Or. Admin. Code § 410-120-1320 - Authorization of Payment
(1) Some
services or items covered by the Division require authorization before the
service can be provided. See the appropriate Division rules for information on
services requiring authorization and the process to be followed to obtain
authorization.
(2) Documentation
submitted when requesting authorization must support the medical justification
for the service. A complete request is one that contains all necessary
documentation and meets any other requirements as described in the appropriate
Division rules.
(3) The Division
will authorize for the level of care or type of service that meets the client's
medical need. Only services which are medically appropriate and for which the
required documentation has been supplied may be authorized. The authorizing
agency may request additional information from the provider to determine
medical appropriateness or appropriateness of the service.
(4) The Division will not make payment for
authorized services under the following circumstances:
(a) The client was not eligible at the time
services were provided. The provider is responsible for checking the client's
eligibility each time services are provided;
(b) The provider cannot produce appropriate
documentation to support medical appropriateness, or the appropriate
documentation was not submitted to the authorizing agency;
(c) The service has not been adequately
documented (see OAR 410-120-1360, Requirements for
Financial, Clinical and Other Records); that is, the documentation in the
provider's files is not adequate to determine the type, medical
appropriateness, or quantity of services provided and required documentation is
not in the provider's files;
(d)
The services billed or provided are not consistent with the information
submitted when authorization was requested or the services provided are
determined retrospectively not to be medically appropriate;
(e) The services billed are not consistent
with those provided;
(f) The
services were not provided within the timeframe specified on the authorization
of payment document;
(g) The
services were not authorized or provided in compliance with the rules in these
General Rules and in the appropriate provider rules.
(5) Retroactive authorizations:
(a) Authorization for payment may be given
for a past date of service if:
(A) The client
was made retroactively eligible or was retroactively disenrolled from a CCO or
PHP on the date of service;
(B) The
services provided meet all other criteria and Oregon Administrative Rules,
and;
(C) The request for
authorization is received within 90 days of the date of service;
(b) Any requests for authorization
after 90 days from date of service require documentation from the Provider that
authorization could not have been obtained within 90 days of the date of
service.
(6) Payment
authorization is valid for the time period specified on the authorization
notice, but not to exceed 12 months, unless the Client's benefit package no
longer covers the service, in which case the authorization will terminate on
the date coverage ends.
(7) When
clients have other health care coverage (third-party resources, or TPR), the
Division only requires payment authorization for the services that TPR does not
cover. Examples include::
(a) When Medicare is
the primary payer for a service, no payment authorization from the Division is
required, unless specified in the appropriate Division program rules;
(b) When other TPR is primary, such as Blue
Cross, CHAMPUS, etc., the Division requires payment authorization when the
other insurer or resource does not cover the service or reimburses less than
the Division rate.
Notes
Statutory/Other Authority: ORS 413.042 & 414.065
Statutes/Other Implemented: ORS 414.065
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