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Notice of intent: OHA will add clinical coverage criteria to the Medicaid State Plan.
Effective date
Jan 1, 2027
Identified
Jun 20, 2026
Summary
Oregon Health Authority will submit a State Plan Amendment to add clinical coverage criteria to the Medicaid State Plan, effective January 1, 2027. The change supports Oregon's transition away from the 1115 waiver authority for the Prioritized List of Health Services. The Health Evidence Review Commission will continue to define medically necessary services and clinical coverage criteria, and OHA will have a process to assess medical necessity when requested services do not meet clinical coverage criteria. Public comments were due by 5 p.m. Friday, June 26, 2026.
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What to do
Action · 10 steps
01Future effective date January 1, 2027: Billing team must bill organ transplant services only when they are medically necessary and meet the requirements for physician and hospital services, because no payment is made for any transplant not specifically listed, except for EPSDT children under 21.
02Physician and oral surgeon payment is subject to OHA clinical coverage criteria.
03Service categories that require prior authorization include elective rehabilitative procedures, transplants, MRI, bariatric surgeries and evaluations, laparoscopy, and selective reconstructive surgeries such as eye lid correction.
04Non-emergency services by out-of-state physicians or oral surgeons, other than in contiguous areas, must be prior authorized.
05The Division may disallow payment for physician or oral surgeon services provided during inpatient hospitalizations in which prior approval was required but not obtained.
06For podiatrist services, selected procedures require prior authorization of payment, and routine foot care is excluded from coverage.
07For dental services, crowns; complete, immediate or partial dentures; oral surgical services; and orthodontics require prior authorization.
08Dental services for children under 21 follow EPSDT standards, and the age limits in the dental section have been removed.
09For preventive services, coverage and billing codes must comply with changes made to USPSTF, ACIP, Oregon Immunization Program or West Coast Health Alliance recommendations.
10The comment deadline of June 26, 2026 has passed, so confirm current applicability before acting on this notice.
Original notice
Notice of intent: OHA will add clinical coverage criteria to the Medicaid State Plan.
oregon.gov · Always check the source before changing claims.