OAR 410-140-0040
Prior Authorization
(1)
Prior Authorization (PA) is defined in OAR 410-120-0000 (Acronyms and Definitions). Providers must obtain a PA from the:(a)
Enrolled member’s Prepaid Health Plan (PHP) or Coordinated Care Organization (CCO); and(b)
The Division for clients who receive services on a fee-for-services basis and are not enrolled with a PHP or CCO.(2)
A PA does not guarantee eligibility or reimbursement. Providers shall verify the client’s eligibility on the date of service and whether a PHP, CCO, or the Division is responsible for reimbursement.(3)
A PA is not required for clients with both Medicare and Division coverage when the service or item is covered by Medicare.(4)
Provider’s shall determine if a PA is required and comply with all PA requirements outlined in these rules.(5)
Provider’s shall ensure:(a)
That all PA requests are completed and submitted correctly. The Division does not accept PA requests via the phone. See Visual Services Supplemental Information Guide found at www.oregon.gov/OHA/HSD/OHP/Pages/Policy-Vision.aspx;(b)
PA requests shall include:(A)
A statement of medical appropriateness showing the need for the item or service and why other options are inappropriate;(B)
Diopter information and appropriate International Classification of Diseases, 10th revision, Clinical Modification (ICD-10-CM) diagnosis codes;(C)
All relevant documentation that is needed for Division staff to make a determination for authorization of payment, including clinical data or evidence, medical history, any plan of treatment, or progress notes;(c)
The service is adequately documented. (See OAR 410-120-1360 (Requirements for Financial, Clinical and Other Records) Requirements for Financial, Clinical and Other Records.) Providers must maintain documentation to adequately determine the type, medical appropriateness, or quantity of services provided;(d)
The services or items provided are consistent with the information submitted when authorization was requested;(e)
The services billed are consistent with the services provided; and(f)
The services are provided within the timeframe specified on the PA document.(6)
Providers shall comply with the Division’s PA requirements or other policies necessary for reimbursement before providing services to any OHP client who is not enrolled in a PHP. Services or items denied due to provider error (e.g., required documentation not submitted, PA not obtained, etc.) may not be billed to the client.(7)
The following vision services require PA:(a)
Contact lenses for adults (age 21 and older) and excludes a primary keratoconus diagnosis, which is exempt from the PA requirement. (See OAR 410-140-0160 (Contact Lens Services and Supplies) Contact Lens Services for service and supply coverage and limitations);(b)
Vision therapy greater than six sessions. Six sessions are allowed per calendar year without PA. (See OAR 410-140-0280 (Vision Therapy Services) Vision Therapy Services); and(c)
Specific vision materials (See OAR 410-140-0260 (Contractor Services for Provider Ordering Vision Materials and Supplies) Purchase of Ophthalmic Materials for more information.):(A)
Frames not included in the Division’s contract with contractor, SWEEP Optical; and(B)
Specialty lenses or lenses considered as “not otherwise classified” by Health Care Common Procedure Coding System (HCPCS);(d)
An unlisted ophthalmological service or procedure, or “By Report” (BR) procedures.(8)
The Division shall send notice of all approved PA requests for vision materials to the Division’s contractor, SWEEP Optical; who forwards a copy of the PA approval and confirmation number to the requesting provider. (See OAR 410-140-0260 (Contractor Services for Provider Ordering Vision Materials and Supplies) Purchase of Ophthalmic Materials.)
Source:
Rule 410-140-0040 — Prior Authorization, https://secure.sos.state.or.us/oard/view.action?ruleNumber=410-140-0040.