SECTION 317:30-5-211.3. Prior authorization (PA)

(a)   General. Prior authorization is the electronic or written authorization issued by OHCA to a provider prior to the provision of a service. Providers should obtain a PA before providing services.

(b)   Requirements. Billing must follow correct coding guidelines as promulgated by CMS or per uniquely and publicly promulgated OHCA guidelines. DME claims must include the most appropriate HCPCS code as assigned by the Medicare Pricing, Data, Analysis, and Coding (PDAC) or its successor. Authorizations for services not properly coded will be denied. The following services require prior authorization:

(1)   services that exceed quantity/frequency limits;

(2)   medical need for an item that is beyond OHCA's standards of coverage;

(3)   use of a Not Otherwise Classified (NOC) code or miscellaneous codes;

(4)   services for which a less costly alternative may exist; and

(5)   procedures indicating that a PA is required on the OHCA fee schedule.

(c)   Prior authorization requests. Refer to OAC 317:30-5-216.

[Source: Added at 24 Ok Reg 2890, eff 7-1-07 (emergency); Added at 25 Ok Reg 1161, eff 5-25-08; Amended at 32 Ok Reg 1043, eff 8-27-15]