1. (1) The Division requires authorization of payment for the following items or services:

   1. (a) All nursing service visits, except the assessment nursing visit, associated with home enteral/parenteral nutrition or IV services;
   2. (b) All oral formula and nutritional supplements;
   3. (c) Human Donor Milk;
   4. (d) Items and services identified as requiring authorization in OAR Chapter 410, Division 148 administrative rules;
   5. (e) All drugs and goods identified as requiring payment authorization in the Pharmaceutical Services administrative rules (chapter 410, division 121). Contact the Division’s Pharmacy Benefit Manager to determine those items that require prior authorization.
2. (2) The Division shall approve payment for the above home enteral/parenteral nutrition and/or IV services entities when the Division administrative rules are met, and services are medically appropriate and medically necessary as defined in OAR Chapter 410 Division 120 for adult beneficiaries and as defined in Chapter 410 Division 151 for EPSDT beneficiaries.
3. (3) The Division requires authorization of payment for those services that require authorization even though the client has other insurance that may cover the service. Authorization of payment is not required for Medicare covered services.
4. (4) For services requiring authorization, providers must contact the Division’s Medical Unit for authorization within five (5) working days following initiation of services. Authorization shall be given based on medical appropriateness, appropriateness of level of care given, cost and/or effectiveness.

5. (5) How to obtain payment authorization:

   1. (a) The Division’s Medical Unit is responsible for authorization for services for clients identified as Medically Fragile Children's Unit clients;
   2. (b) Contact the Division’s Pharmacy Benefit Manager, prior authorization help desk to request oral nutrition supplements;
   3. (c) Contact the Division’s Medical Unit to request all other authorization;

   4. (d) Payment authorization does not guarantee reimbursement.

      [Publications: Publications referenced are available from the agency.]

Statutory/Other Authority

ORS 413.042

Statutes/Other Implemented

ORS 414.065

History

DMAP 116-2024, amend filed 08/09/2024, effective 08/09/2024
DMAP 38-2011, f. 12-13-11, cert. ef. 1-1-12
DMAP 26-2008, f. 6-13-08, cert. ef. 7-1-08
OMAP 63-2003, f. 9-5-03, cert. ef. 10-1-03
OMAP 22-2003, f. 3-26-03, cert. ef. 4-1-03
OMAP 46-2001, f. 9-24-01, cert. ef. 10-1-01, Renumbered from 410-121-0680
OMAP 29-2000, f. 9-29-00, cert. ef. 10-1-00
OMAP 7-1998, f. 2-27-98, cert. ef. 3-1-98
HR 3-1995, f. & cert. ef. 2-1-95
HR 26-1993, f. & cert. ef. 10-1-93
HR 9-1992, f. & cert. ef. 4-1-92
HR 26-1990, f. 8-31-90, cert. ef. 9-1-90, Renumbered from 461-016-0220
AFS 56-1989, f. 9-28-89, cert. ef. 10-1-89, Renumbered from 461-016-0090
AFS 4-1989, f. 1-31-89, cert. ef. 2-1-89
AFS 15-1987, f. 3-31-87, cert. ef. 4-1-87
AFS 52-1986, f. & cert. ef. 7-2-86
AFS 53-1985, f. 9-20-85, cert. ef. 10-1-85
AFS 26-1984, f. & cert. ef. 6-19-84
AFS 12-1984, f. 3-16-84, cert. ef. 4-1-84
AFS 99-1982, f. 10-25-82, cert. ef. 11-1-82
AFS 52-1982, f. 5-28-82, cert. ef. 6-30-82
AFS 44-1982, f. 4-30-82, cert. ef. 5-1-82
AFS 70-1981, f. 9-30-81, cert. ef. 10-1-81
PWC 869, f. 12-30-77, cert. ef. 1-1-78
PWC 831, f. 2-18-77, cert. ef. 3-1-77
PWC 818(Temp), f. 10-22-76, cert. ef. 11-1-76