The Oregon Administrative Rules contain OARs filed through November 15, 2015

 
QUESTIONS ABOUT THE CONTENT OR MEANING OF THIS AGENCY'S RULES?
CLICK HERE TO ACCESS RULES COORDINATOR CONTACT INFORMATION

 



OREGON HEALTH AUTHORITY, DIVISION OF MEDICAL ASSISTANCE PROGRAMS




 



DIVISION 120
MEDICAL ASSISTANCE PROGRAMS
SCROLL DOWN TO VIEW OARs 410-120-0000 through 410-120-1295
JUMP FORWARD TO OARs 410-120-1300 through 410-120-1980
410-120-0000
Acronyms and Definitions
Identification of acronyms and definitions
within this rule specifically pertain to their use within the Oregon Health Authority
(Authority), Division of Medical Assistance Programs (Division), or the Addictions
and Mental Health Division (AMH) administrative rules, applicable to the medical
assistance program. This rule does not include an exhaustive list of Division acronyms
and definitions. For more information, see Oregon Health Plan (OHP) program OAR
410-141-0000, Acronyms and Definitions; 410-200-0015, General Definitions; and any
appropriate governing acronyms and definitions in the Department of Human Services
(Department) chapter 411 or 413 administrative rules; or contact the Division.
(1) “Abuse” means
provider practices that are inconsistent with sound fiscal, business, or medical
practices and result in an unnecessary cost to the Authority or in reimbursement
for services that are not medically necessary or that fail to meet professionally
recognized standards for health care. It also includes recipient practices that
result in unnecessary cost to the Authority.
(2) “Action”
means a termination, suspension, or reduction of eligibility or covered services.
(3) “Acupuncturist”
means a person licensed to practice acupuncture by the relevant state licensing
board.
(4) “Acupuncture Services”
means services provided by a licensed acupuncturist within the scope of practice
as defined under state law.
(5) “Acute” means
a condition, diagnosis, or illness with a sudden onset and that is of short duration.
(6) “Acquisition Cost”
means, unless specified otherwise in individual program administrative rules, the
net invoice price of the item, supply, or equipment plus any shipping or postage
for the item.
(7) “Addiction and
Mental Health Division (AMH)” means a division within the Authority that administers
mental health and addiction programs and services.
(8) “Adequate Record
Keeping” means documentation that supports the level of service billed. See
410-120-1360, Requirements for Financial, Clinical, and Other Records, and the individual
provider rules.
(9) “Administrative
Medical Examinations and Reports” means examinations, evaluations, and reports,
including copies of medical records, requested on the DMAP 729 form through the
local Department branch office or requested or approved by the Authority to establish
client eligibility for a medical assistance program or for casework planning.
(10) “Advance Directive”
means an individual’s instructions to an appointed person specifying actions
to take in the event that the individual is no longer able to make decisions due
to illness or incapacity.
(11) “Adverse Event”
means an undesirable and unintentional, though not unnecessarily unexpected, result
of medical treatment.
(12) “Aging and People
with Disabilities (APD)” means the division in the Department of Human Services
(Department) that administers programs for seniors and people with disabilities.
This division was formerly named “Seniors and People with Disabilities (SPD).”
(13) “All-Inclusive
Rate” or “Bundled Rate” means the nursing facility rate established
for a facility. This rate includes all services, supplies, drugs, and equipment
as described in OAR 411-070-0085 and in the Division’s Pharmaceutical Services
program administrative rules and the Home Enteral/Parenteral Nutrition and IV Services
program administrative rules, except as specified in OAR 410-120-1340, Payment.
(14) “Allied Agency”
means local and regional governmental agency and regional authority that contracts
with the Authority or Department to provide the delivery of services to covered
individuals (e.g., local mental health authority, community mental health program,
Oregon Youth Authority, Department of Corrections, local health departments, schools,
education service districts, developmental disability service programs, area agencies
on aging (AAAs), federally recognized American Indian tribes).
(15) “Alternative Care
Settings” means sites or groups of practitioners that provide care to members
under contract with a PHP or CCO, including urgent care centers, hospice, birthing
centers, out-placed medical teams in community or mobile health care facilities,
long-term care facilities, and outpatient surgical centers.
(16) “Ambulance”
means a specially equipped and licensed vehicle for transporting sick or injured
persons that meets the licensing standards of the Authority or the licensing standards
of the state in which the ambulance provider is located.
(17) “Ambulatory Payment
Classification” means a reimbursement method that categorizes outpatient visits
into groups according to the clinical characteristics, the typical resource use,
and the costs associated with the diagnoses and the procedures performed. The groups
are called Ambulatory Payment Classifications (APCs).
(18) “Ambulatory Surgical
Center (ASC)” means a facility licensed as an ASC by the Authority.
(19) “American Indian/Alaska
Native (AI/AN)” means a member of a federally recognized Indian tribe, band,
or group, and an Eskimo or Aleut or other Alaska native enrolled by the Secretary
of the Interior pursuant to the Alaska Native Claims Settlement Act, 43 U.S.C. 1601,
or a person who is considered by the Secretary of the Interior to be an Indian for
any purpose.
(20) “American Indian/Alaska
Native (AI/AN) Clinic” means a clinic recognized under Indian Health Services
(IHS) law or by the Memorandum of Agreement between IHS and the Centers for Medicare
and Medicaid Services (CMS).
(21) “Ancillary Services”
means services supportive of or necessary for providing a primary service, such
as anesthesiology, which is an ancillary service necessary for a surgical procedure.
(22) “Anesthesia Services”
means administration of anesthetic agents to cause loss of sensation to the body
or body part.
(23) “Appeal”
means a request for review of an action.
(24) “Area Agency on
Aging (AAA)” means the designated entity with which the Department contracts
to meet the requirements of the Older Americans Act and ORS Chapter 410 in planning
and providing services to the elderly or elderly and disabled population.
(25) “Atypical Provider”
means an entity able to enroll as a billing provider (BP) or rendering provider
for medical assistance programs related non-health care services but that does not
meet the definition of health care provider for National Provider Identification
(NPI) purposes.
(26) “Audiologist”
means a person licensed to practice audiology by the State Board of Examiners for
Speech Pathology and Audiology.
(27) “Audiology”
means the application of principles, methods, and procedures of measurement, testing,
appraisal, prediction, consultation, counseling, and instruction related to hearing
and hearing impairment for the purpose of modifying communicative disorders involving
speech, language, auditory function, including auditory training, speech reading
and hearing aid evaluation, or other behavior related to hearing impairment.
(28) “Automated Voice
Response (AVR)” means a computer system that provides information on clients'
current eligibility status from the Division by computerized phone or web-based
response.
(29) “Behavioral Health”
means mental health, mental illness, addiction disorders, and
substance use disorders.
(30) “Behavioral Health
Assessment” means a qualified mental health professional’s determination
of a member’s need for mental health services.
(31) “Behavioral Health
Case Management” means services provide to members who need assistance to
ensure access to mental health benefits and services from local, regional, or state
allied agencies or other service providers.
(32) “Behavioral Health
Evaluation” means a psychiatric or psychological assessment used to determine
the need for mental health or substance use disorder services.
(33) “Benefit Package”
means the package of covered health care services for which the client is eligible.
(34) “Billing Agent
or Billing Service” means third party or organization that contracts with
a provider to perform designated services in order to facilitate an Electronic Data
Interchange (EDI) transaction on behalf of the provider.
(35) “Billing Provider
(BP)” means a person, agent, business, corporation, clinic, group, institution,
or other entity who submits claims to or receives payment from the Division on behalf
of a rendering provider and has been delegated the authority to obligate or act
on behalf of the rendering provider.
(36) “Buying Up”
means the practice of obtaining client payment in addition to the Division or managed
care plan payment to obtain a non-covered service or item. (See 410-120-1350 Buying
Up.)
(37) “By Report (BR)":
means services designated, as BR requires operative or clinical and other pertinent
information to be submitted with the billing as a basis for payment determination.
This information must include an adequate description of the nature and extent of
need for the procedure. Information such as complexity of symptoms, final diagnosis,
pertinent physical findings, diagnostic and therapeutic procedures, concurrent problems,
and follow-up care will facilitate evaluation.
(38) “Case Management
Services” means services provided to ensure that CCO members obtain health
services necessary to maintain physical, mental, and emotional development and oral
health. Case management services include a comprehensive, ongoing assessment of
medical, mental health, substance use disorder or dental needs plus the development
and implementation of a plan to obtain or make referrals for needed medical, mental,
chemical dependency, or dental services, referring members to community services
and supports that may include referrals to Allied Agencies.
(39) “Certified Traditional
Health Worker” means an individual who has successfully completed a training
program or doula training as required by OAR 410-180-0305, known to the Centers
of Medicare and Medicaid as non-traditional health worker.
(40) “Child Welfare
(CW)” means a division within the Department responsible for administering
child welfare programs, including child abuse investigations and intervention, foster
care, adoptions, and child safety.
(41) “Children's Health
Insurance Program (CHIP)” means a federal and state funded portion of the
Oregon Health Plan (OHP) established by Title XXI of the Social Security Act and
administered by the Authority.
(42) “Chiropractor”
means a person licensed to practice chiropractic by the relevant state licensing
board.
(43) “Chiropractic
Services” means services provided by a licensed chiropractor within the scope
of practice as defined under state law and federal regulation.
(44) “Citizen/Alien-Waived
Emergency Medical (CAWEM)” means aliens granted lawful temporary resident
status or lawful permanent resident status under the Immigration and Nationality
Act are eligible only for emergency services and limited service for pregnant women.
Emergency services for CAWEM are defined in OAR 410-120-1210 (3)(f).
(45) “Claimant”
means a person who has requested a hearing.
(46) “Client”
means an individual found eligible to receive OHP health services. “Client”
is inclusive of members enrolled in PHPs and CCOs.
(47) “Clinical Nurse
Specialist” means a registered nurse who has been approved and certified by
the Board of Nursing to provide health care in an expanded specialty role.
(48) “Clinical Social
Worker” means a person licensed to practice clinical social work pursuant
to state law.
(49) “Clinical Record”
means the medical, dental, or mental health records of a client or member.
(50) “Co-morbid Condition”
means a medical condition or diagnosis coexisting with one or more other current
and existing conditions or diagnoses in the same patient.
(51) “Comfort Care”
means medical services or items that give comfort or pain relief to an individual
who has a terminal Illness, including the combination of medical and related services
designed to make it possible for an individual with terminal Illness to die with
dignity and respect and with as much comfort as is possible given the nature of
the illness.
(52) “Community Health
Worker” means an individual who:
(a) Has expertise or experience
in public health;
(b) Works in an urban or
rural community either for pay or as a volunteer in association with a local health
care system;
(c) To the extent practicable,
shares ethnicity, language, socioeconomic status, and life experiences with the
residents of the community where the worker serves;
(d) Assists members of the
community to improve their health and increases the capacity of the community to
meet the health care needs of its residents and achieve wellness;
(e) Advocates for the individual
patient and community health needs, building individual and community capacity to
advocate for their health;
(f) Provides health education
and information that is culturally appropriate to the individuals being served;
(g) Assists community residents
in receiving the care they need;
(h) May give peer counseling
and guidance on health behaviors; and
(i) May provide direct services
such as first aid or blood pressure screening.
(53) “Community Mental
Health Program (CMHP)” means the organization of all services for individuals
with mental or emotional disorders operated by, or contractually affiliated with,
a local Mental Health Authority operated in a specific geographic area of the state
under an intergovernmental agreement or direct contract with the Authority’s
Addictions and Mental Health Division (AMH).
