Or. Admin. Code § 410-127-0080 - Prior Authorization
(1)
Home health providers must obtain prior authorization (PA) for services as
specified in rule.
(2) Providers
must request PA as follows (see the Home Health Supplemental Information
booklet for contact information) and include the documentation requirements
from the Supplemental (e.g. plan of care, primary diagnosis, initial
assessment, evaluation, etc.):
(a) For
clients enrolled in a Coordinated Care Organization (CCO) or a Prepaid Health
Plan (PHP), from the CCO or the PHP;
(b) For all other clients, from the Division
of Medical Assistance Programs (Division).
(3) For services requiring authorization,
providers must contact the responsible unit for authorization within five
working days following initiation or continuation of services. The FAX or
postmark date on the request will be honored as the request date. It is the
provider's responsibility to obtain payment authorization. Authorization will
be given based on medical appropriateness and appropriate level of care, cost
and/or effectiveness as supported by submitted documentation. The plan of care
submitted must include the client's condition, the rationale for the care plan,
including justification for the required skill level of care and the summary of
care for additional certification periods.
(4) Payment authorization does not guarantee
reimbursement (e.g. eligibility changes, incorrect identification number,
provider contract ends).
(5) For
rules related to authorization of payment, including retroactive eligibility,
see General Rules, 410-120-1320.
Notes
Stat. Auth.: ORS 413.042
Stats. Implemented: ORS 414.065
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