Or. Admin. Code § 410-151-0003 - Utilization Management Requirements
(1) The Oregon Health Authority (Authority)
and Managed Care Entities (MCEs) do not have the right to pre-establish limits
or caps on the amount of services or number of visits covered for EPSDT
Beneficiaries. Instead, coverage decisions must be made in accordance with OAR
410-151-0002. However, it is
acceptable to establish limits (for example, 10 physical therapy visits)
subject to prior authorization for coverage of additional services.
(2) The Authority and MCEs do not have the
right to require prior authorization for any EPSDT screening
services.
(3) The Authority and
MCEs shall promptly complete prior authorization procedures in accordance with
OAR 410-141-3835 and OAR
410-130-0200 and the individual
program chapter 410 and 309 OARs as applicable.
(4) The Authority and MCEs shall ensure
prompt delivery of EPSDT Medically Necessary and EPSDT Medically Appropriate
(or EPSDT Dentally Appropriate) services to EPSDT Beneficiaries.
Notes
Statutory/Other Authority: ORS 413.042
Statutes/Other Implemented: ORS 414.025, 414.065 & 414.150
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