(54) “Condition/Treatment
Pair” means diagnoses described in the International Classification of Diseases
Clinical Modifications, 9th edition (ICD-9-CM); the Diagnostic and Statistical Manual
of Mental Disorders, 4th edition (DSM-IV); and treatments described in the Current
Procedural Terminology, 4th edition (CPT-4); or American Dental Association Codes
(CDT-2) or the Authority AMH Medicaid Procedure Codes and Reimbursement Rates, that,
when paired by the Health Evidence Review Commission, constitute the line items
in the Prioritized List of Health Services. Condition/treatment pairs may contain
many diagnoses and treatments.
(55) “Contested Case
Hearing” means a proceeding before the Authority under the Administrative
Procedures Act when any of the following contests an action:
(a) A client or member or
their representative;
(b) A PHP or CCO member’s
provider; or
(c) A PHP or CCO.
(56) “Contiguous Area”
means the area up to 75 miles outside the border of the State of Oregon.
(57) “Contiguous Area
Provider” means a provider practicing in a contiguous area.
(58) “Continuing Treatment
Benefit” means a benefit for clients who meet criteria for having services
covered that were either in a course of treatment or scheduled for treatment the
day immediately before the date the client’s benefit package changed to one
that does not cover the treatment.
(59) “Coordinated Care
Organization (CCO)” as defined in OAR 410-141-0000.
(60) “Co-Payments”
means the portion of a claim or medical, dental, or pharmaceutical expense that
a client must pay out of their own pocket to a provider or a facility for each service.
It is usually a fixed amount that is paid at the time service is rendered. (See
410-120-1230 Client Copayment.)
(61) “Cost Effective”
means the lowest cost health service or item that, in the judgment of Authority
staff or its contracted agencies, meets the medical needs of the client.
(62) “Covered Services”
means medically appropriate health services described in ORS Chapter 414 and applicable
administrative rules that the legislature funds, based on the Prioritized List of
Health Services.
(63) “Current Dental
Terminology (CDT)” means a listing of descriptive terms identifying dental
procedure codes used by the American Dental Association.
(64) “Current Procedural
Terminology (CPT)” means the physicians' CPT is a listing of descriptive terms
and identifying codes for reporting medical services and procedures performed by
physicians and other health care providers.
(65) “Date of Receipt
of a Claim” means the date on which the Authority receives a claim as indicated
by the Internal Control Number (ICN) assigned to a claim. Date of receipt is shown
as the Julian date in the 5th through 7th position of the ICN.
(66) “Date of Service”
means the date on which the client receives medical services or items, unless otherwise
specified in the appropriate provider rules. For items that are mailed or shipped
by the provider, the date of service is the date on which the order was received,
the date on which the item was fabricated, or the date on which the item was mailed
or shipped.
(67) “Declaration for
Mental Health Treatment” means a written statement of an individual’s
decisions concerning his or her mental health treatment. The individual makes the
declaration when they are able to understand and make decisions related to treatment
that is honored when the individual is unable to make such decisions.
(68) “Dental Emergency
Services” means dental services provided for severe tooth pain, unusual swelling
of the face or gums, or an avulsed tooth.
(69) “Dental Services”
means services provided within the scope of practice as defined under state law
by or under the supervision of a dentist or dental hygienist.
(70) “Dentist”
means a person licensed to practice dentistry pursuant to state law of the state
in which he or she practices dentistry or a person licensed to practice dentistry
pursuant to federal law for the purpose of practicing dentistry as an employee of
the federal government.
(71) “Denturist”
means a person licensed to practice denture technology pursuant to state law.
(72) “Denturist Services”
means services provided within the scope of practice as defined under state law
by or under the personal supervision of a denturist.
(73) “Dental Hygienist”
means a person licensed to practice hygiene under the direction of a licensed professional
within the scope of practice pursuant to state law.
(74) “Dental Hygienist
with an Expanded Practice Permit” means a person licensed to practice dental
hygiene services as authorized by the Board of Dentistry with an Expanded Practice
Dental Hygienist Permit (EPDHP) pursuant to state law.
(75) “Dentally Appropriate”
means services that are required for prevention, diagnosis, or treatment of a dental
condition and that are:
(a) Consistent with the symptoms
of a dental condition or treatment of a dental condition;
(b) Appropriate with regard
to standards of good dental practice and generally recognized by the relevant scientific
community and professional standards of care as effective;
(c) Not solely for the convenience
of the client or a provider of the service;
(d) The most cost effective
of the alternative levels of dental services that can be safely provided to a client.
(76) “Department of
Human Services (Department or DHS)” means the agency established in ORS Chapter
409, including such divisions, programs and offices as may be established therein.
(77) “Department Representative”
means a person who represents the Department and presents the position of the Department
in a hearing.
(78) “Diagnosis Code”
means as identified in the International Classification of Diseases, 9th revision,
Clinical Modification (ICD-9-CM). The primary diagnosis code is shown in all billing
claims, unless specifically excluded in individual provider rules. Where they exist,
diagnosis codes shall be shown to the degree of specificity outlined in OAR 410-120-1280,
Billing.
(79) “Diagnosis Related
Group (DRG)” means a system of classification of diagnoses and procedures
based on the ICD-9-CM.
(80) “Diagnostic Services”
mean those services required to diagnose a condition, including but not limited
to: radiology, ultrasound, other diagnostic imaging, electrocardiograms, laboratory
and pathology examinations, and physician or other professional diagnostic or evaluative
services.
(81) “Division of Medical
Assistance Programs (Division)” means a division within the Authority. The
Division is responsible for coordinating the medical assistance programs within
the State of Oregon including the Oregon Health Plan (OHP) Medicaid demonstration,
the State Children's Health Insurance Program (SCHIP-Title XXI), and several other
programs.
(82) “Durable Medical
Equipment, Prosthetics, Orthotics and Medical Supplies (DMEPOS)” means equipment
that can stand repeated use and is primarily and customarily used to serve a medical
purpose. Examples include wheelchairs, respirators, crutches, and custom built orthopedic
braces. Medical supplies are non-reusable items used in the treatment of illness
or injury. Examples of medical supplies include diapers, syringes, gauze bandages,
and tubing.
(83) “Early and Periodic
Screening, Diagnosis and Treatment (EPSDT) Services (aka, Medicheck)” mean
the Title XIX program of EPSDT services for eligible clients under age 21. It is
a comprehensive child health program to assure the availability and accessibility
of required medically appropriate health care services and to help Authority clients
and their parents or guardians effectively use them.
(84) “Electronic Data
Interchange (EDI)” means the exchange of business documents from application
to application in a federally mandated format or, if no federal standard has been
promulgated, using bulk transmission processes and other formats as the Authority
designates for EDI transactions. For purposes of rules 407-120-0100 through 407-120-0200,
EDI does not include electronic transmission by web portal.
(85) “EDI Submitter”
means an individual or an entity authorized to establish an electronic media connection
with the Authority to conduct an EDI transaction. An EDI submitter may be a trading
partner or an agent of a trading partner.
(86) “Electronic Verification
System (EVS)” means eligibility information that has met the legal and technical
specifications of the Authority in order to offer eligibility information to enrolled
providers of the Division.
(87) “Emergency Department”
means the part of a licensed hospital facility open 24 hours a day to provide care
for anyone in need of emergency treatment.
(88) “Emergency Medical
Condition” means a medical condition manifesting itself by acute symptoms
of sufficient severity (including severe pain) such that a prudent layperson who
possesses an average knowledge of health and medicine could reasonably expect the
absence of immediate medical attention to result in placing the health of the individual
(or with respect to a pregnant woman, the health of the woman or her unborn child)
in serious jeopardy, serious impairment to bodily functions, or serious dysfunction
of any bodily organ or part. An emergency medical condition is determined based
on the presenting symptoms (not the final diagnosis) as perceived by a prudent layperson
(rather than a health care professional) and includes cases in which the absence
of immediate medical attention would not in fact have had the adverse results described
in the previous sentence. (This definition does not apply to clients with CAWEM
benefit package. CAWEM emergency services are governed by OAR 410-120-1210(3)(f)(B)).
(89) “Emergency Medical
Transportation” means transportation necessary for a client with an emergency
medical condition as defined in this rule and requires a skilled medical professional
such as an Emergency Medical Technician (EMT) and immediate transport to a site,
usually a hospital, where appropriate emergency medical service is available.
(90) “Emergency Services”
means health services from a qualified provider necessary to evaluate or stabilize
an emergency medical condition, including inpatient and outpatient treatment that
may be necessary to assure within reasonable medical probability that the patient’s
condition is not likely to materially deteriorate from or during a client’s
discharge from a facility or transfer to another facility.
(91) “Evidence-Based
Medicine” means the conscientious, explicit, and judicious use of current
best evidence in making decisions about the care of individual patients. The practice
of evidence-based medicine means integrating individual clinical expertise with
the best available external clinical evidence from systematic research. By individual
clinical expertise we mean the proficiency and judgment that individual clinicians
acquire through clinical experience and clinical practice. Increased expertise is
reflected in many ways, but especially in more effective and efficient diagnosis
and in the more thoughtful identification and compassionate use of individual patients'
predicaments, rights, and preferences in making clinical decisions about their care.
By best available external clinical evidence we mean clinically relevant research,
often from the basic sciences of medicine, but especially from patient-centered
clinical research into the accuracy and precision of diagnostic tests (including
the clinical examination), the power of prognostic markers, and the efficacy and
safety of therapeutic, rehabilitative, and preventive regimens. External clinical
evidence both invalidates previously accepted diagnostic tests and treatments and
replaces them with new ones that are more powerful, more accurate, more efficacious,
and safer. (Source: BMJ 1996; 312:71-72 (13 January)).
(92) “False Claim”
means a claim that a provider knowingly submits or causes to be submitted that contains
inaccurate, misleading, or omitted information and such inaccurate, misleading,
or omitted information would result, or has resulted, in an overpayment.
(93) “Family Planning
Services” means services for clients of child bearing age (including minors
who can be considered to be sexually active) who desire such services and that are
intended to prevent pregnancy or otherwise limit family size.
(94) “Federally Qualified
Health Center (FQHC)” means a federal designation for a medical entity that
receives grants under Section 329, 330, or 340 of the Public Health Service Act
or a facility designated as an FQHC by Centers for Medicare and Medicaid (CMS) upon
recommendation of the U.S. Public Health Service.
(95) “Fee-for-Service
Provider” means a health care provider who is not reimbursed under the terms
of an Authority contract with a Coordinated Care Organization or Prepaid Health
Plan (PHP). A medical provider participating in a PHP or a CCO may be considered
a fee-for-service provider when treating clients who are not enrolled in a PHP or
a CCO.
(96) “Fraud”
means an intentional deception or misrepresentation made by a person with the knowledge
that the deception could result in some unauthorized benefit to him or some other
person. It includes any act that constitutes fraud under applicable federal or state
law.
(97) “Fully Dual Eligible”
means for the purposes of Medicare Part D coverage (42 CFR 423.772), Medicare clients
who are also eligible for Medicaid, meeting the income and other eligibility criteria
adopted by the Department for full medical assistance coverage.
(98) “General Assistance
(GA)” means medical assistance administered and funded 100 percent with State
of Oregon funds through OHP.
(99) “Health Care Interpreter”
Certified or Qualified as defined in ORS 413.550.
(100) “Health Care
Professionals” means individuals with current and appropriate licensure, certification,
or accreditation in a medical, mental health, or dental profession who provide health
services, assessments, and screenings for clients within their scope of practice,
licensure, or certification.
