OAR 410-147-0060
Prior Authorization
(1)
Most Oregon Health Plan (OHP) clients have prepaid health services, contracted for by the Oregon Health Authority (Authority) through enrollment in a prepaid health plan (PHP). client’s who are not enrolled in a PHP, receive services on an “open card” or "fee-for-service” (FFS) basis.(2)
It is the responsibility of the Provider to verify whether a PHP or Division is responsible for reimbursement. Refer to OAR 410-120-1140 (Verification of Eligibility and Coverage) Verification of Eligibility.(3)
If a client is enrolled in a PHP there may be Prior Authorization (PA) requirements for some services that are provided through the PHP. It is the Federally Qualified Health Center (FQHC) or Rural Health Clinic(RHC) responsibility to comply with the PHP’s PA requirements or other policies necessary for reimbursement from the PHP before providing services to any OHP client enrolled in a PHP. The FQHC or RHC needs to contact the client’s PHP for specific instructions.(4)
Clients who are enrolled in a PHP can receive family planning services, human immunodeficiency virus (HIV) and acquired immune deficiency syndrome (AIDS) prevention services (excludes any treatment for HIV or AIDS) through an FQHC or RHC without PA from the PHP as provided under the terms of Oregon’s Section 1115 (CMS) Waiver. If the FQHC or RHC does not have a contract or other arrangements with a PHP, and the PHP denies payment, the Division of Medical Assistance Programs (Division) will reimburse for these services per a clinic’s encounter rate (see OAR 410-147-0120 (Division Encounter and Recognized Practitioners)(12)(b)).(5)
If a client receives services on a FFS basis, a PA may be required by Division for certain covered services or items before the service can be provided or before payment will be made. An FQHC or RHC assumes full financial risk in providing services to a FFS client prior to receiving authorization, or in providing services that are not in compliance with OARs. See OAR 410-120-1320 (Authorization of Payment) Authorization of Payment and any applicable program rules.(6)
If the service or item is subject to Prior Authorization, the FQHC or RHC 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 those services provided; and(d)
The services are provided within the timeframe specified on the authorization of payment document.
Source:
Rule 410-147-0060 — Prior Authorization, https://secure.sos.state.or.us/oard/view.action?ruleNumber=410-147-0060.