MedicaidPrior AuthHigh impact
Handling of requests for prior authorization (PA), including during appeals and hearings
Oregon Health Plan·OR·Plan
Effective date
Apr 1, 2025
We identified it
Aug 19, 2026
Summary
Oregon Health Authority clarifies CCO requirements for handling prior authorization (PA) requests, including mandatory outreach procedures and appeals process compliance. CCOs must accept all PA requests regardless of timing relative to appeals, make at least three outreach attempts using different methods to gather missing information, and must route provider-initiated reconsiderations through formal appeals processes rather than duplicate PA submissions. This policy prepares for the transition to 7-day PA processing timelines effective January 1, 2026.
Action Required
IMMEDIATE (Policy effective April 1, 2025) - Billing and Prior Authorization Teams: (1) Update all PA submission procedures to ensure your practice complies with CCO outreach requirements—understand that CCOs will make at least 3 attempts via 2+ different methods before denying for insufficient information; (2) Train providers and billing staff to submit complete PA requests on first submission to avoid processing delays; (3) Establish internal process to route any provider requests for PA reconsideration following a denial through formal appeals channels instead of resubmitting duplicate PA requests; (4) Document all member and provider communications when resubmitting PAs post-denial to demonstrate appeals compliance; (5) Review OARs 410-141-3875, 410-141-3885, 410-141-3890, 410-141-3895 and 42 CFR 438.400-438.424 to ensure appeals procedures align with CCO requirements; (6) Before January 1, 2026: Update systems and workflows to accommodate 7-day PA processing timelines (currently 14 days, with 14-day extension available). Failure to comply with appeals process requirements may result in claim denials and potential compliance violations during 2025 CMR audits.