OAR 410-172-0650
Prior Authorization

(1) Some services or items covered by the Division require authorization before the service may be provided. Services requiring prior authorization are published on the Medicaid Behavioral Health Services Fee Schedule.
(2) The Division shall authorize payment for the type of service or level of care that meets the recipient’s medical need and that has been adequately documented.
(3) The Division shall authorize only services that are medically appropriate and for which the required documentation has been supplied. The Division may request additional information from the provider to determine medical appropriateness.
(4) Documentation submitted when requesting prior authorization shall support the medical justification for the service. The authorization request shall contain:
(a) A cover sheet detailing relevant provider and recipient Medicaid numbers;
(b) Requested dates of service;
(c) HCPCS or CPT Procedure code requested;
(d) Amount of service or units requested; and
(e) A behavioral health assessment and service plan meeting the requirements described in OAR 309-019-0135 (Entry and Assessment) through 0140; or
(f) Any additional clinical information supporting medical justification for the services requested;
(g) For substance use disorder services (SUD), the Division uses the American Society of Addiction Medicine (ASAM) Patient Placement Criteria second edition-revised (PPC-2R) to determine the appropriate level of SUD treatment of care. Providers shall use the ASAM;
(h) For Applied Behavior Analysis (ABA) services, the Division requires submission of the following:
(A) ABA services for the treatment of autism spectrum disorder shall have an evaluation as described in OAR 410-172-0770 (Individual Eligibility for Applied Behavioral Analysis Treatment)(1)(a–j) and a referral for treatment as described in OAR 410-172-0760 (Applied Behavior Analysis)(1) from one of the licensed practitioners described in OAR 410-172-0760 (Applied Behavior Analysis)(1)(a–d) who are, in addition, experienced in the diagnosis of autism spectrum disorder;
(B) ABA services for the treatment of stereotyped movement disorder with self-injurious behavior due to neurodevelopmental disorder shall have an evaluation as described in OAR 410-172-0770 (Individual Eligibility for Applied Behavioral Analysis Treatment)(2) and a referral for treatment as described in OAR 410-172-0760 (Applied Behavior Analysis)(2) from a licensed practitioner, practicing within the scope of their license who has experience or training in the diagnosis and treatment of stereotyped movement disorder with self-injurious behavior due to neurodevelopmental disorder;
(C) A treatment plan, including a functional behavior assessment, as needed, from a licensed health care professional as defined in ORS 676.802 (Definitions for ORS 676.802, 676.806 and 676.810 to 676.820)(2)(a–h), or by a behavior analyst or assistant behavior analyst licensed by the Oregon Behavior Analysis Regulatory Board, or by an individual holding a declaration of practice through the Oregon Behavior Analysis Regulatory Board as described in OAR 824-010-0005 (Definitions)(10).
(i) For Intensive In-Home Behavioral Treatment Services (IIHBT), the Division requires submission of the following, in addition to the requirements described in 410-172-0650 (Prior Authorization)(4)(a-f) to the Division or the Division’s contractor:
(A) For the initial Prior Authorization request for sixty (60) days that includes:
(i) Documentation by, at minimum, a Qualified Mental Health Professional, Licensed Medical Practitioner, Licensed Clinical Practitioner, or psychologist, justifying IIBHT level of care;
(ii) Sufficient information and documentation to justify the presence of a qualifying DSM-5 diagnosis that is the medically necessary reason for services;
(iii) An assessment of risk of injury to self or others which includes a safety plan and counseling with the youth and family to reduce the risk of suicide and harm to others through lethal means, including but not limited to firearms and medications;
(B) For requests for continued prior authorization every thirty (30) days include:
(i) Documentation by, at minimum, a Qualified Mental Health Professional, Licensed Medical Practitioner, Licensed Clinical Practitioner, psychologist, justifying medical necessity for continued IIBHT level of care;
(ii) Documentation supporting the full extent of services for which payment has been requested as described on OAR 410-172-0620 (Documentation Standards); and
(C) For a 30-day prior authorization for transition out of IIBHT services include:
(i) The services and supports necessary to ensure a successful transition plan;
(ii) Prevention strategies;
(iii) Action steps to engage prevention strategies;
(iv) A description of the crisis management roles and responsibilities specific to each person on the treatment team;
(v) Communication protocols;
(vi) A plan for ongoing maintenance of skills and progress of IIBHT services;
(vii) Development of connections to post-IIBHT resources and supports, including formal and natural supports; and
(viii) Written instructions on how and when to access IIBHT services, in the future, as needed.
(D) IIBHT transition will be based on clinical documentation demonstrating symptoms improving or expected to approve, as well as, IIBHT treatment team written recommendation for transition.
(j) Residential treatment services for children may require a letter of approval by a designated quality improvement organization (QIO);
(k) Some services require additional approval or authorization by a physician, the Division, or designee. Services requiring additional approval are listed on the Behavioral Health Fee Schedule or described in this rule.
(5) The Division may not authorize services under the following circumstances:
(a) The request received by the Division was not complete;
(b) The provider did not hold the appropriate license, certificate, or credential at the time services were requested;
(c) The recipient was not eligible for Medicaid at the time services were requested;
(d) The provider cannot produce appropriate documentation to support medical appropriateness, or the appropriate documentation was not submitted to the Division;
(e) The services requested are not in compliance with OAR 410-120-1260 (Provider Enrollment) through 1860;
(f) The provider is not currently enrolled in the Medicaid program or has not met requirements of OAR 410-120-1260 (Provider Enrollment), provider is currently suspended from the Medicaid program, or provider’s Division-assigned provider number is deactivated for any reason.
(6) Authorization for payment may be given for a past date of service if:
(a) On the date of service, the recipient was made retroactively eligible or was retroactively dis-enrolled from a CCO or PHP;
(b) The services provided meet all other criteria and Division administrative rules; and
(c) The request for authorization is received within 90 days of the date of service.
(7) Any requests for authorization after 90 days from date of service require documentation from the provider demonstrating the specific reason why authorization could not have been obtained within 90 days of the date of service.
(8) Payment authorization is valid for the time-period specified on the authorization notice but may not exceed 12 months unless the recipient’s benefit package no longer covers the service, in which case the authorization shall terminate on the date coverage ends.
(9) Prior authorization of services shall be subject to periodic utilization review and retrospective review to ensure services meet the definition of medical appropriateness.
(10) Payments shall be made for the provision of active treatment services. If active treatment is not documented during any period in which the Division prior authorized the services, the Division may limit or cancel prior authorization or recoup the payments.
(11) If providers fail to comply with requests for documents for purposes of verifying medical appropriateness within the specified time-frames, the Division may deem the records non-existent, cancel prior authorization and recoup payments.
(12) In applying OAR 410-141-3061, OAR 410-172-0650 (Prior Authorization) (5)(f), and OAR 410-172-0650 (Prior Authorization)(6), the Division may construe them as much as possible to be complementary. In the event that OAR 410-141-3061, OAR 410-172-0650 (Prior Authorization)(5)(f) and OAR 410-172-0650 (Prior Authorization)(6) may not be complementary, the Division shall apply the following order of precedence to guide its interpretation: OAR 410-120-0025 (Administration of Division of Medical Assistance Programs, Regulation and Rule Precedence), OAR 410-141-3061, OAR 410-172-0650 (Prior Authorization)(5)(f), and OAR 410-172-0650 (Prior Authorization)(6).

