Or. Admin. Code § 410-140-0420

Current through Register Vol. 64, No. 1, January 1, 2025

Section 410-140-0420 - Prior Authorizations

(1) If a member has FFS the Division may require a Prior Authorization (PA) for certain covered services or items before the service may be provided and before payment is made; and

(2) Prior Authorization (PA) is defined in OAR 410-120-0000, OAR 410-120-1320, and OAR 410-140-0420. Providers must obtain a PA from the:

(a) Enrolled member's Managed Care Entity (MCE); or

(b) The Division for members who receive services on a fee-for-services basis and are not enrolled with an MCE.

(3) A PA does not guarantee eligibility or reimbursement. Providers must verify the member's eligibility on the date of service whether an MCE, or the Division is responsible for reimbursement.

(4) A PA is not required for members with Medicare or TPL and Division coverage when the service or item is covered by Medicare or TPL.

(5) Providers shall determine if a PA is required and comply with all PA requirements outlined in these rules.

(6) Providers shall ensure:

(a) That all PA requests are completed and submitted correctly. The Division does not accept PA requests via the phone. See Visual Services Supplemental Information Guide found at www.oregon.gov/OHA/HSD/OHP/Pages/Policy-Vision.aspx;

(b) PA requests must include:

(A) A statement of medical appropriateness and medical necessity showing the need for the item or service and why other options are inappropriate;

(B) Diopter information and appropriate International Classification of Diseases, 10th revision, Clinical Modification (ICD-10-CM) diagnosis codes;

(C) All relevant documentation that is needed for Division staff to make a determination for authorization of payment, including clinical data or evidence, medical history, any plan of treatment, or progress notes;

(c) The service is adequately documented. (See OAR 410-120-1360 Requirements for Financial, Clinical and Other Records.) Providers must maintain documentation to adequately determine the type, medical appropriateness, or quantity of services provided;

(d) The services or items provided are consistent with the information submitted when PA was requested;

(e) The services billed are consistent with the services provided; and

(f) The services are provided within the timeframe specified on the PA document.

(7) Providers shall comply with the Division's PA requirements or other policies necessary for reimbursement before providing services to any OHP member who is not enrolled in an MCE. Services or items denied due to provider error (e.g., required documentation not submitted, PA not obtained, etc.) may not be billed to the member.

(8) The following vision services require PA:

(a) Contact lenses for adults (age 21 and older) and excludes a primary keratoconus diagnosis, which is exempt from the PA requirement. (See OAR 410-140-0160 Contact Lens Services for service and supply coverage and limitations);

(b) Vision therapy greater than six (6) sessions. Six (6) sessions are allowed per calendar year without PA. (See OAR 410-140-0280 Vision Therapy Services); and

(c) Specific vision materials (See OAR 410-140-0260 Purchase of Ophthalmic Materials for more information.):

(A) Frames not included in the Division's contract with contractor, SWEEP Optical; and

(B) Specialty lenses or lenses considered as "not otherwise classified" by Health Care Common Procedure Coding System (HCPCS);

(d) Any unlisted ophthalmological service or procedure, or "By Report" (BR) procedures.

(9) The Division shall send notice of all approved PA requests for vision materials to the Division's contractor, SWEEP Optical; who forwards a copy of the PA approval and confirmation number to the requesting provider. (Refer to OAR 410-140-0200)

Or. Admin. Code § 410-140-0420

DMAP 127-2024, adopt filed 10/08/2024, effective 10/8/2024

Statutory/Other Authority: ORS 413.042

Statutes/Other Implemented: 343.146, 414.065, 683.010 -683.340 & 743A.250