1. (1) Some services or items covered by the Oregon Health Authority require authorization before the service can be provided. See the appropriate Oregon Health Authority rules for information on services requiring authorization and the process to be followed to obtain authorization, such as "OAR 410-120-1360 Requirements for Financial, Clinical and Other Records.”
2. (2) Documentation submitted when requesting authorization must support the medical justification for the service. A complete request is one that contains all necessary documentation and meets any other requirements as described in the appropriate Oregon Health Authority rules.
3. (3) The Oregon Health Authority shall authorize for the level of care or type of service that meets the client's medical need. Only services which are medically appropriate and for which the required documentation has been supplied may be authorized. The authorizing agency may request additional information from the provider to determine medical appropriateness or appropriateness of the service.
4. (4) The Oregon Health Authority may not consider quality of life in general measures (e.g., Quality Adjusted Life Years or QALYs), either directly or by considering a source that relies on a quality of life in general measure, in establishing utilization controls (e.g., prior authorization) or otherwise making benefit determinations.  “Quality of life in general measure” means an assessment of the value, effectiveness or cost-effectiveness of a treatment that gives greater value to a year of life lived in perfect health than the value given to a year of life lived in less than perfect health. “Quality of life in general measure” does not mean an assessment of the value, effectiveness or cost-effectiveness of a treatment during a clinical trial in which a study participant is asked to rate the participant’s physical function, pain, general health, vitality, social functions or other similar domains (e.g., the Short Form Health Survey or SF-36).

5. (5) The Oregon Health Authority may not make payment for authorized services under the following circumstances:

   1. (a) The client was not eligible at the time services were provided. The provider is responsible for checking the client's eligibility each time services are provided;
   2. (b) The provider cannot produce appropriate documentation to support medical appropriateness, or the appropriate documentation was not submitted to the authorizing agency;
   3. (c) The service has not been adequately documented (see OAR 410-120-1360, Requirements for Financial, Clinical and Other Records).The documentation in the provider's files is not adequate to determine the type, medical appropriateness, or quantity of services provided and required documentation is not in the provider's files;
   4. (d) The services billed or provided are not consistent with the information submitted when authorization was requested or the services provided are determined retrospectively not to be medically appropriate;
   5. (e) The services billed are not consistent with those provided;
   6. (f) The services were not provided within the timeframe specified on the authorization of payment document;
   7. (g) The services were not authorized or provided in compliance with the rules in these General Rules and in the appropriate provider rules.

6. (6) Retroactive authorizations:

   1. (a) Authorization for payment may be given for a past date of service if:

      1. (A) The client was made retroactively eligible or was retroactively disenrolled from a CCO or PHP on the date of service; and
      2. (B) The services provided meet all other criteria and Oregon Administrative Rules, and;
      3. (C) The request for authorization is received within ninety (90) days of the date of service;
   2. (b) Any requests for authorization after ninety (90) days from date of service require documentation from the Provider that authorization could not have been obtained within ninety (90) days of the date of service.
7. (7) Payment authorization is valid for the time period specified on the authorization notice, but not to exceed twelve (12) months, unless the Client’s benefit package no longer covers the service, in which case the authorization will terminate on the date coverage ends.

8. (8) When clients have other health care coverage (third-party resources, or TPR), the Oregon Health Authority only requires payment authorization for the services that TPR does not cover. Examples include:

   1. (a) When Medicare is the primary payer for a service, no payment authorization from the Oregon Health Authority is required, unless specified in the appropriate Oregon Health Authority program rules;
   2. (b) When other TPR is primary, such as Blue Cross, CHAMPUS, etc., the Oregon Health Authority requires payment authorization when the other insurer or resource does not cover the service or reimburses less than the Oregon Health Authority rate.

Statutory/Other Authority

ORS 413.042 & 414.065

Statutes/Other Implemented

ORS 414.065

History

DMAP 131-2024, amend filed 10/30/2024, effective 11/10/2024
DMAP 110-2024, minor correction filed 07/10/2024, effective 07/10/2024
DMAP 108-2024, minor correction filed 06/20/2024, effective 06/20/2024
DMAP 24-2023, minor correction filed 03/31/2023, effective 03/31/2023
DMAP 49-2012, f. 10-31-12, cert. ef. 11-1-12
DMAP 24-2007, f. 12-11-07, cert. ef. 1-1-08
OMAP 39-2005, f. 9-2-05, cert. ef. 10-1-05
OMAP 10-2005, f. 3-9-05, cert. ef. 4-1-05
OMAP 62-2003, f. 9-8-03, cert. ef. 10-1-03
OMAP 35-2000, f. 9-29-00, cert. ef. 10-1-00
OMAP 31-1999, f. & cert. ef. 10-1-99
OMAP 10-1999, f. & cert. ef. 4-1-99
HR 5-1997, f. 1-31-97, cert. ef. 2-1-97
HR 6-1996, f. 5-31-96, cert. ef. 6-1-96
HR 40-1994, f. 12-30-94, cert. ef. 1-1-95
HR 22-1994, f. 5-31-94, cert. ef. 6-1-94
HR 32-1993, f. & cert. ef. 11-1-93, Renumbered from 410-120-0180
HR 41-1991, f. & cert. ef. 10-1-91
HR 32-1990, f. 9-24-90, cert. ef. 10-1-90
HR 2-1990, f. 2-12-90, cert. ef. 3-1-90, Renumbered from 461-013-0106 & 461-013-0180
AFS 38-1986, f. 4-29-86, cert. ef. 16-1-86
AFS 37-1984, f. 8-30-84, cert. ef. 9-1-84
AFS 11-1984(Temp), f. 3-14-84, cert. ef. 3-15-84
AFS 7-1984(Temp), f. 2-28-84, cert. ef. 3-15-84
AFS 117-1982, f. 12-30-82, cert. ef. 1-1-83
AFS 52-1982, f. 5-28-82, cert. ef. 6-30-82
Renumbered from 461-013-0041, AFS 47-1982, f. 4-30-82, cert. ef. 5-1-82
AFS 33-1981, f. 6-23-81, cert. ef. 7-1-81
AFS 13-1981, f. 2-27-81, cert. ef. 3-1-81
AFS 5-1981, f. 1-23-81, cert. ef. 3-1-81, Renumbered from 461-013-0060
AFS 14-1979, f. 6-29-79, cert. ef. 7-1-79
PWC 812, f. & cert. ef. 10-1-76
PWC 803(Temp), f. & cert. ef. 7-1-76
PWC 683, f. 7-19-74, cert. ef. 8-11-74