Source: Rule 410-172-0650 — Prior Authorization, https://secure.­sos.­state.­or.­us/oard/view.­action?ruleNumber=410-172-0650.

410‑172‑0600
Acronyms and Definitions 410‑172‑0610
Provider Enrollment 410‑172‑0620
Documentation Standards 410‑172‑0630
Medically Appropriate 410‑172‑0640
Behavioral Health Services Fee Schedule 410‑172‑0650
Prior Authorization 410‑172‑0660
Rehabilitative Behavioral Health Services 410‑172‑0670
Substance Use Disorder Treatment Services 410‑172‑0680
Residential Treatment Services for Children 410‑172‑0690
Admission Procedure for Residential Treatment Services for Children 410‑172‑0695
Intensive In-Home Behavioral Health Treatment Services for Youth (IIHBT) 410‑172‑0705
Residential Rate Standardization 410‑172‑0710
Residential Personal Care 410‑172‑0720
Prior Authorization and Re-Authorization for Residential Treatment 410‑172‑0730
Payment Limitations for Behavioral Health Services 410‑172‑0745
Exception Criteria for Facial Gender Confirmation Surgery (FGCS) 410‑172‑0760
Applied Behavior Analysis 410‑172‑0770
Individual Eligibility for Applied Behavioral Analysis Treatment 410‑172‑0780
Behavioral Health Personal Care Attendant Program 410‑172‑0790
Eligibility for Behavioral Health Personal Care Attendant Services 410‑172‑0800
Personal Care Attendant Employer-Employee Relationship 410‑172‑0810
Personal Care Attendant Qualifications 410‑172‑0820
Provider Termination 410‑172‑0830
Personal Care Attendant Service Assessment, Authorization, and Monitoring 410‑172‑0840
Personal Care Attendant Payment Limitations 410‑172‑0850
Telemedicine for Behavioral Health 410‑172‑0860
Billing for Dual Eligible Individuals
Last Updated

Jun. 8, 2021

Rule 410-172-0650’s source at or​.us