OAR 410-125-0085
Outpatient Services

(1)

Outpatient services that may require prior authorization (PA) include (see the individual program in the Authority’s Health Systems Division (Division)) Oregon Administrative Rules:

(a)

Physical Therapy (chapter 410, division 131);

(b)

Occupational Therapy (chapter 410, division 131);

(c)

Speech Therapy (chapter 410, division 129);

(d)

Audiology (chapter 410, division 129);

(e)

Hearing Aids (chapter 410, division 129);

(f)

Dental Procedures (chapter 410, division 123);

(g)

Drugs (chapter 410, division 121);

(h)

Apnea monitors, services, and supplies (chapter 410, division 122);

(i)

Home Parenteral/Enteral Therapy (chapter 410, division 148);

(j)

Durable Medical Equipment and Medical supplies (chapter 410, division 122);

(k)

Certain hospital services.

(2)

The National Drug Code (NDC) must be included on the electronic (837I) and paper (UB 04) claims for physician administered drug codes required by the Deficit Reduction Act of 2005.

(3)

Outpatient surgical procedures:

(a)

For Coordinated Care Organization (CCO) members: Contact the CCO. The CCO may have different PA requirements than the Division. Some services are not covered under CCO contracts and require PA from the Division, or the Division’s Dental Services program analyst;

(b)

For Medicare clients enrolled in a CCO: These services must be authorized by the CCO even if Medicare is the primary payer. Without this authorization, the provider may not be paid beyond any Medicare payments (see also OAR 410-125-0103 (Medicare Clients));

(c)

For fee-for-service clients on the OHP Plus benefit package:

(A)

Surgical procedures listed in OAR 410-125-0080 (Inpatient Services) require PA when performed in an outpatient or day surgery setting, unless they are urgent or emergent;

(B)

Contact the Division for PA (unless indicated otherwise in OAR 410-125-0080 (Inpatient Services)).

(d)

Out-of-State services: Outpatient services provided by hospitals located less than 75 miles from the border of Oregon do not require PA unless specified in the Division’s Hospital Services Program rules. All non-urgent or non-emergent services provided by hospitals located more than 75 miles from the border of Oregon require PA. For clients enrolled in a CCO, contact the CCO for authorization. For clients not enrolled in a health plan, contact the Division’s Provider Clinical Support Unit.

(4)

Psychiatric Emergency Services (PES):

(a)

Psychiatric emergency services as defined by OAR 309-023-0110 (Definitions) delivered in a PES facility as described in OAR 309-023-0120 (PES Facility Requirements) shall be reimbursed for a maximum of 20 hours per admittance;

(b)

Psychiatric emergency services shall be reimbursed with a bundled, hourly rate using a fee-for-service rate methodology that is based on rates paid for similar services, using similar providers at a similar level-of-care.

Source: Rule 410-125-0085 — Outpatient Services, https://secure.­sos.­state.­or.­us/oard/view.­action?ruleNumber=410-125-0085.

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 410-125-0085’s source at or​.us