OAR 410-151-0003: Utilization Management Requirements

(1) The Oregon Health Authority (Authority) and Managed Care Entities (MCEs) do not have the right to pre-establish limits or caps on the amount of services or number of visits covered for EPSDT Beneficiaries. Instead, coverage decisions must be made in accordance with OAR 410-151-0002. However, it is acceptable to establish limits (for example, 10 physical therapy visits) subject to prior authorization for coverage of additional services. (2) The Authority and MCEs do not have the right to require prior authorization for any EPSDT screening services. (3) The Authority and MCEs shall promptly complete prior authorization procedures in accordance with OAR 410-141-3835 and OAR 410-130-0200 and the individual program chapter 410 and 309 OARs as applicable. (4) The Authority and MCEs shall ensure prompt delivery of EPSDT Medically Necessary and EPSDT Medically Appropriate (or EPSDT Dentally Appropriate) services to EPSDT Beneficiaries.