Current through Register Vol. 63, No. 9, September 1, 2024
(1) Prior
Authorization (PA) is defined in OAR
410-120-0000 and OAR
410-120-1320. Providers must
obtain a PA from the:
(a) Enrolled member's
Prepaid Health Plan (PHP) or Coordinated Care Organization (CCO); and
(b) The Division for members who receive
services on a fee-for-services basis and are not enrolled with a PHP or
CCO.
(2) A PA does not
guarantee eligibility or reimbursement. Providers shall verify the member's
eligibility on the date of service and whether a PHP, CCO, or the Division is
responsible for reimbursement.
(3)
A PA is not required for members with both Medicare and Division coverage when
the service or item is covered by Medicare.
(4) Provider's shall determine if a PA is
required and comply with all PA requirements outlined in these rules.
(5) Provider's 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 shall include:
(A) A statement of medical appropriateness
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
authorization 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.
(6) 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 a PHP. 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.
(7) 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 sessions.
Six 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) An unlisted
ophthalmological service or procedure, or "By Report" (BR)
procedures.
(8) 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. (See OAR
410-140-0260 Purchase of
Ophthalmic Materials.)
Tables referenced are available from the
agency.
Statutory/Other Authority: ORS
413.042
Statutes/Other Implemented: ORS
343.146,
414.065,
683.010 &
743A.250
