Or. Admin. Code § 410-141-3835

Current through Register Vol. 63, No. 12, December 1, 2024

Section 410-141-3835 - MCE Service Authorization

(1) Coverage of services is outlined by MCE contract and Oregon Health Plan (OHP) benefits coverage in OAR 410-120-1210 and OAR 410-120-1160.

(2) A member may access urgent and emergency services 24 hours a day, seven (7) days a week without prior authorization.

(3) The MCE may not require a member to obtain the approval of a primary care physician to gain access to behavioral assessment and evaluation services. A member may self-refer to assessment, evaluation, and behavioral health services from the Provider Network. Members may obtain primary care services in a behavioral health setting, and behavioral health services in a primary care setting without authorization.

(4) A member may access the following outpatient behavioral health services from within the MCE's Provider Network, without Prior Authorization, including but not limited to:

(a) "Assertive Community Treatment" as defined in OAR 309-019-0105, "Enhanced Care Services" as defined in OAR 309-019-0105, "Enhanced Care Outreach Services" as defined in OAR 309-019-0105, "Wraparound" as defined in OAR 309-019-0105, "Behavior Supports, Crisis Care" as defined in OAR 309-019-0105, "Respite Care" as defined in OAR 309-019-0105, and "Intensive Outpatient Services and Supports" as defined in OAR 309-019-0165;

(b) Behavioral Health Peer Delivered Services as defined in OAR 309-019-0125 from within the MCE's Provider Network;

(c) Medication-Assisted Treatment for Substance Use Disorders as defined in OAR 309-019-0105, including opioid and opiate use disorders, within the MCE's Provider Network without Prior Authorization of payment during the first thirty (30) days of treatment.

(5) Contractors must permit out-of-network IHCPs to refer an MCE-enrolled American Indian/Alaska Native to a network provider for covered services as required by 42 CFR 438.14(b)(6).

(6) The MCE shall ensure the services are furnished in an amount, duration, and scope that is no less than the amount, duration, and scope for the same services furnished to beneficiaries under FFS Medicaid and as described in ORS chapter 414 and applicable administrative rules, based on the Prioritized List of Health Services and OAR 410-120-1160, 410-120-1210, and 410-141-3830.

(7) MCEs may not arbitrarily deny or reduce the amount, duration, or scope of a required service solely because of diagnosis, type of illness, or condition of the beneficiary.

(8) MCEs shall observe required timelines for standard authorizations, expedited authorizations, and specific OHP rule requirements for authorizations for services, including but not limited to residential treatment or substance use disorder treatment services and requirements for advance notice set forth in OAR 410-141-3885. MCEs shall observe required timely access to service timelines as indicated in OAR 410-141-3515.

(9) MCEs may place appropriate limits on a service authorization for Covered Services based on Medical Necessity and Medical Appropriateness as defined in OAR 410-120-0000, or for utilization control provided that the MCE:

(a) Ensures the services are sufficient in amount, duration, or scope to reasonably achieve the purpose for which the services are furnished;

(b) Authorizes the services supporting individuals with ongoing or chronic conditions or those conditions requiring long-term services and supports in a manner that reflects the member's ongoing need for the services and supports;

(c) Provides family planning services in a manner that protects and enables the member's freedom to choose the method of family planning to be used consistent with 42 CFR § 441.20 and the member's free choice of provider consistent with 42 USC § 1396a(a)(23)(B) and 42 CFR § 431.51; and

(d) Ensures compensation to individuals or entities that conduct utilization management activities is not structured to provide incentives for the individual or entity to deny, limit, delay, or discontinue medically necessary services to any member.

