Or. Admin. Code § 410-125-0080 - Inpatient Services
(1)
Elective (not urgent or emergent) hospital admission:
(a) Coordinated Care Organization (CCO) and
Mental Health Organization (MHO) clients: Contact the client's CCO, or MHO. The
health plan may have different prior authorization (PA) requirements than the
Division;
(b) Medicare clients: The
Division does not require PA for inpatient services provided to clients with
Medicare Part A or B coverage;
(c)
Division clients: Oregon Health Plan (OHP) clients covered by the OHP Plus
Benefit Package:
(A) For a list of medical
and surgical procedures that require PA, see the Division's Medical-Surgical
Services Program, rules OAR chapter 410, division 130, specifically OAR
410-130-0200, table 130-0200-1,
unless they are urgent or emergent defined in OAR
410-125-0401;
(B) For PA, contact the Division unless
otherwise indicated in the Medical-Surgical Service program rules, specifically
OAR 410-130-0200, Table
130-0200-1.
(2) Transplant services:
(a) Complete rules for transplant services
are in the Division's Transplant Services Program rules, OAR chapter 410,
division 124;
(b) Clients are
eligible for transplants covered by the Oregon Health Evidence Review
Commission's Prioritized List of Health Services (Prioritized List). See the
Transplant Services Program administrative rules for criteria.
(3) Out-of-State non-contiguous
hospitals:
(a) All non-emergent and
non-urgent services provided by hospitals more than 75 miles from the Oregon
border require PA;
(b) Contact the
Division's Medical Director's office for authorization for clients not enrolled
in a Prepaid Health Plan (PHP). For clients enrolled in a PHP, contact the
plan.
(4) Out-of-State
contiguous hospitals: The Division prior authorizes services provided by
contiguous-area hospitals, less than 75 miles from the Oregon border, following
the same rules and procedures governing in-state providers.
(5) Transfers to another hospital:
(a) Transfers for the purpose of providing a
service listed in the Medical-Surgical Services program rules, specifically OAR
410-130-0200, Table 130-0200-1,
e.g., inpatient physical rehabilitation care, require PA.
(b) For transfers to a skilled nursing
facility, intermediate care facility, or swing bed, contact Aging and People
with Disabilities (APD). APD reimburses nursing facilities and swing beds
through contracts with the facilities. For CCO clients, transfers require
authorization and payment (for first 20 days) from the CCO;
(c) For transfers for the same or lesser
level inpatient care to a general acute-care hospital, the Division shall cover
transfers, including back transfers that are primarily for the purpose of
locating the patient closer to home and family, when the transfer is expected
to result in significant social or psychological benefit to the patient:
(A) The assessment of significant benefit
shall be based on the amount of continued care the patient is expected to need
(at least seven days) and the extent to which the transfer locates the patient
closer to familial support;
(B)
Payment for transfers not meeting these guidelines may be denied on the basis
of post-payment review.
(d) Exceptions:
(A) Emergency transfers do not require
PA;
(B) In-state or contiguous
non-emergency transfers for the purpose of providing care that is unavailable
in the transferring hospital do not require PA unless the planned service is
listed in the Medical-Surgical Service Program rules, specifically OAR
410-130-0200, Table
130-0200-1;
(C) All non-urgent
transfers to out-of-state, non-contiguous hospitals require PA.
(6) Dental procedures
provided in a hospital setting:
(a) For prior
authorization requirements, see the Division's Dental Services Program rules;
specifically OAR 410-123-1260 and
410-123-1490;
(b) Emergency dental services do not require
PA;
(c) For prior authorization for
fee-for-service clients, contact the Division's Dental Services Program
analyst. (See the Division's Dental Services Program Supplemental information,
http://www.oregon.gov/OHA/HSD/OHP/Pages/Policy-Dental.aspx);
(d) For clients enrolled in a CCO, contact
the client's health plan.
(7) Long-term acute care (LTAC) hospital
services authorization requirements:
(a) For
an initial thirty-day stay:
(A) LTAC provider
must, before admitting the client, submit a request for prior authorization to
the Division;
(B) Include
sufficient medical information to justify the requested initial stay;
(C) Meet the clinical criteria outlined in
the LTAC Hospital guide at:
http:www.oregon.gov/OHA/HSD/OHP/Pages/Policy-Hospital.aspx [File Link Not
Available].
(b)
Extension of stay:
(A) Submit request for
prior authorization to the Division;
(B) Include sufficient medical justification
for the extended stay.
Notes
Statutory/Other Authority: ORS 413.042
Statutes/Other Implemented: ORS 414.065
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