Or. Admin. Code § 410-172-0650 - Prior Authorization
(1)
Some services or items covered by the Division require authorization before the
service may be provided. Services requiring prior authorization are published
on the Medicaid Behavioral Health Services Fee Schedule.
(2) The Division shall authorize payment for
the type of service or level of care that meets the recipient's medical need
and that has been adequately documented.
(3) The Division shall authorize only
services that are medically appropriate and for which the required
documentation has been supplied. The Division may request additional
information from the provider to determine medical appropriateness.
(4) Documentation submitted when requesting
prior authorization shall support the medical justification for the service.
The authorization request shall contain:
(a) A
cover sheet detailing relevant provider and recipient Medicaid
numbers;
(b) Requested dates of
service;
(c) HCPCS or CPT Procedure
code requested;
(d) Amount of
service or units requested; and
(e)
A behavioral health assessment and service plan meeting the requirements
described in OAR 309-019-0135 through 0140;
or
(f) Any additional clinical
information supporting medical justification for the services
requested;
(g) For substance use
disorder services (SUD), the Division uses the American Society of Addiction
Medicine (ASAM) Patient Placement Criteria second edition-revised (PPC-2R) to
determine the appropriate level of SUD treatment of care. Providers shall use
the ASAM;
(h) For Applied Behavior
Analysis (ABA) services, the Division requires submission of the following:
(A) ABA services for the treatment of autism
spectrum disorder shall have an evaluation as described in OAR
410-172-0770(1)
(a-j) and a referral for treatment as described in OAR
410-172-0760(1)
from one of the licensed practitioners described in OAR
410-172-0760(1)
(a-d) who are, in addition, experienced in the diagnosis of autism spectrum
disorder;
(B) ABA services for the
treatment of stereotyped movement disorder with self-injurious behavior due to
neurodevelopmental disorder shall have an evaluation as described in OAR
410-172-0770(2)
and a referral for treatment as described in OAR
410-172-0760(2)
from a licensed practitioner, practicing within the scope of their license who
has experience or training in the diagnosis and treatment of stereotyped
movement disorder with self-injurious behavior due to neurodevelopmental
disorder;
(C) A treatment plan,
including a functional behavior assessment, as needed, from a licensed health
care professional as defined in ORS
676.802(2)(a-h),
or by a behavior analyst or assistant behavior analyst licensed by the Oregon
Behavior Analysis Regulatory Board, or by an individual holding a declaration
of practice through the Oregon Behavior Analysis Regulatory Board as described
in OAR 824-010-0005(10).
(i) For Intensive In-Home Behavioral
Treatment Services (IIHBT), the Division requires submission of the following,
in addition to the requirements described in
410-172-0650(4)
(a-f), to the Division or the Division's contractor:
(A) Initial prior authorization request may
not exceed sixty (60) days, and authorization for continued services may be
approved in 30-day increments. Each request shall include:
(i) Documentation by, at minimum, a Qualified
Mental Health Professional, Licensed Medical Practitioner licensed in the state
of Oregon, Licensed Clinical Practitioner, or psychologist licensed by the
Oregon Board of Psychology, justifying IIBHT level of care;
(ii) Sufficient information and documentation
to justify the presence of two or more primary mental health diagnoses that
meets the medically necessary reason for services; and
(iii) Documentation displaying intensive
behavioral health needs, that may include significant health and safety risks
or concerns, impacting multiple life domains (school, home, community) as
identified on a mental health assessment.
(B) A 30-day authorization for transition out
of IIBHT services may be requested to support transition management for the
treatment team, youth, and their family, and shall include an updated service
plan describing ongoing maintenance of services and supports necessary for
transition planning.
(j)
Residential treatment services for children may require a letter of approval by
a designated Quality Improvement Organization (QIO);
(k) Some services require additional approval
or authorization by a physician, the Division, or designee. Services requiring
additional approval are listed on the Behavioral Health Fee Schedule or
described in this rule.
(5) The Division may not authorize services
under the following circumstances:
(a) The
request received by the Division was not complete;
(b) The provider did not hold the appropriate
license, certificate, or credential at the time services were
requested;
(c) The recipient was
not eligible for Medicaid at the time services were requested;
(d) The provider cannot produce appropriate
documentation to support medical appropriateness, or the appropriate
documentation was not submitted to the Division;
(e) The services requested are not in
compliance with OAR 410-120-1260 through
1860;
(f) The provider is not
currently enrolled in the Medicaid program or has not met requirements of OAR
410-120-1260, provider is
currently suspended from the Medicaid program, or provider's Division-assigned
provider number is deactivated for any reason.
(6) Authorization for payment may be given
for a past date of service if:
(a) On the date
of service, the recipient was made retroactively eligible or was retroactively
disenrolled from a CCO or PHP;
(b)
The services provided meet all other criteria and Division administrative
rules; and
(c) The request for
authorization is received within 90 days of the date of
service.
(7) Any requests
for authorization after 90 days from date of service require documentation from
the provider demonstrating the specific reason why authorization could not have
been obtained within 90 days of the date of service.
(8) Payment authorization is valid for the
time-period specified on the authorization notice but may not exceed 12 months
unless the recipient's benefit package no longer covers the service, in which
case the authorization shall terminate on the date coverage ends.
(9) Prior authorization of services shall be
subject to periodic utilization review and retrospective review to ensure
services meet the definition of medical appropriateness.
(10) Payments shall be made for the provision
of active treatment services. If active treatment is not documented during any
period in which the Division prior authorized the services, the Division may
limit or cancel prior authorization or recoup the payments.
(11) If providers fail to comply with
requests for documents for purposes of verifying medical appropriateness within
the specified time-frames, the Division may deem the records non-existent,
cancel prior authorization and recoup payments.
(12) In applying OAR
410-141-3061, OAR
410-172-0650
(5)(f), and OAR
410-172-0650(6),
the Division may construe them as much as possible to be complementary. In the
event that OAR 410-141-3061, OAR
410-172-0650(5)(f)
and OAR 410-172-0650(6)
may not be complementary, the Division shall apply the following order of
precedence to guide its interpretation: OAR
410-120-0025, OAR
410-141-3061, OAR
410-172-0650(5)(f),
and OAR 410-172-0650(6).
Notes
Statutory/Other Authority: ORS 413.042 & 430.640
Statutes/Other Implemented: ORS 413.042, 430.640, ORS 414.025, 414.065, 430.705 & 430.715
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