’s medical need consistent with the Health Evidence Review Commission’s (HERC) Prioritized List of Health Services (Prioritized List) and guideline notes, as referenced in OAR 410-141-3830. (4) Codes for which medical need has not been specified by the HERC shall be authorized based on medical appropriateness as the term is defined in OAR 410-120-0000. (5) PA requests for coverage of planned births taking place in a clinic, birth center or home setting will be referred to as community births or as out-of-hospital births. To obtain PA for coverage of these services, providers must meet the requirements and submit the forms and required supporting documentation as described in the Planned Community Births (Out-of-Hospital Births) Prior Authorization and Billing Guide, effective September 2021 available at: https://www.oregon.gov/oha/HSD/OHP/Tools/Planned-Community-Birth-Guide.pdf . (a) Due to the current COVID-19 public health emergency and surge in Oregon cases impacting hospital capacities, initial documentation to assess pregnancy risk per OAR 410-130-0240 must be received by the Division no later than 38 weeks, 0 days gestation, through the COVID health emergency or until rescinded or revised by the Division; (b) Documentation requirements reflecting prior prenatal care must be met. Requests for ongoing documentation to continue the support of assessment of pregnancy risk must also be met per OAR 410-120-1320(2)(3). (6) PA is not required: (a) For clients with both Medicare and Medical Assistance Program coverage, and the service is covered by Medicare. However, PA is still required for bariatric surgeries and most transplants, even if they are covered by Medicare; (b) For kidney and cornea transplants unless they are performed out-of-state; (c) For emergent procedures or services; (d) For hospital admissions unless the procedure requires PA. (7) A second opinion may be requested by the Division or the contractor before PA is given. (8) Treating and performing practitioners are responsible for obtaining PA. (9) PA documentation must be complete and legible. (10) PA shall be considered based on the documentation submitted. (11) Refer to Table 130-0200-1 for all services and procedures requiring PA. [ED. NOTE: To view attachments referenced in rule text, click here to view rule.]