(101) “Healthcare Common
Procedure Coding System (HCPCS)” means a method for reporting health care
professional services, procedures, and supplies. HCPCS consists of the Level l —
American Medical Association's Physician's Current Procedural Terminology (CPT),
Level II — National codes, and Level III — Local codes. The Division
uses HCPCS codes; however, the Division uses Current Dental Terminology (CDT) codes
for the reporting of dental care services and procedures.
(102) “Health Evidence
Review Commission” means a commission that, among other duties, develops and
maintains a list of health services ranked by priority from the most to the least
important representing the comparative benefits of each service to the population
served.
(103) “Health Insurance
Portability and Accountability Act (HIPAA) of 1996 (HIPAA)” means the federal
law (Public Law 104-191, August 21, 1996) with the legislative objective to assure
health insurance portability, reduce health care fraud and abuse, enforce standards
for health information, and guarantee security and privacy of health information.
(104) “Health Maintenance
Organization (HMO)” means a public or private health care organization that
is a federally qualified HMO under Section 1310 of the U.S. Public Health Services
Act. HMOs provide health care services on a capitated, contractual basis.
(105) “Health Plan
New/non-categorical client (HPN)” means an individual who is 19 years of age
or older, is not pregnant, is not receiving Medicaid through another program, and
who must meet all eligibility requirements to become an OHP client.
(106) “Hearing Aid
Dealer” means a person licensed by the Board of Hearing Aid Dealers to sell,
lease, or rent hearing aids in conjunction with the evaluation or measurement of
human hearing and the recommendation, selection, or adaptation of hearing aids.
(107) “Home Enteral
Nutrition” means services provided in the client's place of residence to an
individual who requires nutrition supplied by tube into the gastrointestinal tract
as described in the Home Enteral/Parenteral Nutrition and IV Services program provider
rules.
(108) “Home Health
Agency” means a public or private agency or organization that has been certified
by Medicare as a Medicare home health agency and that is licensed by the Authority
as a home health agency in Oregon and meets the capitalization requirements as outlined
in the Balanced Budget Act (BBA) of 1997.
(109) “Home Health
Services” means part-time or intermittent skilled nursing services, other
therapeutic services (physical therapy, occupational therapy, speech therapy), and
home health aide services made available on a visiting basis in a place of residence
used as the client's home.
(110) “Home Intravenous
Services” means services provided in the client's place of residence to an
individual who requires that medication (antibiotics, analgesics, chemotherapy,
hydrational fluids, or other intravenous medications) be administered intravenously
as described in the Home Enteral/Parenteral Nutrition and IV Services program administrative
rules.
(111) “Home Parenteral
Nutrition” means services provided in the client's residence to an individual
who is unable to absorb nutrients via the gastrointestinal tract, or for other medical
reasons, requires nutrition be supplied parenterally as described in the Home Enteral/Parenteral
Nutrition and IV Services program administrative rules.
(112) “Hospice”
means a public agency or private organization or subdivision of either that is primarily
engaged in providing care to terminally ill individuals and is certified by the
federal Centers for Medicare and Medicaid Services as a program of hospice services
meeting current standards for Medicare and Medicaid reimbursement and Medicare Conditions
of Participation and is currently licensed by the Oregon Health Authority (Authority),
Public Health Division.
(113) “Hospital”
means a facility licensed by the Office of Public Health Systems as a general hospital
that meets requirements for participation in OHP under Title XVIII of the Social
Security Act. The Division does not consider facilities certified by CMS as long-term
care hospitals, long-term acute care hospitals, or religious non-medical facilities
as hospitals for reimbursement purposes. Out-of-state hospitals will be considered
hospitals for reimbursement purposes if they are licensed as a short term acute
care or general hospital by the appropriate licensing authority within that state
and if they are enrolled as a provider of hospital services with the Medicaid agency
within that state.
(114) “Hospital-Based
Professional Services” means professional services provided by licensed practitioners
or staff based on a contractual or employee/employer relationship and reported as
a cost on the Hospital Statement of Reasonable Cost report for Medicare and the
Calculation of Reasonable Cost (division 42) report for the Division.
(115) “Hospital Dentistry”
means dental services normally done in a dental office setting, but due to specific
client need (as detailed in OAR chapter 410 division 123) are provided in an ambulatory
surgical center or inpatient or outpatient hospital setting under general anesthesia
(or IV conscious sedation, if appropriate).
(116) “Hospital Laboratory”
means a laboratory providing professional technical laboratory services as outlined
under laboratory services in a hospital setting as either an inpatient or outpatient
hospital service whose costs are reported on the hospital's cost report to Medicare
and to the Division.
(117) “Indian Health
Care Provider” means an Indian health program or an urban Indian organization.
(118) “Indian Health
Program” means any Indian Health Service (IHS) facility, any federally recognized
tribe or tribal organization, or any FQHC with a 638 designation.
(119) “Indian Health
Service (IHS)” means an operating division (OPDIV) within the U.S. Department
of Health and Human Services (HHS) responsible for providing medical and public
health services to members of federally recognized tribes and Alaska Natives.
(120) “Indigent”
means for the purposes of access to the Intoxicated Driver Program Fund (ORS 813.602),
individuals with-out health insurance coverage, public or private, who meet standards
for indigence adopted by the federal government as defined in 813.602(5).
(121) “Individual Adjustment
Request Form (DMAP 1036)” means a form used to resolve an incorrect payment
on a previously paid claim, including underpayments or overpayments.
(122) “Inpatient Hospital
Services” means services that are furnished in a hospital for the care and
treatment of an inpatient. (See Division Hospital Services program administrative
rules in chapter 410, division 125 for inpatient covered services.)
(123) “Institutional
Level of Income Standards (ILIS)” means three times the amount SSI pays monthly
to a person who has no other income and who is living alone in the community. This
is the standard used for Medicaid eligible individuals to calculate eligibility
for long-term nursing care in a nursing facility, Intermediate Care Facilities for
Individuals with Intellectual Disabilities (ICF/IID), and individuals on ICF/IID
waivers or eligibility for services under Aging and People with Disabilities (APD)
Home and Community Based Services program.
(124) “Institutionalized”
means a patient admitted to a nursing facility or hospital for the purpose of receiving
nursing or hospital care for a period of 30 days or more.
(125) “International
Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) (including
volumes 1, 2, and 3, as revised annually)” means a book of diagnosis codes
used for billing purposes when treating and requesting reimbursement for treatment
of diseases.
(126) “Laboratory”
means a facility licensed under ORS 438 and certified by CMS, Department of Health
and Human Services (DHHS), as qualified to participate under Medicare and to provide
laboratory services (as defined in this rule) within or apart from a hospital. An
entity is considered to be a laboratory if the entity derives materials from the
human body for the purpose of providing information for the diagnosis, prevention,
or treatment of any disease or impairment of or the assessment of the health of
human beings. If an entity performs even one laboratory test, including waived tests
for these purposes, it is considered to be a laboratory under the Clinical Laboratory
Improvement Act (CLIA).
(127) “Laboratory Services”
means those professional and technical diagnostic analyses of blood, urine, and
tissue ordered by a physician or other licensed practitioner of the healing arts
within his or her scope of practice as defined under state law and provided to a
patient by or under the direction of a physician or appropriate licensed practitioner
in an office or similar facility, hospital, or independent laboratory.
(128) “Licensed Direct
Entry Midwife” means a practitioner who has acquired the requisite qualifications
to be registered or legally licensed to practice midwifery by the Public Health
Division.
(129) “Liability Insurance”
means insurance that provides payment based on legal liability for injuries or illness.
It includes, but is not limited to, automobile liability insurance, uninsured and
underinsured motorist insurance, homeowner’s liability insurance, malpractice
insurance, product liability insurance, Worker's Compensation, and general casualty
insurance. It also includes payments under state wrongful death statutes that provide
payment for medical damages.
(130) “Managed Care
Organization (MCO)” means a contracted health delivery system providing capitated
or prepaid health services, also known as a Prepaid Health Plan (PHP). An MCO is
responsible for providing, arranging, and making reimbursement arrangements for
covered services as governed by state and federal law. An MCO may be a Chemical
Dependency Organization (CDO), Fully Capitated Health Plan (FCHP), Dental Care Organization
(DCO), Mental Health Organization (MHO), or Physician Care Organization (PCO).
(131) “Maternity Case
Management” means a program available to pregnant clients. The purpose of
maternity case management is to extend prenatal services to include non-medical
services that address social, economic, and nutritional factors. For more information
refer to the Division’s Medical-Surgical Services program administrative rules.
(132) “Medicaid”
means a joint federal and state funded program for medical assistance established
by Title XIX of the Social Security Act as amended and administered in Oregon by
the Authority.
(133) “Medical Assistance
Eligibility Confirmation” means verification through the Electronic Verification
System (EVS), AVR, Secure Web site or Electronic Data Interchange (EDI), or an authorized
Department or Authority representative.
(134) “Medical Assistance
Program” means a program for payment of health services provided to eligible
Oregonians, including Medicaid and CHIP services under the OHP Medicaid Demonstration
Project and Medicaid and CHIP services under the State Plan.
(135) “Medical Care
Identification” means the card commonly called the “medical card”
or medical ID issued to clients (called the Oregon Health ID starting Aug. 1, 2012).
(136) “Medical Services”
means care and treatment provided by a licensed medical provider directed at preventing,
diagnosing, treating, or correcting a medical problem.
(137) “Medical Transportation”
means transportation to or from covered medical services.
(138) “Medically Appropriate”
means services and medical supplies that are required for prevention, diagnosis,
or treatment of a health condition that encompasses physical or mental conditions
or injuries and that are:
(a) Consistent with the symptoms
of a health condition or treatment of a health condition;
(b) Appropriate with regard
to standards of good health practice and generally recognized by the relevant scientific
community, evidence-based medicine, and professional standards of care as effective;
(c) Not solely for the convenience
of an OHP client or a provider of the service or medical supplies; and
(d) The most cost effective
of the alternative levels of medical services or medical supplies that can be safely
provided to a Division client or CCO member in the Division or CCO’s judgment.
(139) “Medicare”
means a federally administered program offering health insurance benefits for persons
aged 65 or older and certain other aged or disabled persons. This program includes:
(a) Hospital Insurance (Part
A) for inpatient services in a hospital or skilled nursing facility, home health
care, and hospice care; and
(b) Medical Insurance (Part
B) for physicians' services, outpatient hospital services, home health care, end-stage
renal dialysis, and other medical services and supplies;
(c) Prescription drug coverage
(Part D) means covered Part D drugs that include prescription drugs, biological
products, insulin as described in specified paragraphs of section 1927(k) of the
Social Security Act, and vaccines licensed under section 351 of the Public Health
Service Act. It also includes medical supplies associated with the injection of
insulin. Part D covered drugs prohibit Medicaid Title XIX Federal Financial Participation
(FFP). For limitations, see the Division’s Pharmaceutical Services program
administrative rules in chapter 410, division 121.
(140) “Medicare Advantage”
means an organization approved by CMS to offer Medicare health benefits plans to
Medicare beneficiaries.
(141) “Medicheck for
Children and Teens” means services also known as Early and Periodic Screening,
Diagnosis, and Treatment (EPSDT) services. The Title XIX program of EPSDT services
is for eligible clients under age 21. It is a comprehensive child health program
to assure the availability and accessibility of required medically appropriate health
care services and to help Authority clients and their parents or guardians effectively
use them.