(10) Once a member is determined to be eligible for HRSN Services as outlined in OAR 410-120-2000, MCEs may place appropriate limits on a service authorization for HRSN Services or for utilization control provided the MCE:

(a) Ensures the HRSN Services are sufficient in amount, duration, or scope to reasonably achieve the purpose for which the services are furnished; and

(b) Authorizes the HRSN Services supporting individuals with ongoing or chronic conditions or those conditions requiring long-term services and supports in a manner that reflects the member's ongoing need for the services and supports;

(c) Ensures compensation to individuals or entities that conduct utilization management activities is not structured to provide incentives for the individual or entity to deny, limit, delay, or discontinue the delivery of HRSN Services to any member who is eligible for those services under OAR 410-120-2000.

(11) For authorization of services:

(a) Each MCE shall follow the following timeframes for authorization requests other than for drug services:

(A) For standard authorization requests for services not previously authorized, provide notice as expeditiously as the member's condition requires and no later than fourteen (14) days following receipt of the request for service with a possible extension of up to Fourteen (14) additional days if the following applies:

(i) The member, the member's representative, or provider requests an extension; or

(ii) The MCE justifies to the Authority upon request a need for additional information and how the extension is in the member's interest.

(B) For notices of adverse benefit determinations that affect services previously authorized, the MCE shall mail the notice at least ten (10) days before the date the adverse benefit determination takes effect:

(i) The MCE shall make an expedited authorization decision and provide notice as expeditiously as the member's health condition requires and no later than 72 hours after receipt of the request for service, which period of time shall be determined by the time and date stamp on the receipt of the request;

(ii) The MCE may extend the 72 hour period up to fourteen (14) days if the member requests an extension or if the MCE justifies to the Authority upon request a need for additional information and how the extension is in the member's interest.

(b) Prior authorization requests for outpatient drugs, including a practitioner administered drug (PAD), shall be addressed by the MCEs as follows:

(A) Respond to requests for prior authorizations for outpatient drugs within 24 hours as described in 42 CFR 438.210(d)(3) and section 1927(d)(5) of the Social Security Act. An initial response shall include:

(i) A written, telephonic or electronic communication of approval of the drug as requested to the member, and prescribing practitioner, and when known to the MCE, the pharmacy; or

(ii) A written notice of adverse benefit determination of the drug to the member, and telephonic or electronic notice to the prescribing practitioner, and when known to the MCE, the pharmacy if the drug is denied or partially approved; or

(iii) A written, telephonic, or electronic request for additional documentation to the prescribing practitioner when the prior authorization request lacks the MCE's standard information collection tools such as prior authorization forms or other documentation necessary to render a decision; or

(iv) A written, telephonic, or electronic acknowledgment of receipt of the prior authorization request that gives an expected timeframe for a decision. An initial response indicating only acceptance of a request shall not delay a decision to approve or deny the drug within 72 hours.

(B) The 72 hour window for a coverage decision begins with the initial date and time stamp of a prior authorization request for a drug;

(C) If the response is a request for additional documentation, the MCE shall identify and notify the prescribing practitioner of the documentation required to make a coverage decision and comply within the following timeframes:

(i) Upon receiving the MCE's completed prior authorization forms and required documentation, the MCE shall issue a decision as expeditiously as the member's health requires, but no later than 72 hours from the date and time stamp of the initial request for prior authorization as follows:

(I) If the drug is approved as requested, the MCE shall notify the member in writing and prescribing practitioner, and when known to the MCE, the pharmacy, telephonically, or electronically; or

(II) If the drug is denied or partially approved, the MCE shall issue a written notice of adverse benefit determination to the member, and telephonic or electronic notice to the prescribing practitioner, and when known to the MCE, the pharmacy.

(ii) If the requested additional documentation is not received within 72 hours from the date and time stamp of the initial request for prior authorization, the MCE shall issue a written notice of adverse benefit determination to the member, and telephonic or electronic notice to the prescribing practitioner, and when known to the MCE, the pharmacy.

(D) The MCE shall provide approved services as expeditiously as the member's health condition requires;

(E) If an emergency situation justifies the immediate medical need for the drug during this review process, an emergency supply of 72 hours or longer shall be made available until the MCE makes a coverage decision.

