Current through Register Vol. 60, No. 12, December 1, 2021
(1) Most OHP
clients have prepaid health services contracted for by the Authority through
enrollment in a Managed Care Entity (MCE).
(2) The provider shall verify whether an MCE
or the Division is responsible for reimbursement. Refer to OAR 410-120-1140
Verification of Eligibility and Coverage.
(3) If a client is enrolled in an MCE, there
may be PA requirements for some services that are provided through the MCE.
Providers shall comply with the MCE's PA requirements or other policies
necessary for reimbursement from the MCE before providing services to any OHP
client enrolled in an MCE. The physical or occupational therapy (PT/OT)
provider shall contact the client's MCE for specific instructions.
A PT/OT provider assumes full financial
risk in providing services to a FFS client in providing services that are not
in compliance with Oregon Administrative Rules. See also OAR 410-120-1320
Authorization of Payment.
(a) PT/OT initial
evaluations and re-evaluations are not subject to PPR and do not require a
To ensure reimbursement of
PT/OT services and procedures beyond the initial evaluation, the PT/OT provider
must submit all required supporting documentation:
(A) Upon submission of the first claim in a
series of claims in each therapy plan of care as established by prescribing
practitioner per OAR 410-131-0080 for claims subject to PPR;
Request a PA within five working days
following 30 rehabilitative or 30 habilitative visits within a calendar year if
additional visits are necessary:
requests dated within five working days may be approved retroactively to
include services provided within five days prior to the date of the PA
(ii) PA requests dated
beyond five working days may not be authorized retroactively and if authorized
shall be effective the date of the PA request. The Division recognizes the
facsimile or postmark as the PA date of request.
(c) All claims subject to PPR or
that require PA must include a therapy plan of care; and
(d) A PA is not required for Medicare-covered
PT/OT services provided to dual-eligible clients (Medicare clients who are also
If the service or item is subject to PPR or requiring PA, the PT/OT provider
shall follow and comply with PPR and PA requirements in these rules and the
General Rules, (OAR chapter 410, division 120) including but not limited to:
(a) The service is adequately documented (see
OAR 410-120-1360 Requirements for Financial, Clinical and Other Records).
Providers shall maintain documentation in the provider's files to adequately
determine the type, medical appropriateness, or quantity of services
(b) The services provided
are consistent with the information submitted when authorization was
(c) The services billed
are consistent with those services provided;
(d) The services are provided within the
timeframe specified on the authorization of payment document; and
(e) Includes the PA number on all claims for
occupational and physical therapy services that require PA, or the Division
shall deny the claim.
The following services are subject to PPR
when paired above the funding line on the HERC prioritized list (see OAR
410-141-0520) if visits have not exceeded the allowed 30 habilitative and 30
rehabilitative visits allowed in a calendar year:
(a) 95831 Manual muscle testing of arm, leg
(b) 95832 Manual muscle
testing of hand;
(c) 95833 Manual
muscle testing of whole body;
95834 Manual muscle testing of whole body including hands;
(e) 95851 Range of motion testing of arm, leg
or each spine section;
Range of motion testing of hand;
(g) 97012 Application of mechanical traction
to 1 or more areas;
Application of whirlpool therapy to 1 or more areas;
(i) 97036 Physical therapy treatment to 1 or
more areas, Hubbard tank, each 15 minutes;
(j) 97110 Therapeutic exercise to develop
strength, endurance, range of motion, and flexibility, each 15
(k) 97112 Therapeutic
procedure to re-educate brain-to-nerve-to-muscle function, each 15 minutes;
(l) 97113 Water pool therapy with
therapeutic exercises to 1 or more areas, each 15 minutes;
(m) 97116 Walking training to 1 or more
areas, each 15 minutes;
Therapeutic massage to 1 or more areas, each 15 minutes;
(o) 97140 Manual (physical) therapy
techniques to 1 or more regions, each 15 minutes;
(p) 97150 Therapeutic procedures in a group
setting (1 visit = 1 unit);
97530 Therapeutic activities to improve function, with one-on-one contact
between patient and provider, each 15 minutes;
(r) 97532 Development of cognitive skills to
improve attention, memory, or problem solving, each 15 minutes;
(s) 97535 Self-care or home management
training, each 15 minutes;
97542 Wheelchair management, each 15 minutes;
(u) 97755 Assistive technology assessment to
enhance functional performance, each 15 minutes; and
(v) 97761 Training in use of prosthesis for
arms and/or legs, per 15 minutes.
PA is required when:
(a) There is documented need for extended
service, considering 60 minutes as the maximum length of a treatment
(b) There is documented
need for continuing rehabilitative or habilitative therapy, considering 30
habilitative and 30 rehabilitative visits in a calendar year.
(c) Requesting services for treatments that
are below the funded line or not otherwise excluded from coverage per OAR
Or. Admin. R.
PWC 706, f.
1-2-75, ef. 2-1-75; PWC 760, f. 9-5-75, ef. 10-1-75; AFS 46-1982, f. 4-30-82,
ef. 5-1-82; AFS 52-1982, f. 5-28-82, ef. 6-30-82; AFS 98-1982, f. 10-25-82, ef.
11-1-82; AFS 14-1984(Temp), f. & ef. 4-2-84; AFS 22-1984(Temp), f. &
ef. 5-1-84; AFS 40-1984, f. 9-18-84, ef. 10-1-84; AFS 63-1987, f. 12-30-87, ef.
4-1-88; HR 8-1991, f. 1-25-91, cert. ef. 2-1-91, Renumbered from 461-023-0015;
HR 19-1992, f. & cert. ef. 7-1-92; HR 28-1993, f. & cert. ef. 10-1-93;
HR 43-1994, f. 12-30-94, cert. ef. 1-1-95; HR 2-1997, f. 1-31-97, cert. ef.
2-1-97; OMAP 8-1998, f. & cert. ef. 3-2-98; OMAP 18-1999, f. & cert.
ef. 4-1-99; OMAP 32-2000, f. 9-29-00, cert. ef. 10-1-00; OMAP 41-2001, f.
9-24-01, cert. ef. 10-1-01; OMAP 53-2002, f. & cert. ef. 10-1-02; OMAP
92-2003, f. 12-30-03 cert. ef. 1-1-04; OMAP 59-2004, f. 9-10-04, cert. ef.
10-1-04; DMAP 35-2011, f. 12-13-11, cert. ef. 1-1-12; DMAP 49-2016, f. 7-26-16,
cert. ef. 8-1-16; DMAP 56-2017, amend filed 12/26/2017, effective 01/01/2018;
DMAP 100-2018, amend filed 11/06/2018, effective 11/06/2018; DMAP 102-2018,
amend filed 12/13/2018, effective 12/13/2018;
18-2019, temporary amend filed 06/18/2019, effective
7/1/2019 through 12/27/2019;
44-2019, amend filed 11/06/2019, effective
Table 410-131-0160-1 is attached.
Table 410-131-0160-1 Services Require Prior Authorization
(Once visits exceed 30 visits a year for children (age 20 years or
97150 (1 visit = 1 unit)
Statutory/Other Authority: ORS
Statutes/Other Implemented: ORS