OAR 410-146-0060
Prior Authorization

(1) Some covered services or items require prior authorization (PA) by the Division before the service may be provided or before payment will be made. Refer to Oregon Administrative Rule (OAR) 410-120-1320 (Authorization of Payment) Authorization of Payment.
(2) Most Oregon Health Plan (OHP) clients have prepaid health services contracted by the Oregon Health Authority (Authority) through enrollment in a PHP. Refer to OAR 410-120-1140 (Verification of Eligibility and Coverage) Verification of Eligibility.
(3) An OHP client who is an American Indian or Alaska Native (AI/AN) with proof of Indian heritage is exempt from mandatory enrollment in a PHP and can request disenrollment from a PHP if automatically enrolled. An AI/AN OHP client may choose to remain in the Medicaid fee-for-service (FFS) delivery system for physical, dental, and behavioral health care, including SUD health care and receive services from an Indian Health Service facility, tribal health clinic or program or urban clinic. Refer to OAR 410-141-0060.
(4) If a client is enrolled in a PHP there may be PA requirements for some services that are provided through the PHP. The IHCP shall contact the PHP prior to providing services to any:
(a) Non-AI/AN OHP clients enrolled in a PHP and with whom the IHCP has a contract to comply with the PHP’s PA requirements or other policies necessary for reimbursement from the PHP. The IHCP must contact the client’s PHP for specific instructions;
(b) AI/AN OHP client enrolled in a PHP with whom the IHCP does not have a contract to comply with PA requirements in these rules, the General Rules, and applicable Division program rules.
(5) If a client receives services on a FFS basis or is an AI/AN PHP-enrolled client with whom the IHCP does not have a contract and plans to bill the Division directly on an FFS basis, a PA may be required from the Division for certain services. An IHCP assumes full financial risk in providing services to a client prior to receiving authorization or in providing services that are not in compliance with Oregon Administrative Rules.
(6) If the service or item is subject to PA, the IHCP must follow and comply with PA requirements in these rules, the General Rules, and applicable program rules, including but not limited to:
(a) 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 in the provider’s files to adequately determine the type, medical appropriateness, or quantity of services provided;
(b) The services provided are consistent with the information submitted when authorization was requested;
(c) The services billed are consistent with the services provided; and
(d) The services are provided within the timeframe specified on the authorization of payment document.

Source: Rule 410-146-0060 — Prior Authorization, https://secure.­sos.­state.­or.­us/oard/view.­action?ruleNumber=410-146-0060.

Last Updated

Jun. 8, 2021

Rule 410-146-0060’s source at or​.us