OAR 410-141-3835: CCO Service Authorization

(1) Coverage of services is outlined by CCO contract and Oregon Health Plan (OHP) benefits coverage in OAR 410-120-1210 and OAR 410-120-1160. (2) A member may access urgent and emergency services 24 hours a day, seven (7) days a week without prior authorization. (3) The CCO must not require a member to obtain the approval of a primary care physician to gain access to behavioral assessment and evaluation services. A member may self-refer to assessment, evaluation, and behavioral health services from the Provider Network. Members may obtain primary care services in a behavioral health setting, and behavioral health services in a primary care setting without authorization. (4) A member may access the following outpatient services from within the CCO's Provider Network, without Prior Authorization, including but not limited to: (a) “Assertive Community Treatment” as defined in OAR 309-019-0105, “Enhanced Care Services” as defined in OAR 309-019-0105, “Enhanced Care Outreach Services” as defined in OAR 309-019-0105, “Wraparound” as defined in OAR 309-019-0105, “Behavior Supports, Crisis Care” as defined in OAR 309-019-0105, “Respite Care” as defined in OAR 309-019-0105, and “Intensive Outpatient Services and Supports” as defined in OAR 309-019-0105; (b) Behavioral Health Peer Delivered Services as defined in OAR 309-019-0125 from within the CCO's Provider Network; (c) Medication-Assisted Treatment for Substance Use Disorders as defined in OAR 309-019-0105, including opioid and opiate use disorders. Prior authorization may only be required: (A) For a medication approved by the United States Food and Drug Administration after January 1, 2024; or (B) For a brand name drug for medication-assisted treatment if a generic equivalent is available to substitute for the prescribed brand name drug. For the purposes of this rule, a different formulation of the medication is not a generic equivalent. (d) Drugs prescribed for the prevention or treatment of human immunodeficiency virus (HIV): (A) When the drug has been approved by the United States Food and Drug Administration for the prevention or treatment of HIV and determined to be medically necessary by the prescribing provider; (B) Step therapy must also not be required for these drugs. (5) Contractors must permit out-of-network IHCPs to refer a CCO-enrolled American Indian/Alaska Native to a network provider for covered services as required by 42 CFR 438.14(b)(6). (6) The CCO shall ensure the services are furnished in an amount, duration, and scope that is no less than the amount, duration, and scope for the same services furnished to beneficiaries under FFS Medicaid and as described in ORS chapter 414 and applicable administrative rules, based on the Prioritized List of Health Services and OAR 410-120-1160, 410-120-1210, and 410-141-3830. (7) CCOs must not arbitrarily deny or reduce the amount, duration, or scope of a required service solely because of diagnosis, type of illness, or condition of the beneficiary. (8) CCOs shall observe required timelines for standard authorizations, expedited authorizations, and specific OHP rule requirements for authorizations for services, including but not limited to residential treatment or substance use disorder treatment services and requirements for advance notice set forth in OAR 410-141-3885. CCOs shall observe required timely access to service timelines as indicated in OAR 410-141-3515. (9) CCOs may place appropriate limits on a service authorization for Covered Services based on Medical Necessity and Medical Appropriateness as defined in OAR 410-120-0000, or for utilization control provided that the CCO: (a) Ensures the services are sufficient in amount, duration, or scope to reasonably achieve the purpose for which the services are furnished; (b) Authorizes the services supporting individuals with ongoing or chronic conditions or those conditions requiring long-term services and supports in a manner that reflects the member's ongoing need for the services and supports; (c) Provides family planning services in a manner that protects and enables the member's freedom to choose the method of family planning to be used consistent with 42 CFR § 441.20 and the member's free choice of provider consistent with 42 USC § 1396a(a)(23)(B) and 42 CFR § 431.51; and (d) Ensures compensation to individuals or entities that conduct utilization management activities is not structured to provide incentives for the individual or entity to deny, limit, delay, or discontinue medically necessary services to any member. (10) CCOs must not use quality of life in general measures in establishing utilization controls (e.g., prior authorization) or otherwise making benefit determinations per OAR 410-120-1320. (11) Once a member is determined to be eligible for health-related social needs (HRSN) Services as outlined in OAR 410-120-2000, OAR 410-120-2005, and OAR 410-120-2015, CCOs may place appropriate limits on a service authorization for HRSN Services or for utilization control provided the CCO: (a) Ensures the HRSN Services are sufficient in amount, duration, or scope to reasonably achieve the purpose for which the services are furnished; (b) Authorizes the HRSN Services supporting individuals with ongoing or chronic