Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 172 - MEDICAID PAYMENT FOR BEHAVIORAL HEALTH SERVICES › Section 410-172-0650 - Prior Authorization

Current through Register Vol. 63, No. 7, July 1, 2024
(1) Some
			 services or items covered by the Division require authorization before the
			 service may be provided. Services requiring prior authorization are published
			 on the Medicaid Behavioral Health Services Fee Schedule.
(2) The Division shall authorize payment for
			 the type of service or level of care that meets the recipient's medical need
			 and that has been adequately documented.
(3) The Division shall authorize only
			 services that are medically appropriate and for which the required
			 documentation has been supplied. The Division may request additional
			 information from the provider to determine medical appropriateness.
(4) Documentation submitted when requesting
			 prior authorization shall support the medical justification for the service.
			 The authorization request shall contain:
(a) A
			 cover sheet detailing relevant provider and recipient Medicaid
			 numbers;
(b) Requested dates of
			 service;
(c) HCPCS or CPT Procedure
			 code requested;
(d) Amount of
			 service or units requested; and
(e)
			 A behavioral health assessment and service plan meeting the requirements
			 described in OAR 309-019-0135  through 0140; or
(f) Any additional clinical information
			 supporting medical justification for the services requested;
(g) For substance use disorder services
			 (SUD), the Division uses the American Society of Addiction Medicine (ASAM)
			 Patient Placement Criteria second edition-revised (PPC-2R) to determine the
			 appropriate level of SUD treatment of care. Providers shall use the
			 ASAM;
(h) For Applied Behavior
			 Analysis (ABA) services, the Division requires submission of the following:
(A) ABA services for the treatment of autism
			 spectrum disorder shall have an evaluation as described in OAR
			 410-172-0770(1) (a-j) and a referral for treatment as described in OAR
			 410-172-0760(1)  from one of the licensed practitioners described in OAR
			 410-172-0760(1) (a-d) who are, in addition, experienced in the diagnosis of
			 autism spectrum disorder;
(B) ABA
			 services for the treatment of stereotyped movement disorder with self-injurious
			 behavior due to neurodevelopmental disorder shall have an evaluation as
			 described in OAR 410-172-0770(2)  and a referral for treatment as described in
			 OAR 410-172-0760(2)  from a licensed practitioner, practicing within the scope
			 of their license who has experience or training in the diagnosis and treatment
			 of stereotyped movement disorder with self-injurious behavior due to
			 neurodevelopmental disorder;
(C) A
			 treatment plan, including a functional behavior assessment, as needed, from a
			 licensed health care professional as defined in ORS
			 676.802(2)(a-h),
			 or by a behavior analyst or assistant behavior analyst licensed by the Oregon
			 Behavior Analysis Regulatory Board, or by an individual holding a declaration
			 of practice through the Oregon Behavior Analysis Regulatory Board as described
			 in OAR 824-010-0005(10).
(i) For Intensive In-Home Behavioral
			 Treatment Services (IIHBT), the Division requires submission of the following,
			 in addition to the requirements described in 410-172-0650(4) (a-f), to the
			 Division or the Division's contractor:
(A)
			 Initial prior authorization request may not exceed sixty (60) days, and
			 authorization for continued services may be approved in 30-day increments. Each
			 request shall include:
(i) Documentation by,
			 at minimum, a Qualified Mental Health Professional, Licensed Medical
			 Practitioner licensed in the state of Oregon, Licensed Clinical Practitioner,
			 or psychologist licensed by the Oregon Board of Psychology, justifying IIBHT
			 level of care;
(ii) Sufficient
			 information and documentation to justify the presence of two or more primary
			 mental health diagnoses that meets the medically necessary reason for services;
			 and
(iii) Documentation displaying
			 intensive behavioral health needs, that may include significant health and
			 safety risks or concerns, impacting multiple life domains (school, home,
			 community) as identified on a mental health assessment.
(B) A 30-day authorization for transition out
			 of IIBHT services may be requested to support transition management for the
			 treatment team, youth, and their family, and shall include an updated service
			 plan describing ongoing maintenance of services and supports necessary for
			 transition planning.
(j)
			 Residential treatment services for children may require a letter of approval by
			 a designated Quality Improvement Organization (QIO);
(k) Some services require additional approval
			 or authorization by a physician, the Division, or designee. Services requiring
			 additional approval are listed on the Behavioral Health Fee Schedule or
			 described in this rule.