OAR 410-131-0160: Prepayment Review (PPR) and Prior Authorization (PA) for Payment

(1) Most OHP clients have prepaid health services contracted for by the Authority through enrollment in a Managed Care Entity (MCE). (2) The provider shall verify whether an MCE or the Division is responsible for reimbursement. Refer to OAR 410-120-1140 Verification of Eligibility and Coverage. (3) If a client is enrolled in an MCE, there may be PA requirements for some services that are provided through the MCE. Providers shall comply with the MCE’s PA requirements or other policies necessary for reimbursement from the MCE before providing services to any OHP client enrolled in an MCE. The physical or occupational therapy (PT/OT) provider shall contact the client’s MCE for specific instructions. (4) A PT/OT provider assumes full financial risk in providing services to a FFS client in providing services that are not in compliance with Oregon Administrative Rules. See also OAR 410-120-1320 Authorization of Payment. (a) PT/OT initial evaluations and re-evaluations are not subject to PPR and do not require a PA; (b) To ensure reimbursement of PT/OT services and procedures beyond the initial evaluation, the PT/OT provider must submit all required supporting documentation: (A) Upon submission of the first claim in a series of claims in each therapy plan of care as established by prescribing practitioner per OAR 410-131-0080 for claims subject to PPR; (B) Request a PA within five working days following 30 rehabilitative or 30 habilitative visits within a calendar year if additional visits are necessary: (i) PA requests dated within five working days may be approved retroactively to include services provided within five days prior to the date of the PA request; (ii) PA requests dated beyond five working days may not be authorized retroactively and if authorized shall be effective the date of the PA request. The Division recognizes the facsimile or postmark as the PA date of request. (c) All claims subject to PPR or that require PA must include a therapy plan of care; and (d) A PA is not required for Medicare-covered PT/OT services provided to dual-eligible clients (Medicare clients who are also Medicaid-eligible). (5) If the service or item is subject to PPR or requiring PA, the PT/OT provider shall follow and comply with PPR and PA requirements in these rules and the General Rules, (OAR chapter 410, division 120) including but not limited to: (a) The service is adequately documented (see OAR 410-120-1360 Requirements for Financial, Clinical and Other Records). Providers shall 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; (d) The services are provided within the timeframe specified on the authorization of payment document; and (e) Includes the PA number on all claims for occupational and physical therapy services that require PA, or the Division shall deny the claim. (6) The following services are subject to PPR when paired above the funding line on the HERC prioritized list (see OAR 410-141-3820) if visits have not exceeded the allowed 30 habilitative and 30 rehabilitative visits allowed in a calendar year: (a) 95831 Manual muscle testing of arm, leg or trunk; (b) 95832 Manual muscle testing of hand; (c) 95833 Manual muscle testing of whole body; (d) 95834 Manual muscle testing of whole body including hands; (e) 95851 Range of motion testing of arm, leg or each spine section; (f) 95852 Range of motion testing of hand; (g) 97012 Application of mechanical traction to 1 or more areas; (h) 97022 Application of whirlpool therapy to 1 or more areas; (i) 97036 Physical therapy treatment to 1 or more areas, Hubbard tank, each 15 minutes; (j) 97110 Therapeutic exercise to develop strength, endurance, range of motion, and flexibility, each 15 minutes; (k) 97112 Therapeutic procedure to re-educate brain-to-nerve-to-muscle function, each 15 minutes; (L) 97113 Water pool therapy with therapeutic exercises to 1 or more areas, each 15 minutes; (m) 97116 Walking training to 1 or more areas, each 15 minutes; (n) 97124 Therapeutic massage to 1 or more areas, each 15 minutes; (o) 97140 Manual (physical) therapy techniques to 1 or more regions, each 15 minutes; (p) 97150 Therapeutic procedures in a group setting (1 visit = 1 unit); (q) 97530 Therapeutic activities to improve function, with one-on-one contact between patient and provider, each 15 minutes; (r) 97532 Development of cognitive skills to improve attention, memory, or problem solving, each 15 minutes; (s) 97535 Self-care or home management training, each 15 minutes; (t) 97542 Wheelchair management, each 15 minutes; (u) 97755 Assistive technology assessment to enhance functional performance, each 15 minutes; and (v) 97761 Training in use of prosthesis for arms and/or legs, per 15 minutes. (7) PA is required when: (a) There is documented need for extended service, considering 60 minutes as the maximum length of a treatment session; (b) There is documented need for continuing rehabilitative or habilitative therapy, considering 30 habilitative and 30 rehabilitative visits in a calendar year. (c) Requesting services for treatments that are below the funded line or not otherwise excluded from coverage per OAR 410-141-3820.