Current through Register Vol. 60, No. 12, December 1, 2021
Outpatient services that may require prior authorization (PA) include (see the
individual program in the Authority's Health Systems Division (Division))
Oregon Administrative Rules:
Therapy (chapter 410, division 131);
(b) Occupational Therapy (chapter 410,
(c) Speech Therapy
(chapter 410, division 129);
Audiology (chapter 410, division 129);
(e) Hearing Aids (chapter 410, division 129);
(f) Dental Procedures (chapter
410, division 123);
(chapter 410, division 121);
Apnea monitors, services, and supplies (chapter 410, division 122);
(i) Home Parenteral/Enteral Therapy (chapter
410, division 148);
Medical Equipment and Medical supplies (chapter 410, division 122);
(k) Certain hospital services.
(2) The National Drug Code (NDC)
must be included on the electronic (837I) and paper (UB 04) claims for
physician administered drug codes required by the Deficit Reduction Act of
(a) For Coordinated Care
Organization (CCO) members: Contact the CCO. The CCO may have different PA
requirements than the Division. Some services are not covered under CCO
contracts and require PA from the Division, or the Division's Dental Services
(b) For Medicare
clients enrolled in a CCO: These services must be authorized by the CCO even if
Medicare is the primary payer. Without this authorization, the provider may not
be paid beyond any Medicare payments (see also OAR 410-125-0103);
For fee-for-service clients on the OHP
Plus benefit package:
(A) Surgical procedures
listed in OAR 410-125-0080 require PA when performed in an outpatient or day
surgery setting, unless they are urgent or emergent;
(B) Contact the Division for PA (unless
indicated otherwise in OAR 410-125-0080).
(d) Out-of-State services: Outpatient
services provided by hospitals located less than 75 miles from the border of
Oregon do not require PA unless specified in the Division's Hospital Services
Program rules. All non-urgent or non-emergent services provided by hospitals
located more than 75 miles from the border of Oregon require PA. For clients
enrolled in a CCO, contact the CCO for authorization. For clients not enrolled
in a health plan, contact the Division's Provider Clinical Support Unit.
Emergency Services (PES):
emergency services as defined by OAR 309-023-0110 delivered in a PES facility
as described in OAR 309-023-0120 shall be reimbursed for a maximum of 20 hours
emergency services shall be reimbursed with a bundled, hourly rate using a
fee-for-service rate methodology that is based on rates paid for similar
services, using similar providers at a similar level-of-care.
Or. Admin. R.
HR 42-1991, f. & cert.
ef. 10-1-91; HR 39-1992, f. 12-31-92, cert. ef. 1-1-93; HR 36-1993, f. &
cert. ef. 12-1-93; HR 5-1994, f. & cert. ef. 2-1-94; HR 4-1995, f. &
cert. ef. 3-1-95; OMAP 34-1999, f. & cert. ef. 10-1-99; OMAP 70-2004, f.
9-15-04, cert. ef. 10-1-04; DMAP 39-2008, f. 12-11-08, cert. ef. 1-1-09; DMAP
32-2010, f. 12-15-10, cert. ef. 1-1-11; DMAP 37-2011, f. 12-13-11, cert. ef.
1-1-12; DMAP 75-2013(Temp), f. 12-31-13, cert. ef. 1-1-14 thru 6-30-14; DMAP
23-2014, f. & cert. ef. 4-4-14; DMAP 63-2016(Temp), f. & cert. ef.
11-10-16 thru 5-8-17;
77-2016, f. 12-29-16, cert. ef.
Stat. Auth.: ORS
Stats. Implemented: ORS