(142) “Member”
means an OHP client enrolled with a pre-paid health plan or coordinated care organization.
(143) “National Correct
Coding Initiative (NCCI)” means the Centers for Medicare and Medicaid Services
(CMS) developed the National Correct Coding Initiative (NCCI) to promote national
correct coding methodologies and to control improper coding leading to inappropriate
payment.
(144) “National Drug
Code or (NDC)” means a universal number that identifies a drug. The NDC number
consists of 11 digits in a 5-4-2 format. The Food and Drug Administration assigns
the first five digits to identify the manufacturer of the drug. The manufacturer
assigns the remaining digits to identify the specific product and package size.
Some packages will display less than 11 digits, but the number assumes leading zeroes.
(145) “National Provider
Identification (NPI)” means federally directed provider number mandated for
use on HIPAA covered transactions; individuals, provider organizations, and subparts
of provider organizations that meet the definition of health care provider (45 CFR
160.103) and who conduct HIPAA covered transactions electronically are eligible
to apply for an NPI. Medicare covered entities are required to apply for an NPI.
(146) “Naturopathic
physician” means a person licensed to practice naturopathic medicine by the
Oregon Board of Naturopathic Medicine.
(147) “Naturopathic
Services” means services provided within the scope of practice as defined
under state law and by rules of the Oregon Board of Naturopathic Medicine..
(148) “Non-covered
Services” means services or items for which the Authority is not responsible
for payment or reimbursement. Non-covered services are identified in:
(a) OAR 410-120-1200, Excluded
Services and Limitations; and
(b) 410-120-1210, Medical
Assistance Benefit Packages and Delivery System;
(c) 410-141-0480, OHP Benefit
Package of Covered Services;
(d) 410-141-0520, Prioritized
List of Health Services; and
(e) Any other applicable
Division administrative rules.
(149) “Non-Emergent
Medical Transportation Services (NEMT)”means transportation to or from a source
of covered service, that does not involve a sudden, unexpected occurrence which
creates a medical crisis requiring emergency medical services as defined in OAR
410-120-0000(76) and requiring immediate transportation to a site, usually a hospital,
where appropriate emergency medical care is available.
(150) “Non-Paid Provider”
means a provider who is issued a provider number for purposes of data collection
or non-claims-use of the Provider Web Portal (e.g., eligibility verification).
(151) “Nurse Anesthetist,
C.R.N.A.” means a registered nurse licensed in the State of Oregon as a CRNA
who is currently certified by the National Board of Certification and Recertification
for Nurse Anesthetists.
(152) “Nurse Practitioner”
means a person licensed as a registered nurse and certified by the Board of Nursing
to practice as a nurse practitioner pursuant to state law.
(153) “Nurse Practitioner
Services” means services provided within the scope of practice of a nurse
practitioner as defined under state law and by rules of the Board of Nursing.
(154) “Nursing Facility”
means a facility licensed and certified by the Department and defined in OAR 411-070-0005.
(155) “Nursing Services”
means health care services provided to a patient by a registered professional nurse
or a licensed practical nurse under the direction of a licensed professional within
the scope of practice as defined by state law.
(156) “Nutritional
Counseling” means counseling that takes place as part of the treatment of
a person with a specific condition, deficiency, or disease such as diabetes, hypercholesterolemia,
or phenylketonuria.
(157) “Occupational
Therapist” means a person licensed by the State Board of Examiners for Occupational
Therapy.
(158) “Occupational
Therapy” means the functional evaluation and treatment of individuals whose
ability to adapt or cope with the task of living is threatened or impaired by developmental
deficiencies, physical injury or illness, the aging process, or psychological disability.
The treatment utilizes task-oriented activities to prevent or correct physical and
emotional difficulties or minimize the disabling effect of these deficiencies on
the life of the individual.
(159) “Ombudsman Services”
means advocacy services provided by the Authority to clients whenever the client
is reasonably concerned about access to, quality of, or limitations on the health
services provided.
(160) “Oregon Health
ID” means a card the size of a business card that lists the client name, client
ID (prime number), and the date it was issued.
(161) “Oregon Health
Plan (OHP)” means the Medicaid and Children’s Health Insurance (CHIP)
Demonstration Project that expands Medicaid and CHIP eligibility beyond populations
traditionally eligible for Medicaid to other low-income populations and Medicaid
and CHIP services under the State Plan
(162) “Optometric Services”
means services provided within the scope of practice of optometrists as defined
under state law.
(163) “Optometrist”
means a person licensed to practice optometry pursuant to state law.
(164) “Oregon Health
Authority (Authority )” means the agency established in ORS Chapter 413 that
administers the funds for Titles XIX and XXI of the Social Security Act. It is the
single state agency for the administration of the medical assistance program under
ORS chapter 414. For purposes of these rules, the agencies under the authority of
the Oregon Health Authority are the Public Health Division, the Addictions and Mental
Health Division, and the Division of Medical Assistance Programs.
(165) “Oregon Youth
Authority (OYA)” means the state department charged with the management and
administration of youth correction facilities, state parole and probation services,
and other functions related to state programs for youth corrections.
(166) “Out-of-State
Providers” means any provider located outside the borders of the State of
Oregon:
(a) Contiguous area providers
are those located no more than 75 miles from the border of the State of Oregon;
(b) Non-contiguous area providers
are those located more than 75 miles from the borders of the State of Oregon.
(167) “Outpatient Hospital
Services” means services that are furnished in a hospital for the care and
treatment of an outpatient. For information on outpatient-covered services, see
the Division’s Hospital Services administrative rules found in chapter 410,
division 125.
(168) “Overdue Claim”
means a valid claim that is not paid within 45 days of the date it was received.
(169) “Overpayment”
means a payment made by the Authority to a provider in excess of the correct Authority
payment amount for a service. Overpayments are subject to repayment to the Authority.
(170) “Overuse”
means use of medical goods or services at levels determined by Authority medical
staff or medical consultants to be medically unnecessary or potentially harmful.
(171) “Paid Provider”
means a provider who is issued a provider number for purposes of submitting medical
assistance program claims for payment by the Authority.
(172) “Panel”
means the Hearing Officer Panel established by section 3, chapter 849, Oregon Laws
1999.
(173) “Payment Authorization”
means authorization granted by the responsible agency, office, or organization for
payment prior or subsequent to the delivery of services, as described in these General
Rules and the appropriate program rules. See the individual program rules for services
requiring authorization.
(174) “Peer Review
Organization (PRO)” means an entity of health care practitioners of services
contracted by the state to review services ordered or furnished by other practitioners
in the same professional field.
(175) “Peer Wellness
Specialist” means an individual who is responsible for assessing mental health
service and support needs of the individual’s peers through community outreach,
assisting individuals with access to available services and resources, addressing
barriers to services and providing education and information about available resources
and mental health issues in order to reduce stigmas and discrimination toward consumers
of mental health services and to provide direct services to assist individuals in
creating and maintaining recovery, health, and wellness.
(176) “Person Centered
Care” means care that reflects the individual patient’s strengths and
preferences, reflects the clinical needs of the patient as identified through an
individualized assessment, is based upon the patient’s goals, and will assist
the patient in achieving the goals.
(177) “Personal Health
Navigator” means an individual who provides information, assistance, tools,
and support to enable a patient to make the best health care decisions in the patient’s
particular circumstances and in light of the patient’s needs, lifestyle, combination
of conditions, and desired outcome.
(178) “Pharmaceutical
Services” means services provided by a pharmacist, including medications dispensed
in a pharmacy upon an order of a licensed practitioner prescribing within his or
her scope of practice.
(179) “Pharmacist”
means a person licensed to practice pharmacy pursuant to state law.
(180) “Physical Capacity
Evaluation” means an objective, directly observed measurement of a person's
ability to perform a variety of physical tasks combined with subjective analysis
of abilities of the person.
(181) “Physical Therapist”
means a person licensed by the relevant state licensing authority to practice physical
therapy.
(182) “Physical Therapy”
means treatment comprising exercise, massage, heat or cold, air, light, water, electricity,
or sound for the purpose of correcting or alleviating any physical or mental disability,
or the performance of tests as an aid to the assessment, diagnosis, or treatment
of a human being. Physical therapy may not include radiology or electrosurgery.
(183) “Physician”
means a person licensed to practice medicine pursuant to state law of the state
in which he or she practices medicine or a person licensed to practice medicine
pursuant to federal law for the purpose of practicing medicine under a contract
with the federal government. A physician may be an individual licensed under ORS
677 or ORS 685.
(184) “Physician Assistant”
means a person licensed as a physician assistant in accordance with ORS 677. Physician
assistants provide medical services under the direction and supervision of an Oregon
licensed physician according to a practice description approved by the Board of
Medical Examiners.
(185) “Physician Services”
means services provided within the scope of practice as defined under state law
by or under the personal supervision of a physician.
(186) “Podiatric Services”
means services provided within the scope of practice of podiatrists as defined under
state law.
(187) “Podiatrist”
means a person licensed to practice podiatric medicine pursuant to state law.
(188) “Post-Payment
Review” means review of billings or other medical information for accuracy,
medical appropriateness, level of service, or for other reasons subsequent to payment
of the claim.
(189) “Practitioner”
means a person licensed pursuant to state law to engage in the provision of health
care services within the scope of the practitioner's license or certification.
(190) “Prepaid Health
Plan (PHP)” means a managed health, dental, chemical dependency, or mental
health organization that contracts with the Authority on a case managed, prepaid,
capitated basis under OHP. PHPs may be a Chemical Dependency Organization (CDO),
Dental Care Organization (DCO), Fully Capitated Health Plan (FCHP), Mental Health
Organization (MHO), or Physician Care Organization (PCO)
(191) “Primary Care
Dentist (PCD)” means a dental practitioner who is responsible for supervising
and coordinating initial and primary dental care within their scope of practice
for their members.
(192) “Primary Care
Provider (PCP)” means any enrolled medical assistance provider who has responsibility
for supervising, coordinating, and providing initial and primary care within their
scope of practice for identified clients. PCPs initiate referrals for care outside
their scope of practice, consultations, and specialist care and assure the continuity
of medically appropriate client care. A Federally qualified PCP means a physician
with a specialty or subspecialty in family medicine, general internal medicine,
or pediatric medicine as defined in OAR 410-130-0005.
(193) “Prior Authorization
(PA)” means payment authorization for specified medical services or items
given by Authority staff or its contracted agencies prior to provision of the service.
A physician referral is not a PA.
(194) “Prioritized
List of Health Services” means the listing of conditions and treatment pairs
developed by the Health Evidence Review Commission for the purpose of administering
OHP.
(195) “Private Duty
Nursing Services” means nursing services provided within the scope of license
by a registered nurse or a licensed practical nurse under the general direction
of the patient's physician to an individual who is not in a health care facility.
(196) “Provider”
means an individual, facility, institution, corporate entity, or other organization
that supplies health services or items, also termed a rendering provider, or bills,
obligates, and receives reimbursement on behalf of a rendering provider of services,
also termed a billing provider (BP). The term provider refers to both rendering
providers and BP unless otherwise specified.
(197) “Provider Organization”
means a group practice, facility, or organization that is:
(a) An employer of a provider,
if the provider is required as a condition of employment to turn over fees to the
employer; or
(b) The facility in which
the service is provided, if the provider has a contract under which the facility
submits claims; or
(c) A foundation, plan, or
similar organization operating an organized health care delivery system, if the
provider has a contract under which the organization submits the claim; and
(d) Such group practice,
facility, or organization is enrolled with the Authority, and payments are made
to the group practice, facility, or organization;
(e) An agent if such entity
solely submits billings on behalf of providers and payments are made to each provider.