conditions or those conditions requiring long-term services and supports in a manner that reflects the member's ongoing need for the services and supports; and (c) Ensures compensation to individuals or entities that conduct utilization management activities is not structured to provide incentives for the individual or entity to deny, limit, delay, or discontinue the delivery of HRSN Services to any member who is eligible for those services under OAR 410-120-2000, OAR 410-120-2005, and OAR 410-120-2015. (12) For authorization of services: (a) Each CCO shall follow the following timeframes for authorization requests other than for drug or HRSN services: (A) For standard authorization requests for services not previously authorized and not for repairs of complex rehabilitation technology as defined in Section 2 of Enrolled SB 549 (2025), provide notice per paragraph (G) in this section as expeditiously as the member’s condition requires and no later than seven (7) calendar days following receipt of the request for service. (B) For expedited authorization decisions, provide notice per paragraph (G) in this section as expeditiously as the member's health condition requires and no later than 72 hours after receipt of the request for service, which period of time shall be determined by the time and date stamp on the receipt of the request; (C) If additional documentation is required to render a decision for requests in paragraphs (A) and (B), make one (1) attempt to obtain the information during the seven (7) calendar day standard review period or 72 hour expedited review period. (D) An extension of up to 14 calendar days for a standard or expedited authorization decision in paragraph (A) or (B) is possible if the following applies: (i) The member, the member's representative, or provider requests an extension; or (ii) The CCO needs additional information to process the request, and the extension is in the member’s interest. If the Authority requests, the CCO will justify a need for the additional information and how the extension is in the member's interest. (E) If a 14 calendar day extension has been justified, the CCO shall: (i) Give written notice to the member of the reason for the extension; (iii) Respond to the request for authorization per paragraph (G) in this section as expeditiously as the member's health or mental health condition requires, but no later than the expiration of the extension; and (iii) If the reason for the extension is to obtain additional documentation, make two (2) attempts to obtain the information during the extended review period in addition to the attempt required in paragraph (C) for the initial review period. The total of three (3) attempts shall include the use of two (2) methods to obtain the information. (F) For all prior authorization requests for repairs of complex rehabilitation technology as defined in Section 2 of Enrolled SB 549 (2025), provide notice per paragraph (G) in this section as expeditiously as the member’s condition requires and no later than 72 hours following receipt of the request for service. No extension shall be allowed. (G) Responses to requests for prior authorization of services in paragraphs (A), (B), (E) and (F) in this section shall be in one of the following forms: (i) A written, electronic or telephonic notice of the approval of the service as requested to the requesting provider; or (ii) A written notice of adverse benefit determination per OAR 410-141-3885 to the requesting provider, the member and the member’s representative. (b) Prior authorization requests for outpatient drugs, including a practitioner administered drug (PAD), shall be addressed by the CCOs as follows: (A) Respond to requests for prior authorizations for outpatient drugs within 24 hours as described in 42 CFR 438.210(d)(3) and section 1927(d)(5) of the Social Security Act. This shall include one attempt within the first 24 hours to obtain additional necessary information if needed. An initial response shall include: (i) A written, telephonic or electronic communication of approval of the drug as requested to the member, and prescribing practitioner, and when known to the CCO, the pharmacy; or (ii) A written notice of adverse benefit determination of the drug per OAR 410-141-3885 to the member, and telephonic or electronic notice to the prescribing practitioner, and when known to the CCO, the pharmacy if the drug is denied or partially approved; or (iii) A written, telephonic, or electronic request for additional documentation to the prescribing practitioner when the prior authorization request lacks the CCO's standard information collection tools such as prior authorization forms or other documentation necessary to render a decision; or (iv) A written, telephonic, or electronic acknowledgment of receipt of the prior authorization request that gives an expected timeframe for a decision. An initial response indicating only acceptance of a request must not delay a decision to approve or deny the drug within 72 hours. (B) The 72-hour window for a coverage decision begins with the initial date and time stamp of a prior authorization request for a drug; (C) If the response is a request for additional documentation, the CCO shall identify and notify the prescribing practitioner of the