Or. Admin. Code § 410-147-0060 - Prior Authorization
(1) Most
Oregon Health Plan (OHP) clients have prepaid health services, contracted for
by the Oregon Health Authority (Authority) through enrollment in a Prepaid
Health Plan (PHP). Client's who are not enrolled in a PHP, receive services on
an "open card" or "fee-for-service" (FFS) basis.
(2) It is the responsibility of the Provider
to verify whether a PHP or DMAP is responsible for reimbursement. Refer to OAR
410-120-1140 Verification of
Eligibility.
(3) If a client is
enrolled in a PHP there may be Prior Authorization (PA) requirements for some
services that are provided through the PHP. It is the FQHC or RHC's
responsibility to comply with the PHP's PA requirements or other policies
necessary for reimbursement from the PHP before providing services to any OHP
Client enrolled in a PHP. The FQHC or RHC needs to contact the client's PHP for
specific instructions.
(4) Clients
who are enrolled in a PHP can receive family planning services, human
immunodeficiency virus (HIV) and acquired immune deficiency syndrome (AIDS)
prevention services (excludes any treatment for HIV or AIDS) through an FQHC or
RHC without PA from the PHP as provided under the terms of Oregon's Section
1115 (CMS) Waiver. If the FQHC or RHC does not have a contract or other
arrangements with a PHP, and the PHP denies payment, the Division of Medical
Assistance Programs (DMAP) will reimburse for these services per a clinic's
encounter rate (see OAR
410-147-0120(12)(b)).
(5) If a client receives services on a
"fee-for-service" basis, a PA may be required by DMAP for certain covered
services or items before the service can be provided or before payment will be
made. An FQHC or RHC assumes full financial risk in providing services to a
"fee-for-service" client prior to receiving authorization, or in providing
services that are not in compliance with Oregon Administrative Rules (OARs).
See OAR 410-120-1320 Authorization of
Payment and any applicable program rules.
(6) If the service or item is subject to
Prior Authorization, the FQHC or RHC must follow and comply with PA
requirements in these rules, the General Rules and applicable program rules,
including but not limited to:
(a) The service
is adequately documented (see OAR
410-120-1360, Requirements for
Financial, Clinical and Other Records). Providers must 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; and
(d)
The services are provided within the timeframe specified on the authorization
of payment document.
Notes
Stat. Auth.: ORS 413.042
Stats. Implemented: ORS 414.025 & 414.065
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