DMAP fee-for-service utilization review

Acumentra Health provides prior authorization and post-payment review services for Oregon's Medicaid Title XIX fee-for-service (FFS) program, administered by the Division of Medical Assistance Programs (DMAP) as part of the Oregon Health Plan (OHP).

How to request a prior authorization

Resources for DMAP FFS providers

Prior authorization review

Prior authorization is an assessment of medical necessity, appropriateness, and level of care before a patient is hospitalized or has an outpatient procedure performed. DMAP requires prior authorization for designated nonemergency services.

Acumentra Health provides prior authorization services for specific non-emergency inpatient and outpatient admissions or procedures for DMAP clients not enrolled in a managed care plan.

• Healthcare providers contact Acumentra Health directly to request prior authorization.
• Acumentra Health reviews the request using medical, specialty, and surgical criteria.
• Acumentra Health has three working days to respond to a request. 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.
• A request must contain all the information necessary for Acumentra Health to recommend approval, denial, or a second opinion.

For instructions and information about conditions and procedures requiring prior authorization, please refer to the resources below.

Post-payment review

Post-payment review examines 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 utilization 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.

DMAP authorization and review resources

Prior authorization resources

Hospital Services Rulebook

This is DMAP's guide for hospital-based services.

Download the current Hospital Services Rulebook from DMAP

Limited Hospital Benefit Code List

The Hospital Services Rulebook describes changes to benefits available to OHP Standard (KIT) clients under the “Limited Hospital Benefit.” In the list for this benefit, diagnosis codes with PA next to them require authorization by Acumentra Health when the client is electively admitted to the hospital. Call for authorization, in Oregon at 1-800-425-1250, or outside Oregon at 1-800-325-8933.

Download the current Standard Population Limited Hospital Benefit Code List from DMAP (July 1, 2008)

Medical–Surgical Services Rulebook

The Medical–Surgical Services Rulebook is helpful for physicians and clinics working with DMAP. It lists procedures that require authorization, by CPT codes.

Download the current Medical–Surgical Services Rulebook from DMAP

Prioritized List of Health Services

Download the current Prioritized List from DMAP (October 2008)

How to request prior authorization

Providers can request prior authorization in writing, by phone, or by fax.

Download a prior authorization request form (Word document)

Acumentra Health mailing address

Attention: DMAP Preauthorization
Acumentra Health
2020 SW Fourth Avenue, Suite 520
Portland, Oregon 97201

Acumentra Health prior authorization phone numbers

In Portland: 503-382-3985
In Oregon: 1-800-452-1250
From outside Oregon: 1-800-325-8933

Acumentra Health prior authorization fax numbers

503-432-2095 (24 hours)
503-432-2099 (7:00 a.m. to 4:00 p.m.)

Post-payment review resources

More information about DMAP post-payment review can be found in the Hospital Services Rulebook, available on the DMAP website.

Download the current Hospital Services Rulebook

Information regarding appeals and administrative hearings can also be found in the General Rules Program Rulebook on the DMAP website.

Download the current General Rules Program Rulebook

DMAP contact phone numbers

Automated Voice Response (AVR)
DMAP client eligibility
1-866-692-3864
Provider Web portal: https://www.or-medicaid.gov

RN Hotline
Coverage on diagnosis (ICD-9-CM) and procedure (CPT) codes
1-800-393-9855
503-945-6548 (fax)

Provider Services
Billing or claims questions, appeals, PIN and password resets
1-800-336-6016

Oregon Pharmacy Call Center
Drug authorization requests
1-888-202-2126
1-800-346-0178 (fax)

Prior authorization line
for outpatient physical and occupational therapy, speech therapy, home health, private-duty nursing requests, DME
Routine requests: 503-378-5214 (fax) 
Immediate/urgent requests: 503-378-3435 (fax)

Out-of-state authorization requests
Authorization for services provided 75 miles outside the Oregon border.
1-800-336-6016

OHP Application Center
Client enrollment in OHP
1-800-359-9517