DMAP Fee-for-Service Utilization Review
Oregon Department of Human Services, Division of Medical Assistance Programs
Prior authorization review
Acumentra Health provides prior authorization and post-payment review services for Oregon's Medicaid Title XIX fee-for-service program.
Prior authorization is an assessment of medical necessity, appropriateness, and level of care before a patient is hospitalized or an outpatient procedure is performed. DMAP requires prior authorization for designated nonemergency services.
Healthcare providers contact Acumentra Health directly to request prior authorization. Acumentra Health reviews the request using medical, specialty, and surgical criteria. Requests may be referred to a physician reviewer. If criteria are not met, clients may be asked to seek a second opinion from another physician of the same specialty as the requesting physician.
DMAP providers can find additional information about the conditions and procedures requiring prior authorization and the prior authorization process at the DMAP authorization and review web page.
Post-payment reviews
Post-payment reviews examine hospital services after care has been provided, an inpatient claim for payment has been submitted by the hospital, and reimbursement has been paid by DMAP. Acumentra Health selects hospital records for review using a DMAP-approved sampling method. Reviews are based on InterQual Criteria and DMAP Practice Guidelines.
Post-payment utliization reviews include
- Medical necessity, appropriateness of care, adherence to professionally recognized standards of care, and appropriateness of lengths of stay in rural hospitals
- Verification that prior authorization was obtained or that the admission was of an urgent or emergent nature
When discrepancies arise as to the appropriateness of the paid claim, an adjustment to or recovery of payment may be recommended.
Hospitals can appeal if a claim is denied through post-payment review.
More information about DMAP post-payment review and appeal processes
Contact
For information on Oregon Medicaid enrollment, eligibility, and benefits, please visit the Oregon Health Plan website.
To find out more about the above projects and services use our contact form.