Or. Admin. Code § 410-148-0060 - Authorization

(1) The Division requires authorization of payment for the following items or services:

(a) All nursing service visits, except the assessment nursing visit, associated with home enteral/parenteral nutrition or IV services;

(b) All oral formula and nutritional supplements;

(c) Human Donor Milk;

(d) Items and services identified as requiring authorization in OAR Chapter 410, Division 148 administrative rules;

(e) All drugs and goods identified as requiring payment authorization in the Pharmaceutical Services administrative rules (chapter 410, division 121). Contact the Division's Pharmacy Benefit Manager to determine those items that require prior authorization.

(2) The Division shall approve payment for the above home enteral/parenteral nutrition and/or IV services entities when the Division administrative rules are met, and services are medically appropriate and medically necessary as defined in OAR Chapter 410 Division 120 for adult beneficiaries and as defined in Chapter 410 Division 151 for EPSDT beneficiaries.

(3) The Division requires authorization of payment for those services that require authorization even though the client has other insurance that may cover the service. Authorization of payment is not required for Medicare covered services.

(4) For services requiring authorization, providers must contact the Division's Medical Unit for authorization within five (5) working days following initiation of services. Authorization shall be given based on medical appropriateness, appropriateness of level of care given, cost and/or effectiveness.

(5) How to obtain payment authorization:

(a) The Division's Medical Unit is responsible for authorization for services for clients identified as Medically Fragile Children's Unit clients;

(b) Contact the Division's Pharmacy Benefit Manager, prior authorization help desk to request oral nutrition supplements;

(c) Contact the Division's Medical Unit to request all other authorization;

(d) Payment authorization does not guarantee reimbursement.

Notes

Or. Admin. Code § 410-148-0060

PWC 818(Temp), f. 10-22-76, ef. 11-1-76; PWC 831, f. 2-18-77, ef. 3-1-77; PWC 869, f. 12-30-77, ef. 1-1-78; AFS 70-1981, f. 9-30-81, ef. 10-1-81; AFS 44-1982, f. 4-30-82 & AFS 52-1982, f. 5-28-82, ef. 5-1-82 for providers located in the geographical areas covered by the branch offices of North Salem, South Salem, Dallas, Woodburn, McMinnville, Lebanon, Albany and Corvallis, ef. 6-30-82 for remaining AFS branch offices; AFS 99-1982, f. 10-25-82, ef. 11-1-82; AFS 12-1984, f. 3-16-84, ef. 4-1-84; AFS 26-1984, f. & ef. 6-19-84; AFS 53-1985, f. 9-20-85, ef. 10-1-85; AFS 52-1986, f. & ef. 7-2-86; AFS 15-1987, f. 3-31-87, ef. 4-1-87; AFS 4-1989, f. 1-31-89, cert. ef. 2-1-89; AFS 56-1989, f. 9-28-89, cert. ef. 10-1-89, Renumbered from 461-016-0090; HR 26-1990, f. 8-31-90, cert. ef. 9-1-90, Renumbered from 461-016-0220; HR 9-1992, f. & cert. ef. 4-1-92; HR 26-1993, f. & cert. ef. 10-1-93; HR 3-1995, f. & cert. ef. 2-1-95; OMAP 7-1998, f. 2-27-98, cert. ef. 3-1-98; OMAP 29-2000, f. 9-29-00, cert. ef. 10-1-00; OMAP 46-2001, f. 9-24-01, cert. ef. 10-1-01, Renumbered from 410-121-0680; OMAP 22-2003, f. 3-26-03, cert. ef. 4-1-03; OMAP 63-2003, f. 9-5-03, cert. ef. 10-1-03; DMAP 26-2008, f. 6-13-08, cert. ef. 7-1-08; DMAP 38-2011, f. 12-13-11, cert. ef. 1-1-12; DMAP 116-2024, amend filed 08/09/2024, effective 8/9/2024

Publications: Publications referenced are available from the agency.

Statutory/Other Authority: ORS 413.042

Statutes/Other Implemented: ORS 414.065