(c) For members with special health care needs as determined through an assessment requiring a course of treatment or regular care monitoring, each MCE shall have a mechanism in place to allow members to directly access a specialist (for example, through a standing referral or an approved number of visits) as appropriate for the member's condition and identified needs;

(d) Any service authorization decision not reached within the timeframes specified in this rule shall constitute a denial and becomes an adverse benefit determination. A notice of adverse benefit determination shall be issued on the date the timeframe expires;

(e) MCEs shall give the member written notice of any decision to deny a service authorization request or to authorize a service in an amount, duration, or scope that is less than requested or when reducing a previously authorized service authorization. The notice shall meet the requirements of CFR § 438.404 and OAR 410-141-3885;

(f) The MCE and its subcontractors shall have and follow written policies and procedures to ensure consistent application of review criteria for service authorization requests including the following:

(A) For medical, behavioral, or oral health Covered Services:

(i) The MCE shall consult with the requesting provider for medical, behavioral, or oral health services when necessary:

(I) Requesting all the appropriate information to support decision making as early in the review process as possible; and

(II) Adding documentation in the authorization file on outreach methods and dates when additional information was requested from the requesting provider.

(ii) Decisions shall be made by an individual who has clinical expertise in addressing the member's medical, behavioral, or oral health needs or in consultation with a health care professional with clinical expertise in treating the member's condition or disease. This applies to decisions to:

(I) Deny a service authorization request;

(II) Reduce a previously authorized service request; or

(III) Authorize a service in an amount, duration, or scope that is less than requested.

(B) For HRSN Services, the MCE shall comply with OAR 410-120-2000.

(C) MCEs shall have written policies and procedures for processing prior authorization requests received from any provider. The policies and procedures shall specify timeframes for the following:

(i) Date and time stamping prior authorization requests when received;

(ii) Determining within a specific number of days from receipt whether a prior authorization request is valid or non-valid;

(iii) The specific number of days allowed for follow-up on pended prior authorization requests to obtain additional information;

(iv) The specific number of days following receipt of the additional information that an approval or denial shall be issued;

(v) Providing services after office hours and on weekends that require prior authorization.

(D) An MCE shall make a determination on at least 95 percent of valid prior authorization requests within two (2) working days of receipt of a prior authorization or reauthorization request related to:

(i) Drugs;

(ii) Alcohol;

(iii) Drug services; or

(iv) Care required while in a skilled nursing facility.

(g) MCEs shall notify providers of an approval, a denial, or the need for further information for all other prior authorization requests within fourteen (14) days of receipt of the request as set forth in OAR 410-141-3885 unless otherwise specified in OHP program rules:

(A) MCEs shall make three reasonable attempts using two methods to obtain the necessary information during the fourteen (14) day period;

(B) If the MCE needs to extend the timeframe, the MCE shall give the member written notice of the reason for the extension;

(C) The MCE shall make a determination as the member's health or mental health condition requires, but no later than the expiration of the extension.

(12) Report to the Authority annually requests for prior authorization. The report shall include:

(a) The number of requests received;

(b) The number of requests that were initially denied and the reasons for the denials, including, but not limited to, lack of medical necessity or failure to provide additional clinical information requested by the insurer;

(c) The number of requests that were initially approved; and

(d) The number of denials that were reversed by internal appeals or external reviews.

Or. Admin. Code § 410-141-3835

DMAP 56-2019, adopt filed 12/17/2019, effective 1/1/2020; DMAP 56-2021, amend filed 12/30/2021, effective 1/1/2022; DMAP 35-2024, amend filed 01/22/2024, effective 1/22/2024

Statutory/Other Authority: ORS 413.042, ORS 414.065, 414.651, 414.615, 414.625 & 414.635

Statutes/Other Implemented: ORS 414.065 & ORS 414.610-414.685