OAR 410-125-0080
Inpatient Services

(1)

Elective (not urgent or emergent) hospital admission:

(a)

Coordinated Care Organization (CCO) and Mental Health Organization (MHO) clients: Contact the client’s CCO, or MHO. The health plan may have different prior authorization (PA) requirements than the Division;

(b)

Medicare clients: The Division does not require PA for inpatient services provided to clients with Medicare Part A or B coverage;

(c)

Division clients: Oregon Health Plan (OHP) clients covered by the OHP Plus Benefit Package:

(A)

For a list of medical and surgical procedures that require PA, see the Division’s Medical-Surgical Services Program, rules OAR chapter 410, division 130, specifically OAR 410-130-0200 (Prior Authorization), table 130-0200-1, unless they are urgent or emergent defined in OAR 410-125-0401 (Definitions: Emergent, Urgent, and Elective Admissions);

(B)

For PA, contact the Division unless otherwise indicated in the Medical-Surgical Service program rules, specifically OAR 410-130-0200 (Prior Authorization), Table 130-0200-1.

(2)

Transplant services:

(a)

Complete rules for transplant services are in the Division’s Transplant Services Program rules, OAR chapter 410, division 124;

(b)

Clients are eligible for transplants covered by the Oregon Health Evidence Review Commission’s Prioritized List of Health Services (Prioritized List). See the Transplant Services Program administrative rules for criteria. (3) Out-of-State non-contiguous hospitals:

(a)

All non-emergent and non-urgent services provided by hospitals more than 75 miles from the Oregon border require PA;

(b)

Contact the Division’s Medical Director’s office for authorization for clients not enrolled in a Prepaid Health Plan (PHP). For clients enrolled in a PHP, contact the plan.

(4)

Out-of-State contiguous hospitals: The Division prior authorizes services provided by contiguous-area hospitals, less than 75 miles from the Oregon border, following the same rules and procedures governing in-state providers.

(5)

Transfers to another hospital:

(a)

Transfers for the purpose of providing a service listed in the Medical-Surgical Services program rules, specifically OAR 410-130-0200 (Prior Authorization), Table 130-0200-1, e.g., inpatient physical rehabilitation care, require PA. (b) For transfers to a skilled nursing facility, intermediate care facility, or swing bed, contact Aging and People with Disabilities (APD). APD reimburses nursing facilities and swing beds through contracts with the facilities. For CCO clients, transfers require authorization and payment (for first 20 days) from the CCO;

(c)

For transfers for the same or lesser level inpatient care to a general acute-care hospital, the Division shall cover transfers, including back transfers that are primarily for the purpose of locating the patient closer to home and family, when the transfer is expected to result in significant social or psychological benefit to the patient:

(A)

The assessment of significant benefit shall be based on the amount of continued care the patient is expected to need (at least seven days) and the extent to which the transfer locates the patient closer to familial support;

(B)

Payment for transfers not meeting these guidelines may be denied on the basis of post-payment review.

(d)

Exceptions:

(A)

Emergency transfers do not require PA;

(B)

In-state or contiguous non-emergency transfers for the purpose of providing care that is unavailable in the transferring hospital do not require PA unless the planned service is listed in the Medical-Surgical Service Program rules, specifically OAR 410-130-0200 (Prior Authorization), Table 130-0200-1;

(C)

All non-urgent transfers to out-of-state, non-contiguous hospitals require PA.

(6)

Dental procedures provided in a hospital setting:

(a)

For prior authorization requirements, see the Division’s Dental Services Program rules; specifically OAR 410-123-1260 (OHP Dental Benefits) and 410-123-1490 (Hospital Dentistry);

(b)

Emergency dental services do not require PA;

(c)

For prior authorization for fee-for-service clients, contact the Division’s Dental Services Program analyst. (See the Division’s Dental Services Program Supplemental information, http:/­/­www.oregon.gov/­OHA/­HSD/­OHP/­Pages/­Policy-Dental.aspx);

(d)

For clients enrolled in a CCO, contact the client’s health plan.

(7)

Long-term acute care (LTAC) hospital services authorization requirements:

(a)

For an initial thirty-day stay:

(A)

LTAC provider must, before admitting the client, submit a request for prior authorization to the Division;

(B)

Include sufficient medical information to justify the requested initial stay;

(C)

Meet the clinical criteria outlined in the LTAC Hospital guide at: http:www.oregon.gov/OHA/HSD/OHP/Pages/Policy-Hospital.aspx.

