Oregon Administrative Rules › Chapter 407 - DEPARTMENT OF HUMAN SERVICES › Division 120 - PROVIDER RULES › Section 407-120-0350 - Payments and Overpayments

Current through Register Vol. 63, No. 7, July 1, 2024
(1)
			 Authorization of Payment.
(a) Some services
			 or items covered by the Department require authorization before a service,
			 item, or level of care can be provided or before payment shall be made.
			 Providers must check the appropriate program-specific rules or contracts for
			 information on services or items requiring prior authorization and the process
			 to follow to obtain authorization.
(b) Documentation submitted when requesting
			 authorization must support the program-specific or contract justification for
			 the service, item, or level of care. A request is considered complete if it
			 contains all necessary documentation and meets any other requirements as
			 described in the appropriate program-specific rules or contract.
(c) The authorizing program shall authorize
			 the covered level of care, type of service, or item that meets the client's
			 program-eligible need. The authorizing program shall only authorize services
			 which meet the program-specific or contract coverage criteria and for which the
			 required documentation has been submitted. The authorizing program may request
			 additional information from the provider to determine the appropriateness of
			 authorizing the service, item, or level of care within the scope of program
			 coverage.
(d) Authorizing programs
			 shall not authorize services or make payment for authorized services under the
			 following circumstances:
(A) The client was
			 not eligible at the time services were provided. The provider must check the
			 client's eligibility each time services are provided;
(B) The provider cannot produce appropriate
			 documentation to support that the level of care, type of service, or item meets
			 the program-specific or contract criteria, or the appropriate documentation was
			 not submitted to the authorizing program;
(C) The delivery of the service, item, or
			 level of care has not been adequately documented as described in OAR
			 407-120-0370. Requirements for financial, clinical and other records, and the
			 documentation in the provider's files is not adequate to determine the type,
			 medical appropriateness, or quantity of services, or items provided or the
			 required documentation is not in the provider's files;
(D) The services or items identified in the
			 claim are not consistent with the information submitted when authorization was
			 requested or the services or items provided are retrospectively determined not
			 to be authorized under the program-specific or contract criteria;
(E) The services or items identified in the
			 claim are not consistent with those which were provided;
(F) The services or items were not provided
			 within the timeframe specified on the authorization of services document;
			 or
(G) The services or items were
			 not authorized or provided in compliance with the program-specific rules or
			 contracts.
(e) Payment
			 made for services or items described in subsections (d)(A) through (G) of this
			 rule shall be recovered.
(f)
			 Retroactive Department Client Eligibility.
(A) When a client is determined to be
			 retroactively eligible for a Department program, or is retroactively
			 disenrolled from a PHP or services provided after the client was disenrolled
			 from a PHP, authorization for payment may be given if the following conditions
			 are met:
(i) The client was eligible on the
			 date of service and the program-specific rules or contract authorize the
			 Department to reimburse the provider for services provided to clients made
			 retroactively eligible;
(ii) The
			 services or items provided to the client meet all other program-specific or
			 contract criteria and Oregon Administrative Rules;
(iii) The request for authorization is
			 received by the appropriate Department branch or program office within 90 days
			 of the date of service; and
(iv)
			 The provider is enrolled with the Department on the date of service, or becomes
			 enrolled with the Department no later than the date of service as provided in
			 OAR 407-120-0320(11).
(B)
			 Requests for authorization received after 90 days from date of service require
			 all the documentation required in subsection (f)(A)(i), (ii) and (iv) and
			 documentation from the provider stating why the authorization could not have
			 been obtained within 90 days of the date of service.
(g) Service authorization is valid for the
			 time period specified on the authorization notice, but shall not exceed 12
			 months, unless the client's benefit package no longer covers the service, in
			 which case the authorization terminates on the date coverage ended.
(h) Service authorization for clients with
			 other insurance or for Medicare beneficiaries is governed by program-specific
			 rules or contracts.