documentation required to make a coverage decision and comply within the following timeframes: (i) Upon receiving the CCO's completed prior authorization forms and required documentation, the CCO shall issue a decision as expeditiously as the member's health requires, but no later than 72 hours from the date and time stamp of the initial request for prior authorization as follows: (I) If the drug is approved as requested, the CCO shall notify the member in writing and prescribing practitioner, and when known to the CCO, the pharmacy, telephonically, or electronically; or (II) If the drug is denied or partially approved, the CCO shall issue a written notice of adverse benefit determination to the member, and telephonic or electronic notice to the prescribing practitioner, and when known to the CCO, the pharmacy. (ii) If the requested additional documentation is not received within 72 hours from the date and time stamp of the initial request for prior authorization, the CCO shall issue a written notice of adverse benefit determination to the member, and telephonic or electronic notice to the prescribing practitioner, and when known to the CCO, the pharmacy. (D) The CCO shall provide approved services as expeditiously as the member's health condition requires; (E) If an emergency situation justifies the immediate medical need for the drug during this review process, an emergency supply of 72 hours or longer shall be made available until the CCO makes a coverage decision. (c) For HRSN services, the CCO shall comply with the service authorization timelines in OAR 410-120-2020. (d) For members with special health care needs as determined through an assessment requiring a course of treatment or regular care monitoring, each CCO shall have a mechanism in place to allow members to directly access a specialist (for example, through a standing referral or an approved number of visits) as appropriate for the member's condition and identified needs; (e) Any service authorization decision not reached within the timeframes specified in this rule shall constitute a denial and becomes an adverse benefit determination. A notice of adverse benefit determination shall be issued on the date the timeframe expires; (f) CCOs shall give the member written notice of any decision to deny a service authorization request or to authorize a service in an amount, duration, or scope that is less than requested or when reducing a previously authorized service authorization. The notice shall meet the requirements of CFR § 438.404 and OAR 410-141-3885; (g) The CCO and its subcontractors shall have and follow written policies and procedures to ensure consistent application of review criteria for service authorization requests including the following: (A) For medical, behavioral, or oral health Covered Services: (i) The CCO shall consult with the requesting provider for medical, behavioral, or oral health services when necessary: (I) Requesting all the appropriate information to support decision making as early in the review process as possible; and (II) Adding documentation in the authorization file on outreach methods and dates when additional information was requested from the requesting provider. (ii) Decisions shall be made by an individual who has clinical expertise in addressing the member's medical, behavioral, or oral health needs or in consultation with a health care professional with clinical expertise in treating the member's condition or disease. This applies to decisions to: (I) Deny a service authorization request; (II) Reduce a previously authorized service request; or (III) Authorize a service in an amount, duration, or scope that is less than requested. (B) For HRSN Services, the CCO shall comply with OAR 410-120-2020. (C) CCOs shall have written policies and procedures for processing prior authorization requests received from any provider. The policies and procedures shall specify timeframes for the following: (i) Date and time stamping prior authorization requests when received; (ii) Determining within a specific number of days from receipt whether a prior authorization request is valid or non-valid; (iii) The specific number of days allowed for follow-up on pended prior authorization requests to obtain additional information; (iv) The specific number of days following receipt of the additional information that an approval or denial shall be issued; (v) Providing services after office hours and on weekends that require prior authorization. (D) A CCO shall make a determination on at least 95 percent of valid prior authorization requests within two (2) business days of receipt of a prior authorization or reauthorization request related to: (i) Drugs; (ii) Alcohol; (iii) Drug services; or (iv) Care required while in a skilled nursing facility. (13) Report to the Authority annually requests for prior authorization. The report shall include: (a) The number of requests received; (b) The number of requests that were initially denied and the reasons for the denials, including, but not limited to, lack of medical necessity or failure to provide additional clinical information requested by the insurer; (c) The number of requests that were initially approved; and (d) The number of denials that were reversed by internal appeals or external reviews.