(See Subparts of Provider Organization.)
(198) “Public Health
Clinic” means a clinic operated by a county government.
(199) “Public Rates”
means the charge for services and items that providers, including hospitals and
nursing facilities, made to the general public for the same service on the same
date as that provided to Authority clients.
(200) “Qualified Medicare
Beneficiary (QMB)” means a Medicare beneficiary as defined by the Social Security
Act and its amendments.
(201) “Qualified Medicare
and Medicaid Beneficiary (QMM)” means a Medicare beneficiary who is also eligible
for Division coverage.
(202) “Quality Improvement”
means the efforts to improve the level of performance of a key process or processes
in health services or health care.
(203) “Quality Improvement
Organization (QIO)” means an entity that has a contract with CMS under Part
B of Title XI to perform utilization and quality control review of the health care
furnished, or to be furnished, to Medicare and Medicaid clients; formerly known
as a Peer Review Organization.
(204) “Radiological
Services” means those professional and technical radiological and other imaging
services for the purpose of diagnosis and treatment ordered by a physician or other
licensed practitioner of the healing arts within the scope of practice as defined
under state law and provided to a patient by or under the direction of a physician
or appropriate licensed practitioner in an office or similar facility, hospital,
or independent radiological facility.
(205) “Recipient”
means a person who is currently eligible for medical assistance (also known as a
client).
(206) “Recreational
Therapy” means recreational or other activities that are diversional in nature
(includes, but is not limited to, social or recreational activities or outlets).
(207) “Recoupment”
means an accounts receivable system that collects money owed by the provider to
the Authority by withholding all or a portion of a provider's future payments.
(208) “Referral”
means the transfer of total or specified care of a client from one provider to another.
As used by the Authority, the term referral also includes a request for a consultation
or evaluation or a request or approval of specific services. In the case of clients
whose medical care is contracted through a Prepaid Health Plan (PHP), or managed
by a Primary Care Physician, a referral is required before non-emergency care is
covered by the PHP or the Authority.
(209) “Remittance Advice
(RA)” means the automated notice a provider receives explaining payments or
other claim actions. It is the only notice sent to providers regarding claim actions.
(210) “Rendering provider”
means an individual, facility, institution, corporate entity, or other organization
that supplies health services or items, also termed a provider, or bills, obligates,
and receives reimbursement on behalf of a provider of services, also termed a billing
provider (BP). The term rendering provider refers to both providers and BP unless
otherwise specified.
(211) “Request for
Hearing” means a clear expression in writing by an individual or representative
that the person wishes to appeal a Department or Authority decision or action and
wishes to have the decision considered by a higher authority.
(212) “Representative”
means an individual who can make OHP-related decisions for a client who is not able
to make such decisions themselves.
(213) “Retroactive
Medical Eligibility” means eligibility for medical assistance granted to a
client retroactive to a date prior to the client's application for medical assistance.
(214) “Ride”
means non-emergent medical transportation services for a client either to or from
a location where covered services are provided. “Ride” does not include
client-reimbursed medical transportation or emergency medical transportation in
an ambulance.
(215) “Rural”
means a geographic area that is ten or more map miles from a population center of
30,000 people or less.
(216) “Sanction”
means an action against providers taken by the Authority in cases of fraud, misuse,
or abuse of Division requirements.
(217) “School Based
Health Service” means a health service required by an Individualized Education
Plan (IEP) during a child's education program that addresses physical or mental
disabilities as recommended by a physician or other licensed practitioner.
(218) “Self-Sufficiency”
means the division in the Department of Human Services (Department) that administers
programs for adults and families.
(219) “Service Agreement”
means an agreement between the Authority and a specified provider to provide identified
services for a specified rate. Service agreements may be limited to services required
for the special needs of an identified client. Service agreements do not preclude
the requirement for a provider to enroll as a provider.
(220) “Sliding Fee
Schedule” means a fee schedule with varying rates established by a provider
of health care to make services available to indigent and low-income individuals.
The sliding-fee schedule is based on ability to pay.
(221) “Social Worker”
means a person licensed by the Board of Clinical Social Workers to practice clinical
social work.
(222) “Speech-Language
Pathologist” means a person licensed by the Oregon Board of Examiners for
Speech Pathology.
(223) “Speech-Language
Pathology Services” means the application of principles, methods, and procedure
for the measuring, evaluating, predicting, counseling, or instruction related to
the development and disorders of speech, voice, or language for the purpose of preventing,
habilitating, rehabilitating, or modifying such disorders in individuals or groups
of individuals.
(224) “State Facility”
means a hospital or training center operated by the State of Oregon that provides
long-term medical or psychiatric care.
(225) “Subparts (of
a Provider Organization)” means for NPI application, subparts of a health
care provider organization would meet the definition of health care provider (45
CFR 160.103) if it were a separate legal entity and if it conducted HIPAA-covered
transactions electronically or has an entity do so on its behalf and could be components
of an organization or separate physical locations of an organization.
(226) “Subrogation”
means right of the state to stand in place of the client in the collection of third
party resources (TPR).
(227) “Substance Use
Disorder (SUD) Services” means assessment, treatment, and rehabilitation on
a regularly scheduled basis or in response to crisis for alcohol or other drug abuse
for dependent members and their family members or significant others, consistent
with Level I, Level II, or Level III of the American Society of Addiction Medicine
Patient Placement Criteria 2-Revision (ASAM PPC-2R). SUD is an interchangeable term
with Chemical Dependency (CD), Alcohol and other Drug (AOD), and Alcohol and Drug
(A & D).
(228) “Supplemental
Security Income (SSI)” means a program available to certain aged and disabled
persons that is administered by the Social Security Administration through the Social
Security office.
(229) “Surgical Assistant”
means a person performing required assistance in surgery as permitted by rules of
the State Board of Medical Examiners.
(230) “Suspension”
means a sanction prohibiting a provider's participation in the medical assistance
programs by deactivation of the provider's Authority-assigned billing number for
a specified period of time. No payments, Title XIX, or State Funds will be made
for services provided during the suspension. The number will be reactivated automatically
after the suspension period has elapsed.
(231) “Targeted Case
Management (TCM)” means activities that will assist the client in a target
group in gaining access to needed medical, social, educational, and other services.
This includes locating, coordinating, and monitoring necessary and appropriate services.
TCM services are often provided by allied agency providers.
(232) “Termination”
means a sanction prohibiting a provider's participation in the Division’s
programs by canceling the provider's Authority-assigned billing number and agreement.
No payments, Title XIX, or state funds will be made for services provided after
the date of termination. Termination is permanent unless:
(a) The exceptions cited
in 42 CFR 1001.221 are met; or
(b) Otherwise stated by the
Authority at the time of termination.
(233) “Third Party
Liability (TPL), Third Party Resource (TPR), or Third party payer” means a
medical or financial resource that, under law, is available and applicable to pay
for medical services and items for an Authority client.
(234) “Transportation”
means medical transportation.
(235) “Service Authorization
Request” means a member’s initial or continuing request for the provision
of a service including member requests made by their provider or the member’s
authorized representative.
(236) “Type A Hospital”
means a hospital identified by the Office of Rural Health as a Type A hospital.
(237) “Type B AAA”
means an AAA administered by a unit or combination of units of general purpose local
government for overseeing Medicaid, financial and adult protective services, and
regulatory programs for the elderly or the elderly and disabled.
(238) “Type B AAA Unit”
means a Type B AAA funded by Oregon Project Independence (OPI), Title III—Older
Americans Act, and Title XIX of the Social Security Act.
(239) “Type B Hospital”
means a hospital identified by the Office of Rural Health as a Type B hospital.
(240) “Urban”
means a geographic area that is less than ten map miles from a population center
of 30,000 people or more.
(241) “Urgent Care
Services” means health services that are medically appropriate and immediately
required to prevent serious deterioration of a client’s health that are a
result of unforeseen illness or injury.
(242) “Usual Charge
(UC)” means the lesser of the following unless prohibited from billing by
federal statute or regulation:
(a) The provider's charge
per unit of service for the majority of non-medical assistance users of the same
service based on the preceding month's charges;
(b) The provider's lowest
charge per unit of service on the same date that is advertised, quoted, or posted.
The lesser of these applies regardless of the payment source or means of payment;
(c) Where the provider has
established a written sliding fee scale based upon income for individuals and families
with income equal to or less than 200 percent of the federal poverty level, the
fees paid by these individuals and families are not considered in determining the
usual charge. Any amounts charged to third party resources (TPR) are to be considered.
(243) “Utilization
Review (UR)” means the process of reviewing, evaluating, and assuring appropriate
use of medical resources and services. The review encompasses quality, quantity,
and appropriateness of medical care to achieve the most effective and economic use
of health care services.
(244) “Valid Claim”
means an invoice received by the Division or the appropriate Authority or Department
office for payment of covered health care services rendered to an eligible client
that:
(a) Can be processed without
obtaining additional information from the provider of the goods or services or from
a TPR; and
(b) Has been received within
the time limitations prescribed in these General Rules (OAR 410 division 120).
(245) “Valid Preauthorization”
means a document the Authority, a PHP, or CCO receives requesting a health service
for a member who would be eligible for the service at the time of the service, and
the document contains:
(a) A beginning and ending
date not exceeding twelve months, except for cases of PHP or CCO enrollment where
four months may apply; and
(b) All data fields required
for processing the request or payment of the service including the appropriate billing
codes.
(246) “Vision Services”
means provision of corrective eyewear, including ophthalmological or optometric
examinations for determination of visual acuity and vision therapy and devices.
(247) “Volunteer”
(for the purposes of NEMT) means an individual selected, trained and under the supervision
of the Department who is providing services on behalf of the Department in a non-paid
capacity except for incidental expense reimbursement under the Department Volunteer
Program authorized by ORS 409.360.
[ED. NOTE:
Tables referenced are not included in rule text. Click here for PDF copy of table(s).]
Stat. Auth.: ORS 413.042 & 414.065
Stats. Implemented: ORS 414.065
Hist.: AFS 5-1981, f. 1-23-81,
ef. 3-1-81; AFS 33-1981, f. 6-23-81, ef. 7-1-81; AFS 47-1982, f. 4-30-82 & AFS
52-1982, f. 5-28-82, ef. 5-1-82, for providers located in the geographical areas
covered by the branch offices of North Salem, South Salem, Dallas, Woodburn, McMinnville,
Lebanon, Albany and Corvallis, ef. 6-30-82 for remaining AFS branch offices; AFS
57-1982, f. 6-28-82, ef. 7-1-82; AFS 81-1982, f. 8-30-82, ef. 9-1-82; AFS 4-1984,
f. & ef. 2-1-84; AFS 12-1984, f. 3-16-84, ef. 4-1-84; AFS 13-1984(Temp), f.
& ef. 4-2-84; AFS 37-1984, f. 8-30-84, ef. 9-1-84; AFS 24-1985, f. 4-24-85,
ef. 6-1-85; AFS 13-1987, f. 3-31-87, ef. 4-1-87; AFS 7-1988, f. & cert. ef.
2-1-88; AFS 69-1988, f. & cert. ef. 12-5-88; HR 2-1990, f. 2-12-90, cert. ef.
