(1)For fee-for-service (FFS) clients, prior authorization (PA) is required for all procedure codes listed in Table 130-0200-1. Prior authorization is required in all settings unless otherwise indicated. See indicators in table heading. For details on where to obtain PA, download a copy of the Prior Authorization Handbook at: http://www.oregon.gov/oha/HSD/OHP/Tools/Prior%20Authorization%20Handbook.pdf.
(2)Providers must obtain PA from the OHP payer, either FFS or CCO; that shall be responsible for payment at the time the service is delivered.
(3)The Division shall authorize for the level of care or type of service that meets the client’s medical need consistent with the Health Evidence Review Commission’s (HERC) Prioritized List of Health Services (Prioritized List) and guideline notes, as referenced in OAR 410-141-3830 (Prioritized List of Health Services).
(4)Codes for which medical need has not been specified by the HERC shall be authorized based on medical appropriateness as the term is defined in OAR 410-120-0000 (Acronyms and Definitions).
(5)For out-of-hospital birth PA requests, initial documentation adequate to assess pregnancy risk per OAR 410-130-0240 (Medical Services) must be received on or before 34 weeks gestation.
(a)Exceptions to the 34-week limit may be granted in cases including the following:
(A)Member has recently moved to Oregon;
(B)Member is newly enrolled in Oregon Health Plan; or
(C)Member’s previous prenatal care or birth provider closes their practice.
(b)Documentation requirements reflecting prior prenatal care must still be met. Requests for ongoing documentation to continue the support of assessment of pregnancy risk must also be met per OAR 410-120-1320 (Authorization of Payment)(2)(3).
(6)For bariatric surgery, PA is required in two steps from:
(a)The OHP primary care provider prior to referral to a bariatric surgery center, and
(b)The bariatric surgery center prior to surgery.
(7)PA is not required:
(a)For clients with both Medicare and Medical Assistance Program coverage, and the service is covered by Medicare. However, PA is still required for bariatric surgeries and evaluations and most transplants, even if they are covered by Medicare;
(b)For kidney and cornea transplants unless they are performed out-of-state;
(c)For emergent or urgent procedures or services;
(d)For hospital admissions unless the procedure requires PA.
(8)A second opinion may be requested by the Division or the contractor before PA is given.
(9)Treating and performing practitioners are responsible for obtaining PA.
(10)PA documentation must be complete and legible.
(11)PA shall be considered based on the documentation submitted.
(12)Refer to Table 130-0200-1 for all services and procedures requiring PA.
Rule 410-130-0200 — Prior Authorization,