Umpqua Health Alliance is the OHP CCO for Douglas County (except a few ZIP codes served by other CCOs). Its behavioral health prior-authorization FAQ (February 2026) lists Applied Behavior Analysis among the services that need prior authorization even in network, with six-month authorization periods.
The FAQ says "No PA required for in-network Behavioral Health services unless listed," and lists Applied Behavior Analysis with ECT, TMS and intensive in-home treatment; all out-of-network requests need PA. ECT, ABA and TMS are authorized for six months. In-network providers submit through the CIM portal; out-of-network providers fax the UHA PA form with documentation to 541-677-5881. A single case agreement is needed only to be paid above the Oregon Medicaid behavioral health fee schedule; without a stated rate, a PA "will be reviewed and evaluated at DMAP rates." Retro requests are reviewed "up to 90 days from the date of service."[2][9][3]
Umpqua reviews requests against the Prioritized List and its guideline notes, InterQual, the OARs, UpToDate and its clinical practice guidelines, and decides within OAR 410-141-3835’s timeframes; a decision not made in time "shall constitute a denial." When Umpqua is the secondary payer, "a PA is not required if the primary insurance authorization guidelines are met."[2][9][3]
OHA’s managed-care billing rule binds every CCO, Umpqua Health Alliance included (OAR 410-141-3565, effective January 1, 2025). Initial claims are due "within no more than 120 days of the date of service," or within 365 days for pregnancy, retroactive eligibility, Medicare as primary payer, third-party liability and other delays not caused by the provider; a CCO "may negotiate terms within this timeframe," so your contract can set a shorter limit but not a longer one. For a timely claim that needs correction or resubmission, the CCO must allow "a minimum of 180 days after the initial adjudication date." Other insurance "must be exhausted prior to payment." On payment, CCOs "shall pay or deny at least 90 percent of valid claims within 30 days of receipt and at least 99 percent of valid claims within 90 days of receipt," make an initial determination on 99 percent within 60 days, and "may not require providers to delay claims submission." The rule sets no weekly payment cycle or submission cutoff.[1]
The questions that decide whether a family can start with Umpqua Health Alliance, and what they have to bring. Each maps onto something intake should ask on the first call.
Umpqua publishes no age limit. OHP rules require ABA beyond Guideline Note 75 when medically appropriate "including individuals age 13 and older," and under 21 EPSDT bars age-group-wide denials.[2][5][13]
Umpqua publishes no recency rule. The OHP rule dates only the physical exam and hearing test (OAR 410-172-0770(1)(h)–(i)).[2][5]
Umpqua publishes nothing different, so the OHP rule applies: a physician, psychologist, or developmental-medicine NP or PA experienced in autism (OAR 410-172-0770(1), 0760(1)).[2][5][4]
Umpqua publishes nothing different, so the OHP rule applies: a standardized, validated tool such as the ADOS plus developmental status on assessments such as the Vineland (OAR 410-172-0770(1)(b), (g)).[2][5]
Umpqua adds no referral rule of its own, so the OHP rule applies. Yes. Before services, OAR 410-172-0770(1)(k) requires "A referral for ABA treatment with or without specification of hours or intensity" that includes the diagnosis and a copy of the evaluation, from a physician, psychologist, or nurse practitioner or physician associate specializing in developmental medicine who has experience diagnosing and treating autism (OAR 410-172-0760(1)).[2][5][4]
Umpqua publishes no ABA telehealth rule of its own. The state rule applies: "For purposes of behavioral health services, the Authority shall provide coverage for telemedicine services to the same extent that the services would be covered if they were provided in person" (OAR 410-172-0850(5)), using synchronous two-way video (telephone and e-mail only where HERC guidelines allow). OHA’s behavioral health fee schedule lists modifier GT ("Via Interactive Simultaneous Audio and Video Telecommunication Systems") as an allowable modifier on every ABA code it prices, 97151 through 97157, including the 97151 assessment and 97155 protocol modification.[2][7][8]
Umpqua decides within OAR 410-141-3835’s timeframes, and a decision not reached in time "shall constitute a denial." The rule sets notice within 7 calendar days for standard requests and 72 hours for expedited, with one 14-day extension.[2][9]
When Umpqua is secondary, "a PA is not required if the primary insurance authorization guidelines are met" (pharmacy claims over $50 excepted). Medicaid pays last. OHA must be "the payer of last resort," and "Providers shall make reasonable efforts to obtain payment first from other resources" (OAR 410-120-1280; 42 CFR 433.139). Bill the commercial plan first and follow its authorization rules.[2][12]
Coverage decides whether Umpqua Health Alliance pays. These decide whether the claim survives: how sessions must be staffed and supervised, what may be billed concurrently, the per-day ceilings, who signs the note, where the service is payable, and whose NPI the claim goes out under.
Umpqua publishes no ABA supervision rule, so the state rule applies. OHA does not pay assistant behavior analysts or registered behavior analysis interventionists directly (OAR 410-172-0760(4)); they work under a directly payable Licensed Behavior Analyst, licensed health care professional or declarant. The licensing rule sets the interventionist supervision floor: direct and indirect supervision "for at least 5 percent of the interventionist’s service hours," including direct supervision at least once per calendar month, by a licensed behavior analyst, licensed assistant behavior analyst or licensed health care professional (OAR 824-040-0010). Direct supervision may be remote if it is synchronous audio and video (OAR 824-010-0005).[2][4][11]
Umpqua publishes no ABA session-note rule. The OHP floor applies: each note "signed or initialed by the individual providing the service" (OAR 410-172-0620(4)).[2][6]
Umpqua publishes no ABA rendering-provider rule. The OHP rule applies: only a Licensed Behavior Analyst, licensed health care professional or declarant is eligible for direct payment (OAR 410-172-0760(3)–(4)).[2][4]
Not addressed in Umpqua’s behavioral health PA FAQ.[2]
Ask the plan: Umpqua Health Alliance provider services, or your UHA participation agreement.
Umpqua publishes no ABA unit or hour cap; ABA is authorized in six-month periods and reviewed with InterQual and the guideline notes.[2]
Ask the plan: Umpqua prior authorizations, 541-672-1685: ask how ABA units are set within the six-month authorization.
Umpqua publishes no ABA setting rule.[2]
Ask the plan: Umpqua provider services: ask which settings and place-of-service codes it pays for ABA.
120 days from the date of service under OAR 410-141-3565 (365 days for exceptions such as retroactive eligibility, Medicare or other insurance primary); your contract may set a shorter limit. Corrections and resubmissions get at least 180 days from the initial adjudication.
Yes. ABA is on its behavioral health PA list, in network and out, with six-month authorizations. Check the PA Grid for the assessment codes.
Umpqua does not require its own PA when the primary insurer’s authorization guidelines are met.
Umpqua reviews retro requests up to 90 days from the date of service; later requests go through the provider appeal process.
Payer policies change frequently and vary by plan, state, and funding type. This guide was compiled from the sources above and last reviewed October 2026; it is general information, not billing, legal, or clinical advice. Always verify current requirements against the payer's live policy and a benefits check for the specific member.
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