3-1-90, Renumbered from 461-013-0005; HR 25-1991(Temp), f. & cert. ef. 7-1-91;
HR 41-1991, f. & cert. ef. 10-1-91; HR 32-1993, f. & cert. ef. 11-1-93;
HR 2-1994, f. & cert. ef. 2-1-94; HR 31-1994, f. & cert. ef. 11-1-94; HR
40-1994, f. 12-30-94, cert. ef. 1-1-95; HR 5-1997, f. 1-31-97, cert. ef. 2-1-97;
HR 21-1997, f. & cert. ef. 10-1-97; OMAP 20-1998, f. & cert. ef. 7-1-98;
OMAP 10-1999, f. & cert. ef. 4-1-99; OMAP 31-1999, f. & cert. ef. 10-1-99;
OMAP 11-2000, f. & cert. ef. 6-23-00; OMAP 35-2000, f. 9-29-00, cert. ef. 10-1-00;
OMAP 42-2002, f. & cert. ef. 10-1-02; OMAP 3-2003, f. 1-31-03, cert. ef. 2-1-03;
OMAP 62-2003, f. 9-8-03, cert. ef.10-1-03; OMAP 67-2004, f. 9-14-04, cert. ef. 10-1-04;
OMAP 10-2005, f. 3-9-05, cert. ef. 4-1-05; OMAP 39-2005, f. 9-2-05, cert. ef. 10-1-05;
OMAP 65-2005, f. 11-30-05, cert. ef. 1-1-06; OMAP 15-2006, f. 6-12-06, cert. ef.
7-1-06; OMAP 45-2006, f. 12-15-06, cert. ef. 1-1-07; DMAP 24-2007 f. 12-11-07 cert.
ef. 1-1-08; DMAP 34-2008, f. 11-26-08, cert. ef. 12-1-08; DMAP 13-2009 f. 6-12-09,
cert. ef. 7-1-09; DMAP 11-2011, f. 6-29-11, cert. ef. 7-1-11; DMAP 36-2011, f. 12-13-11,
cert. ef. 1-1-12; DMAP 11-2012(Temp), f. & cert. ef. 3-16-12 thru 9-11-12; DMAP
28-2012, f. 6-21-12, cert. ef. 7-1-12; DMAP 49-2012, f. 10-31-12, cert. ef. 11-1-12;
DMAP 37-2013(Temp), f. 6-27-13, cert. ef. 7-1-13 thru 12-24-13; DMAP 71-2013, f.
& cert. ef. 12-27-13; DMAP 57-2014, f. 9-26-14, cert. ef. 10-1-14; DMAP 5-2015,
f. & cert. ef. 2-10-15; DMAP 29-2015, f. & cert. ef. 5-29-15; DMAP 55-2015,
f. 9-22-15, cert. ef. 10-1-15
410-120-0003
OHP Standard Benefit Package
The OHP Standard benefit package is
eliminated effective January 1, 2014. Although references to OHP Standard exist
elsewhere in rule, the benefit package currently is not funded and is not offered
as a benefit. Those enrolled in OHP Standard are enrolled in other existing benefit
packages.
Stat. Auth.: ORS 413.042
Stats. Implemented: ORS 414.706
Hist.: DAMP 74-2013, f. 12-31-13,
cert. ef. 1-1-14
410-120-0006
Medical Eligibility Standards
As the state Medicaid and CHIP agency,
the Oregon Health Authority (Authority) is responsible for establishing and implementing
eligibility policies and procedures consistent with applicable law. As outlined
in OAR 943-001-0020, the Authority and the Department of Human Services (Department)
work together to adopt rules to assure that medical assistance eligibility procedures
and determinations are consistent across both agencies.
(1) The Authority adopts
and incorporates by reference the rules established in OAR chapter 461 for all overpayment,
personal injury liens and estates administration for Authority programs covered
under OAR chapter 410, division 200.
(2) Any reference to OAR
chapter 461 in contracts of the Authority are deemed to be references to the requirements
of this rule and shall be construed to apply to all eligibility policies, procedures
and determinations by or through the Authority.
(3) For purposes of this
rule, references in OAR chapter 461 to the Department or to the Authority shall
be construed to be references to both agencies.
Stat. Auth.: ORS 413.042
Stats. Implemented: ORS 413.042,
414.065
Hist.: DMAP 10-2011, f. 6-29-11,
cert. ef. 7-1-11; DMAP 18-2011(Temp), f. & cert. ef. 7-15-11 thru 1-11-12;
DMAP 21-2011(Temp), f. 7-29-11, cert. ef. 8-1-11 thru 1-11-12; DMAP 25-2011(Temp),
f. 9-28-11, cert. ef. 10-1-11 thru 1-11-12; DMAP 36-2011, f. 12-13-11, cert. ef.
1-1-12; DMAP 1-2012(Temp), f. & cert. e.f 1-13-12 thru 7-10-12; DMAP 2-2012(Temp),
f. & cert. ef. 1-26-12 thru 7-10-12; DMAP 3-2012(Temp), f. & cert. ef. 1-31-12
thru 2-1-12; DMAP 4-2012(Temp), f. 1-31-12, cert. ef. 2-1-12 thru 7-10-12; DMAP
9-2012(Temp), f. & cert. ef. 3-1-12 thru 7-10-12; DMAP 21-2012(Temp), f. 3-30-12,
cert. ef. 4-1-12 thru 7-10-12; DMAP 25-2012(Temp), f. & cert. ef. 5-1-12 thru
7-10-12; Administrative correction 8-1-12; DMAP 35-2012(Temp), f. & cert. ef.
7-20-12 thru 1-15-13; DMAP 45-2012(Temp), f. & cert. ef. 10-5-12 thru 1-19-13;
DMAP 50-2012, f. 10-31-12, cert. ef. 11-1-12; DMAP 53-2012(Temp), f. & cert.
ef. 11-1-12 thru 4-29-13; DMAP 56-2012(Temp), f. 11-30-12, cert. ef. 12-1-12 thru
4-1-13; DMAP 60-2012, f. 12-27-12, cert. ef. 1-1-13; DMAP 65-2012(Temp), f. 12-28-12,
cert. ef. 1-1-13 thru 6-29-13; DMAP 2-2013(Temp), f. & cert. ef. 1-8-13 thru
6-29-13; DMAP 3-2013(Temp), f. & cert. ef. 1-30-13 thru 6-29-13; DMAP 5-2013(Temp),
f. & cert. ef. 2-20-13 thru 6-29-13; DMAP 7-2013(Temp), f. & cert. ef. 3-1-13
thru 6-29-13; DMAP 12-2013, f. 3-27-13, cert. ef. 4-1-13; DMAP 17-2013, f. &
cert. ef. 4-10-13; DMAP 24-2013, f. & cert. ef. 5-29-13; DMAP 32-2013, f. &
cert. ef. 6-27-13; DMAP 39-2013(Temp), f. 7-26-13, cert. ef. 8-1-13 thru 1-28-14;
DMAP 44-2013(Temp), f. 8-21-13, cert. ef. 8-23-13 thru 1-28-14; DMAP 51-2013, f.
& cert. ef. 10-1-13; DMAP 52-2013(Temp), f. & cert. ef. 10-1-13 thru 3-30-14;
DMAP 55-2013(Temp), f. & cert. ef. 10-2-13 thru 3-31-14; DMAP 59-2013(Temp),
f. 10-31-13, cert. ef. 11-1-13 thru 3-31-14; DMAP 9-2014(Temp), f. 1-31-14, cert.
ef. 2-1-14 thru 3-31-14; DMAP 18-2014, f. 3-28-14, cert. ef. 3-31-14; DMAP 41-2014,
f. & cert. ef. 7-1-14; DMAP 54-2014, f. & cert. ef. 9-23-14; DMAP 12-2015(Temp),
f. 3-5-15, cert. ef. 3-19-15 thru 9-14-15; DMAP 33-2015, f. 6-24-15, cert. ef. 7-1-15;
DMAP 49-2015, f. 9-3-15, cert. ef. 10-1-15
410-120-0025
Administration of Division of Medical Assistance
Programs, Regulation and Rule Precedence
(1) The Oregon Health Authority (Authority)
and its Division of Medical Assistance Programs (Division) may adopt reasonable
and lawful policies, procedures, rules, and interpretations to promote the orderly
and efficient administration of medical assistance programs including the Oregon
Health Plan pursuant to ORS 414.065 (generally, fee-for-service), 414.651(Coordinated
Care Organizations), and 414.115 to 414.145 (services contracts), subject to the
rulemaking requirements of the Oregon Revised Statutes and Oregon Administrative
Rule (OAR) procedures.
(2) In applying its policies,
procedures, rules, and interpretations, the Division shall construe them as much
as possible to be complementary. In the event that Division policies, procedures,
rules and interpretations may not be complementary, the Division shall apply the
following order of precedence to guide its interpretation:
(a) For purposes of the provision
of covered medical assistance to Division clients, including but not limited to
authorization and delivery of service or denials of authorization or services, the
Division, clients, enrolled providers, Coordinated Care Organizations, and the Prepaid
Health Plans shall apply the following order of precedence:
(A) Oregon Revised Statutes
governing medical assistance programs;
(B) Consistent with ORS 413.071,those
federal laws and regulations governing the operation of the medical assistance program
and any waivers granted the Authority by the Centers for Medicare and Medicaid Services
to operate medical assistance programs including the Oregon Health Plan;
(C) Generally for Coordinated
Care Organizations, the requirements applicable to the providing covered medical
assistance to Division clients are found in OAR 410-141-3000 through 410-141-3485;
and where applicable, 410-120-0000 through 410-120-1980; and the provider rules
applicable to the category of medical service;
(D) Generally for Prepaid
Health Plans, the requirements applicable to providing covered medical assistance
to Division clients are found in OAR 410-141-0000 through 410-141-0860; and where
applicable, 410-120-0000 through 410-120-1980; and the provider rules applicable
to the category of medical service;
(E) Generally for enrolled
fee-for-service providers or other contractors, the requirements applicable to
providing covered medical assistance to Division clients are found in OAR 410-120-0000
through 410-120-1980, the Prioritized List and program coverage set forth in410-141-0480
to 410-141-0520, and the provider rules applicable to the category of medical service;
(F) Any other applicable
duly promulgated rules issued by the Division and other offices or units within
the Oregon Health Authority or Department of Human Services necessary to administer
the State of Oregon’s medical assistance programs, such as electronic data
transaction rules in OAR 943-120-0100 to 943-120-0200; and
(G) The basic framework for
provider enrollment in OAR 943-120-0300 through 943-120-0380 that generally apply
to providers enrolled with the Authority or Department, subject to more specific
requirements applicable to the administration of the Oregon Health Plan and medical
assistance programs administered by the Authority. For purposes of this rule, “more
specific” means the requirements, laws and rules applicable to the provider
type and covered services described in paragraphs (A)–(F) of this section.
(b) For purposes of contract
administration solely as between the Authority and its Coordinated Care Organizations
or Prepaid Health Plans, the terms of the applicable contract and the requirements
in section (2)(a) of this rule apply to the provision of covered medical assistance
to Division clients:
(A) Nothing in this rule
shall be deemed to incorporate into contracts provisions of law not expressly incorporated
into such contracts, nor shall this rule be deemed to supersede any rules of construction
of such contracts that may be provided for in such contracts;
(B) Nothing in this rule
gives, is intended to give, or shall be construed to give or provide any benefit
or right, whether directly or indirectly or otherwise, to any individual or entity
unless the individual or entity is identified as a named party to the contract.