(b)

Extension of stay:

(A)

Submit request for prior authorization to the Division;

(B)

Include sufficient medical justification for the extended stay.

Source: Rule 410-125-0080 — Inpatient Services, https://secure.­sos.­state.­or.­us/oard/view.­action?ruleNumber=410-125-0080.

410‑125‑0000
Determining When the Patient Has Medical Assistance 410‑125‑0020
Retroactive Eligibility 410‑125‑0030
Hospital Hold 410‑125‑0040
Title XIX/Title XXI Clients 410‑125‑0041
Non-Title XIX/XXI Clients 410‑125‑0045
Coverage and Limitations 410‑125‑0050
Client Copayments 410‑125‑0080
Inpatient Services 410‑125‑0085
Outpatient Services 410‑125‑0086
Prior Authorization for FCHP/MHO Clients 410‑125‑0090
Inpatient Rate Calculations — Type A, Type B, and Critical Access Oregon Hospitals 410‑125‑0095
Hospitals Providing Specialized Inpatient Services 410‑125‑0101
Hospital-Based Nursing Facilities and Medicaid Swing Beds 410‑125‑0102
Medically Needy Clients 410‑125‑0103
Medicare Clients 410‑125‑0115
Non-Contiguous Area Out-of-State Hospitals — Effective for services rendered on or after October 1, 2003 410‑125‑0120
Transportation To and From Medical Services 410‑125‑0121
Contiguous Area Out-of-State Hospitals — Effective for services rendered on or after October 1, 2003 410‑125‑0124
Retroactive Authorization 410‑125‑0125
Free-Standing Inpatient Psychiatric Facilities 410‑125‑0140
Prior Authorization Does Not Guarantee Payment 410‑125‑0141
DRG Rate Methodology 410‑125‑0142
Graduate Medical Education Reimbursement for Public Teaching Hospitals 410‑125‑0146
Supplemental Reimbursement for Public Academic Teaching University Medical Practitioners 410‑125‑0150
Disproportionate Share 410‑125‑0155
Upper Limits on Payment of Hospital Claims 410‑125‑0162
Hospital Transformation Performance Program 410‑125‑0165
Transfers and Reimbursement 410‑125‑0170
Death Occurring on Day of Admission 410‑125‑0175
Hospitals Providing Specialized Outpatient Services 410‑125‑0180
Public Rates 410‑125‑0181
Non-Contiguous and Contiguous Area Out-of-State Hospitals — Outpatient Services 410‑125‑0190
Outpatient Rate Calculations — Type A, Type B, and Critical Access Oregon Hospitals 410‑125‑0195
Outpatient Services In-State DRG Hospitals 410‑125‑0200
Time Limitation for Submission of Claims 410‑125‑0201
Independent ESRD Facilities 410‑125‑0210
Third Party Resources and Reimbursement 410‑125‑0220
Services Billed on the Electronic 837I or on the Paper UB-04 and Other Claim Forms 410‑125‑0221
Payment in Full 410‑125‑0230
Qualified Directed Payments 410‑125‑0360
Definitions and Billing Requirements 410‑125‑0400
Discharge 410‑125‑0401
Definitions: Emergent, Urgent, and Elective Admissions 410‑125‑0410
Readmission 410‑125‑0450
Provider Preventable Conditions 410‑125‑0550
X-Ray or EKG Procedures Furnished in Emergency Room 410‑125‑0600
Non-Contiguous Out-of-State Hospital Services 410‑125‑0620
Special Reports and Exams and Medical Records 410‑125‑0640
Third Party Payers — Other Resources, Client Responsibility and Liability 410‑125‑0641
Medicare 410‑125‑0720
Adjustment Requests 410‑125‑1020
Filing of Cost Statement 410‑125‑1040
Accounting and Record Keeping 410‑125‑1060
Fiscal Audits 410‑125‑1070
Type A and Type B Hospitals 410‑125‑1080
Documentation 410‑125‑2000
Access to Records 410‑125‑2020
Post Payment Review 410‑125‑2030
Recovery of Payments 410‑125‑2040
Provider Appeals — Administrative Review 410‑125‑2060
Provider Appeals — Hearing Request 410‑125‑2080
Administrative Errors
Last Updated

Jun. 8, 2021

Rule 410-125-0080’s source at or​.us