Or. Admin. Code § 410-131-0160 - Prepayment Review (PPR) and Prior Authorization (PA) for Payment
(1) Most OHP
clients have prepaid health services contracted for by the Authority through
enrollment in a Managed Care Entity (MCE).
(2) The provider shall verify whether an MCE
or the Division is responsible for reimbursement. Refer to OAR
410-120-1140 Verification of
Eligibility and Coverage.
(3) If a
client is enrolled in an MCE, there may be PA requirements for some services
that are provided through the MCE. Providers shall comply with the MCE's PA
requirements or other policies necessary for reimbursement from the MCE before
providing services to any OHP client enrolled in an MCE. The physical or
occupational therapy (PT/OT) provider shall contact the client's MCE for
specific instructions.
(4) A PT/OT
provider assumes full financial risk in providing services to a FFS client in
providing services that are not in compliance with Oregon Administrative Rules.
See also OAR 410-120-1320 Authorization of
Payment.
(a) PT/OT initial evaluations and
re-evaluations are not subject to PPR and do not require a PA;
(b) To ensure reimbursement of PT/OT services
and procedures beyond the initial evaluation, the PT/OT provider must submit
all required supporting documentation:
(A)
Upon submission of the first claim in a series of claims in each therapy plan
of care as established by prescribing practitioner per OAR
410-131-0080 for claims subject
to PPR;
(B) Request a PA within
five working days following 30 rehabilitative or 30 habilitative visits within
a calendar year if additional visits are necessary:
(i) PA requests dated within five working
days may be approved retroactively to include services provided within five
days prior to the date of the PA request;
(ii) PA requests dated beyond five working
days may not be authorized retroactively and if authorized shall be effective
the date of the PA request. The Division recognizes the facsimile or postmark
as the PA date of request.
(c) All claims subject to PPR or that require
PA must include a therapy plan of care; and
(d) A PA is not required for Medicare-covered
PT/OT services provided to dual-eligible clients (Medicare clients who are also
Medicaid-eligible).
(5)
If the service or item is subject to PPR or requiring PA, the PT/OT provider
shall follow and comply with PPR and PA requirements in these rules and the
General Rules, (OAR chapter 410, division 120) including but not limited to:
(a) The service is adequately documented (see
OAR 410-120-1360 Requirements for
Financial, Clinical and Other Records). Providers shall 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;
(d) The
services are provided within the timeframe specified on the authorization of
payment document; and
(e) Includes
the PA number on all claims for occupational and physical therapy services that
require PA, or the Division shall deny the claim.
(6) The following services are subject to PPR
when paired above the funding line on the HERC prioritized list (see OAR
410-141-3820) if visits have not
exceeded the allowed 30 habilitative and 30 rehabilitative visits allowed in a
calendar year:
(a) 95831 Manual muscle
testing of arm, leg or trunk;
(b)
95832 Manual muscle testing of hand;
(c) 95833 Manual muscle testing of whole
body;
(d) 95834 Manual muscle
testing of whole body including hands;
(e) 95851 Range of motion testing of arm, leg
or each spine section;
(f) 95852
Range of motion testing of hand;
(g) 97012 Application of mechanical traction
to 1 or more areas;
(h) 97022
Application of whirlpool therapy to 1 or more areas;
(i) 97036 Physical therapy treatment to 1 or
more areas, Hubbard tank, each 15 minutes;
(j) 97110 Therapeutic exercise to develop
strength, endurance, range of motion, and flexibility, each 15
minutes;
(k) 97112 Therapeutic
procedure to re-educate brain-to-nerve-to-muscle function, each 15
minutes;
(l) 97113 Water pool
therapy with therapeutic exercises to 1 or more areas, each 15
minutes;
(m) 97116 Walking training
to 1 or more areas, each 15 minutes;
(n) 97124 Therapeutic massage to 1 or more
areas, each 15 minutes;
(o) 97140
Manual (physical) therapy techniques to 1 or more regions, each 15
minutes;
(p) 97150 Therapeutic
procedures in a group setting (1 visit = 1 unit);
(q) 97530 Therapeutic activities to improve
function, with one-on-one contact between patient and provider, each 15
minutes;
(r) 97532 Development of
cognitive skills to improve attention, memory, or problem solving, each 15
minutes;
(s) 97535 Self-care or
home management training, each 15 minutes;
(t) 97542 Wheelchair management, each 15
minutes;
(u) 97755 Assistive
technology assessment to enhance functional performance, each 15 minutes;
and
(v) 97761 Training in use of
prosthesis for arms and/or legs, per 15 minutes.
(7) PA is required when:
(a) There is documented need for extended
service, considering 60 minutes as the maximum length of a treatment
session;
(b) There is documented
need for continuing rehabilitative or habilitative therapy, considering 30
habilitative and 30 rehabilitative visits in a calendar year.
(c) Requesting services for treatments that
are below the funded line or not otherwise excluded from coverage per OAR
410-141-3820.
Notes
Table 410-131-0160 -1 is attached.
Table 410-131-0160 -1 Services Require Prior Authorization (Once visits exceed 30 visits a year for children (age 20 years or younger))
|
95831 |
97036 |
97530 |
|
95832 |
97110 |
97532 |
|
95833 |
97112 |
97535 |
|
95834 |
97113 |
97542 |
|
95851 |
97116 |
97755 |
|
95852 |
97124 |
97760 |
|
97012 |
97140 |
97761 |
|
97022 |
97150 (1 visit = 1 unit) |
97762 |
Statutory/Other Authority: ORS 413.042
Statutes/Other Implemented: ORS 414.025 & ORS 414.065
State regulations are updated quarterly; we currently have two versions available. Below is a comparison between our most recent version and the prior quarterly release. More comparison features will be added as we have more versions to compare.
No prior version found.