Stat. Auth.: ORS 413.042
Stats. Implemented: ORS 414.065
Hist.: OMAP 39-2005, f. 9-2-05,
cert. ef. 10-1-05; DMAP 6-2008(Temp), f. & cert. ef. 3-14-08 thru 9-1-08; DMAP
11-2008, f. 4-29-08, cert. ef. 5-1-08; DMAP 28-2012, f. 6-21-12, cert. ef. 7-1-12;
DMAP 48-2013, f. & cert. ef. 9-12-13; DMAP 40-2015, f. & cert. ef. 7-1-15
410-120-0030
Children’s Health Insurance Program
(1) The Children’s Health Insurance
Program (CHIP) is a federal non-entitlement program. The Oregon Health Authority
(Authority), Division of Medical Assistance Program (Division) administers two programs
funded under CHIP in accordance with the Oregon Health Plan (OHP) waiver and the
CHIP state plan:
(a) CHIP: Provides health
coverage for uninsured, low-income children who are ineligible for Medicaid;
(b) CHIP Pre-natal care expansion
program.
(2) The General Rules Program
(OAR 410-120-0000 et. seq.) and the OHP Program rules (OAR 410-141-0000 et. seq.)
applicable to the Medicaid program are also applicable to the Authority’s
CHIP program.
(3) Children under 19 years
of age who meet the income limits, citizenship requirements and eligibility criteria
for medical assistance established in OAR chapter 410 through the program acronym
OHP-CHP receive the OHP benefit package. (For benefits refer to OAR 410-120-1210.)
Stat. Auth.: ORS 413.042
Stats. Implemented: ORS 414.025
& 414.065
Hist.: DMAP 7-2008(Temp),
f. 3-17-08 & cert. ef. 4-1-08 thru 9-15-08; DMAP 14-2008, f. 6-13-08, cert.
ef. 7-1-08; DMAP 29-2009(Temp), f. 9-15-09, cert. ef. 10-1-09 thru 3-25-10; DMAP
37-2009, f. 12-15-09, cert. ef. 1-1-10; DMAP 18-2010, f. 6-23-10, cert. ef. 7-1-10;
DMAP 23-2010, f. & cert. ef. 9-1-10; DMAP 39-2010, f. 12-28-10, cert. ef. 1-1-11;
DMAP 11-2011, f. 6-29-11, cert. ef. 7-1-11; DMAP 19-2012, f. 3-30-12, cert. ef.
4-1-12; DMAP 49-2012, f. 10-31-12, cert. ef. 11-1-12; DMAP 67-2013, f. & cert.
ef. 12-3-13; DMAP 75-2013(Temp), f. 12-31-13, cert. ef. 1-1-14 thru 6-30-14; DMAP
23-2014, f. & cert. ef. 4-4-14
410-120-0035
Public Entity
(1) This rule pertains to Centers for Medicare and Medicaid (CMS) regulations for payments to and from the Oregon Health Authority (Authority) and public entities.
(2) Effective July 1, 2008, unit of government providers responsible by rule or contract for the local match share portion for claims eligible for Federal Financial Participation (FFP) submitted to Medicaid for reimbursement must submit the local match payment prior to the Authority claiming the federal share from CMS:
(a) Before the provider submits its claims to the Authority, the provider must transfer funds from allowable sources to the Authority representing the local match share of the total allowable cost for claimed services;
(b) Upon receipt of provider’s transfer of the local match share and the Authority's receipt of claims in the Medical Management Information System (MMIS) that are reimbursable to the extent of the transferred local match share amount, the Authority will claim FFP from CMS and reimburse the provider for the total reimbursable allowable claimed amount for the services;
(c) Transfer of the local match share to the Authority means that the provider certifies that for the purposes of 42 CFR 433.51, the funds it transfers to the Authority for the local match share are public funds that are not federal funds, or are federal funds authorized by federal law to be used to match other federal funds; and that all sources of funds are allowable under 42 CFR 433 Subpart B.
Stat. Auth.: ORS 413.042

Stats. Implemented: ORS 414.065

Hist.: DMAP 27-2008(Temp), f. 6-13-08, cert. ef. 7-1-08 thru 12-28-08; DMAP 30-2008, f. 9-12-08, cert. ef. 9-15-08
410-120-0045
Applications for Medical Assistance at
Provider locations
(1) The Oregon Health Authority (Authority)
allows Division enrolled providers the opportunity to assist patients applying for
public and private health coverage offered through OHA and Cover Oregon at the provider’s
practice site. Once the provider is determined eligible by the Authority, providers
will receive an approval letter, unique assister identification number, training
requirements and other information.
(2) For purposes of this
rule, the provider’s practice will be referred to as a site. Sites can be,
but are not limited, to the following:
(a) Hospitals;
(b) Federally qualified health
centers/rural health clinics (FQHC/RHCs);
(c) County health departments;
(d) Substance Use Disorder
adult and adolescent treatment and recovery centers;
(e) Tribal health clinics;
(f) Family Planning clinics;
(g) Other primary care clinics
as approved by the Authority.
(3) The site shall send all
employees that will be assisting to a mandatory Authority training session for application
assistance certification. Employees must pass a test provided at that training session
before initiating application assistance service. At least one trained employee
must be a permanent employee of the site. Sites shall ensure that individuals performing
application assistance are recertified at appropriate times as set forth by the
Authority. For purposes of this rule, certified staff will be referred to as “application
assisters.”
(4) Application assisters
will log in to the Cover Oregon portal to provide enrollment assistance. In the
event that the client needs require the use of a paper application, the Application
assister will write the date the application was started and the assister’s
assigned assister identification number in the appropriate space on the application.
Assistance will support patients potentially eligible for public and private health
coverage offered through OHA and Cover Oregon. Sites are not under an obligation
to provide medical program or Cover Oregon application assistance to individuals
other than those they are providing care to. The application assister shall establish
a date of request for applicants by logging into the Cover Oregon portal or writing
the assister’s identification number on the paper application in the appropriate
place with the date the applicant requests an application. Once written on the application,
the date can never be changed, altered or backdated. The inscription must include
the provider’s assigned application assister site code number, in addition
to the date.
(5) The application assister
shall encourage applicants to provide accurate and truthful information, assist
in completing the application and enrollment process and shall assure that the information
contained on the application is complete. The application assister shall not attempt
to pre-determine applicant eligibility or make any assurances regarding the eligibility
for public or private health coverage offered through OHA and Cover Oregon.
(6) The application assister
shall provide information to applicants about public medical programs and Cover
Oregon private insurance products so applicant can make an informed choice when
enrolling into a health insurance product. Language (including sign language) translators
must be available if requested by applicants.
(a) The information given
to the applicant shall, at a minimum, include an explanation of the significance
of the date of request on the hard copy application, review of public medical programs
and Cover Oregon private insurance products that are available, provide unbiased
health coverage choices using filters embedded in the online application and information
provided by OHA or Cover Oregon during enrollment process,, answer questions and
assist in filling out online or paper application forms. The information provided
at these sessions may include, but is not limited to the following:
(A) General eligibility criteria
for public and private coverage accessible through OHA and Cover Oregon;
(B) Health plan choices,
criteria and how to enroll in public medical programs or Cover Oregon private insurance
product choices.
(b) The application assister
must make copies of the original eligibility verification documentation required
to accompany the application, but not uploaded to the Cover Oregon portal.
(7) The site shall log into
Cover Oregon portal to track applications with which they have assisted. If site
uses a hard copy application, site will use reporting process provided by Authority.
(8) Providers, staff, contracted
employees and volunteers are subject to all applicable provisions under General
Rules OAR chapter 410, division 120.
(a) The application assister
shall treat all information they obtain for public medical programs and Cover Oregon
private insurance as confidential and privileged communications. The application
assister shall not disclose such information without the written consent of the
individual, his or her delegated authority, attorney, or responsible parent of a
minor child or child’s guardian. Nothing prohibits the disclosure of information
in summaries, statistical or other form, which does not identify particular individuals;
(b) The Authority and sites
will share information as necessary to effectively serve public medical programs
and Cover Oregon eligible or potentially eligible individuals;
(c) Personally identifiable
health information about applicants and recipients will be subject to the transaction,
security and privacy provisions of the Health Insurance Portability and Accountability
Act (HIPAA) and the administrative rules there under. Sites will cooperate with
the Authority in the adoption of policies and procedures for maintaining the privacy
and security of records and for conducting transactions pursuant to HIPAA requirements.
(9) The Authority will be
responsible for the following:
(a) The Authority will provide
training to application assisters on public medical programs and Cover Oregon private
insurance products, eligibility and enrollment, application procedures and documentation
requirements. The Authority will set dates and times for these additional training
classes as needed, following changes in policy or procedure;
(b) The Authority will make
available public medical programs and Cover Oregon application forms online and
in hard copy (in English, translated languages and alternative formats), health
insurance coverage options, assister identification number instructions, reporting
guidance and other necessary forms;
(c) The Authority and Cover
Oregon will process all applications in accordance with Authority and Cover Oregon
standards;
(d) The Authority and Cover
Oregon will process completed applications, which have satisfactory verification
information, within the time requirements set forth in Authority and Cover Oregon
policy. In the event of a change in policy, the time for completion of processing
shall be changed to the new time requirements.
(10) The Authority and Cover
Oregon will provide all necessary forms and applications as referenced above at
no cost to the site. There are no monetary provisions in this rule for any payment
for the performance of work by the site, except for those costs provided under OAR
410-147-0400 and 410-146-0460. However, the parties acknowledge the exchange and
receipt of other valuable considerations in the spirit of cooperation to the benefit
of all by collaborating and authorizing the performance of the work. The Authority
does not guarantee a particular volume of business under these rules.
(11) The provider may terminate
enrollment at any time as outlined in OAR 410-120-1260(14).
Stat. Auth.: ORS 413.042
Statutes Implemented: ORS 414.041
Hist.: DMAP 12-2010, f. 6-10-10,
cert. ef. 7-1-10; DMAP 49-2012, f. 10-31-12, cert. ef. 11-1-12; DMAP 48-2013, f.
& cert. ef. 9-12-13; DMAP 71-2013, f. & cert. ef. 12-27-13
410-120-0250
PHP or Coordinated Care
Organizations
(1) The Authority provides clients
with health services, through contracts with a Prepaid Health Plan (PHP) or a Coordinated
Care Organization (CCO).
(2) The PHP or CCO is responsible
for providing, arranging and making reimbursement arrangements for covered services
as governed by state and federal law, the PHP or CCO's contract with the Authority
and the OHP administrative rules governing PHPs and CCOs (OAR 410 division 141).
(3) All PHP or CCOs are required to provide benefit coverage
pursuant to OAR 410-120-1210 and 410-141-0480 through 410-141-0520, however, authorization
criteria may vary between PHP or CCOs. It is the providers' responsibility to comply
with the PHP or CCO's Prior Authorization requirements or other policies necessary
for reimbursement from the PHP or CCO, before providing services to any OHP client
enrolled in a PHP or CCO.
Stat. Auth.: ORS 413.042

Stats. Implemented: ORS 414.025, 414.065, 414.631 & 414.651

Hist.: OMAP 62-2003, f. 9-8-03,
cert. ef.10-1-03; OMAP 39-2005, f. 9-2-05, cert. ef. 10-1-05; OMAP 67-2005, f. 12-21-05,
cert. ef. 1-1-06; DMAP 28-2012, f. 6-21-12, cert. ef. 7-1-12
410-120-1140
Verification
of Eligibility and Coverage
(1) To ensure Division reimbursement
of services, providers are responsible to verify the following before rendering
services:
(a) Client eligibility: That
the person is an eligible Oregon Health Plan (OHP) client on the date(s) services
are rendered; and
(b) Benefit coverage: That
the person is enrolled in an OHP benefit package that covers the services they plan
to render. See OAR 410-120-1210 for services covered under each Division benefit
package.
(2) Providers who do not
verify eligibility and benefit coverage with the Division before serving a person
shall assume full financial responsibility in serving that person.
(3) The following types of
client identification (ID) only list the client’s name, Oregon Medicaid ID
number (prime number), and the date the ID was issued. They do not guarantee client
eligibility or benefit coverage:
(a) The standard ID (called
the Oregon Health ID, formerly the DHS Medical Care ID) printed on perforated paper
the size of a business card;
(b) Replacement IDs (printed
on regular printer paper in case of misplaced originals).
(4) When a person presents
a standard or replacement ID, providers must verify client eligibility and benefit
coverage through one of the following (For instructions see the Division General
Rules Supplemental Information available on the web at http://www.oregon.gov/oha/healthplan/pages/general-rules.aspx):
(a) The Division’s
Medicaid Management Information System (MMIS) Provider Web portal;
(b) The Automated Voice Response
(AVR) telephone system;
(c) Batch or real-time electronic
data interchange (EDI) eligibility inquiry (270) and response (271) transactions;
(5) The client may also present
one of the following Temporary Oregon Health IDs; both are full-page forms:
(a) DMAP form 1086: This
document guarantees eligibility and benefit coverage for seven days from the beginning
dates of coverage entered in Part 1 of the form. This temporary ID is issued only
if the client needs immediate care but their eligibility and coverage information
is not yet available for verification as described in part (4) of this rule. Providers
must honor the Temporary Oregon Health ID when presented within seven (7) days of
the beginning date of coverage entered on the form;
(b) OHP 3263A: Approval Notice
for Hospital Presumptive Eligibility for Medical Coverage: This ID is issued for
those who are “presumed” eligible based on certain information and authorizes
benefit coverage only on a temporary basis. The OHP 3263A informs the client of
the exact date by which the Division must receive their full Medicaid application
so that they may be evaluated for ongoing eligibility.
Stat. Auth.: ORS 413.042
Stats. Implemented: ORS 414.065,
414.025 & 411.400
Hist.: PWC 683, f. 7-19-74,
ef. 8-11-74; PWC 803(Temp), f. & ef. 7-1-76; PWC 812, f. & ef. 10-1-76;
AFS 14-1979, f. 6-29-79, ef. 7-1-79; AFS 47-1982, f. 4-30-82 & AFS 52-1982,
f. 5-28-82, ef. 5-1-82 for providers located in the geographical areas covered by
the branch offices of North Salem, South Salem, Dallas, Woodburn, McMinnville, Lebanon,
Albany and Corvallis, ef. 6-30-82, for remaining AFS branch offices; AFS 103-1982,
f. & ef. 11-1-83; AFS 61-1983, f. 12-19-83, ef. 1-1-84; AFS 24-1985, f. 4-24-85,
ef. 6-1-85; AFS 43-1986(Temp), f. 6-13-86, ef. 7-1-86; AFS 57-1986, f. 7-25-86,
ef. 8-1-86; AFS 78-1986(Temp), f. 12-16-86, ef. 1-1-87; AFS 10-1987, f. 2-27-87,
ef. 3-1-87; AFS 53-1987, f. 10-29-87, ef. 11-1-87; AFS 53-1988(Temp), f. 8-23-88,
cert. ef. 9-1-88; HR 2-1990, f. 2-12-90, cert. ef. 3-1-90, Renumbered from 461-013-0040;
Renumbered from 461-013-0103 & 461-013-0109; HR 25-1991(Temp), f. & cert.
ef. 7-1-91; HR 41-1991, f. & cert. ef. 10-1-91; HR 22-1993(Temp), f. & cert.
ef. 9-1-93; HR 32-1993, f. & cert. ef. 11-1-93; OMAP 10-1999, f. & cert.
ef. 4-1-99, Renumbered from 410-120-0080; OMAP 35-2000, f. 9-29-00, cert. ef. 10-1-00;
OMAP 67-2004, f. 9-14-04, cert. ef. 10-1-04; OMAP 39-2005, f. 9-2-05, cert. ef.
10-1-05; DMAP 34-2008, f. 11-26-08, cert. ef. 12-1-08; DMAP 49-2012, f. 10-31-12,
cert. ef. 11-1-12; DMAP 42-2014, f. & cert. ef. 7-3-14
410-120-1160
Medical Assistance
Benefits and Provider Rules
(1) Providers enrolled with and seeking
reimbursement for services through the Division of Medical Assistance Programs (Division)
are responsible for compliance with current federal and state laws and regulations
governing Medicaid services and reimbursement, including familiarity with periodic
law and rule changes. The Division’s administrative rules are posted on the
Oregon Health Authority (Authority) website for the Division and its medical assistance
programs. It is the provider's responsibility to become familiar with and abide
by these rules.
(2) The following services
are covered to the extent included in the Division client's benefit package of health
care services, when medically or dentally appropriate and within the limitations
established by the Division and set forth in the Oregon Administrative Rules (OARs)
for each category of Medical Services:
(a) Acupuncture services
as described in the Medical-Surgical Services program provider rules (OAR chapter
410, division 130);
(b) Administrative examinations
as described in the Administrative Examinations and Billing Services program provider
rules (OAR chapter 410, division 150);
(c) Substance Use Disorder
treatment services:
(A) The Division covers substance
use disorder (SUD) inpatient treatment services for medically managed intensive
inpatient detoxification when provided in an acute care hospital and when hospitalization
is considered medically appropriate. The Division covers medically monitored detoxification
and clinically managed detoxification provided in a free standing detoxification
center or an appropriately licensed SUDs residential treatment facility when considered
medically appropriate;
(B) The Division covers non-hospital
SUD treatment and recovery services on a residential or outpatient basis. For information
to access these services, contact the client's PHP or CCO if enrolled, the community
mental health program (CMHP), an outpatient substance use disorder treatment provider,
the residential treatment program, or the Addictions and Mental Health Division
(AMH);
(C) The Division does not
cover residential level of care provided in an inpatient hospital setting for substance
use disorder treatment and recovery;
(d) Ambulatory surgical center
services as described in the Medical-Surgical Services program provider rules (OAR
410, division 130);
(e) Anesthesia services as
described in the Medical-Surgical Services program provider rules (OAR chapter 410,
division 130);
(f) Audiology services as
described in the Speech-Language Pathology, Audiology and Hearing Aid Services program
provider rules (OAR chapter 410, division 129);
(g) Chiropractic services
as described in the Medical-Surgical Services program provider rules (OAR chapter
410, division 130);
(h) Dental services as described
in the Dental Services program provider rules (OAR chapter 410, division 123);
(i) Early and periodic screening,
diagnosis, and treatment services (EPSDT) are covered for individuals under 21 years
of age as set forth in the individual program provider rules. The Division may authorize
services in excess of limitations established in the OARs when it is medically appropriate
to treat a condition that is identified as the result of an EPSDT screening;
(j) Family planning services
as described in the Medical-Surgical Services program provider rules (OAR chapter
410, division 130);
(k) Federally qualified health
centers and rural health clinics as described in the Federally Qualified Health
Centers and Rural Health Clinics program provider rules (OAR chapter 410, division
147);
(l) Home and community-based
waiver services as described in the Authority and the Department’s OARs of
Child Welfare (CW), Self-Sufficiency Program (SSP), Addictions and Mental Health
Division (AMH), and Aging and People with Disabilities Division (APD);
(m) Home enteral/parenteral
nutrition and IV services as described in the Home Enteral/Parenteral Nutrition
and IV Services program rules (OAR chapter 410, division 148) and related Durable
Medical Equipment. Prosthetics, Orthotics and Supplies program rules (OAR chapter
410, division 122) and Pharmaceutical Services program rules (OAR chapter 410, division
121);
(n) Home health services
as described in the Home Health Services program rules (OAR chapter 410, division
127);
(o) Hospice services as described
in the Hospice Services program rules (OAR chapter 410, division 142);
(p) Indian health services
or tribal facility as described in The Indian Health Care Improvement Act and its
amendments (Public Law 102-573), and the Division’s American Indian/Alaska
Native program rules (OAR chapter 410, division 146);
(q) Inpatient hospital services
as described in the Hospital Services program rules (OAR chapter 410, division 125);
(r) Laboratory services as
described in the Hospital Services program rules (OAR chapter 410, division 125)
and the Medical-Surgical Services program rules (OAR chapter 410, division 130);
(s) Licensed direct-entry
midwife services as described in the Medical-Surgical Services program rules (OAR
chapter 410, division 130);
(t) Maternity case management
as described in the Medical-Surgical Services program rules (OAR chapter 410, division
130);
(u) Medical equipment and
supplies as described in the Hospital Services program, Medical-Surgical Services
program, DMEPOS program, Home Health Services program, Home Enteral/Parenteral
Nutrition and IV Services program, and other rules;
(v) When a client's benefit
package includes mental health, the mental health services provided will be based
on the Health Evidence Review Commission (HERC) Prioritized List of Health Services;
(w) Naturopathic services
as described in the Medical-Surgical Services program rules (OAR chapter 410, division
130);
(x) Nutritional counseling
as described in the Medical-Surgical Services program rules (OAR chapter 410, division
130);
(y) Occupational therapy
as described in the Physical and Occupational Therapy Services program rules (OAR
chapter 410, division 131);
(z) Organ transplant services
as described in the Transplant Services program rules (OAR chapter 410, division
124);
(aa) Outpatient hospital
services including clinic services, emergency department services, physical and
occupational therapy services, and any other outpatient hospital services provided
by and in a hospital as described in the Hospital Services program rules (OAR chapter
410, division 125);
(bb) Physician, podiatrist,
nurse practitioner and licensed physician assistant services as described in the
Medical-Surgical Services program rules (OAR chapter 410, division 130);
(cc) Physical therapy as
described in the Physical and Occupational Therapy and the Hospital Services program
rules (OAR chapter 410, division 131 and 125);
(dd) Post-hospital extended
care benefit as described in OAR chapter 410, division 120 and 141 and Aging and
People with Disabilities (APD) program rules;
(ee) Prescription drugs including
home enteral and parenteral nutritional services and home intravenous services as
described in the Pharmaceutical Services program (OAR chapter 410, division 121),
the Home Enteral/Parenteral Nutrition and IV Services program (OAR chapter 410,
division 148), and the Hospital Services program rules (OAR chapter 410, division
125);
(ff) Preventive services
as described in the Medical-Surgical Services program (OAR chapter 410, division
130), the Dental Services program rules (OAR chapter 410, division 123), and prevention
guidelines associated with the Health Evidence Review Commission's Prioritized
List of Health Services (OAR 410-141-0520);
(gg) Private duty nursing
as described in the Private Duty Nursing Services program rules (OAR chapter 410,
division 132);
(hh) Radiology and imaging
services as described in the Medical-Surgical Services program rules (OAR chapter
410, division 130), the Hospital Services program rules (OAR chapter 410, division
125), and Dental Services program rules (OAR chapter 410, division 123);
(ii) Rural health clinic
services as described in the Federally Qualified Health Center and Rural Health
Clinic Program rules (OAR chapter 410, division 147);
(jj) School-based health
services as described in the School-Based Health Services Program rules (OAR chapter
410, division 133);
(kk) Speech and language
therapy as described in the Speech-Language Pathology, Audiology and Hearing Aid
Services program rules (OAR chapter 410, division 129) and Hospital Services program
rules (OAR chapter 410, division 125);
(LL) Transportation necessary
to access a covered medical service or item as described in the Medical Transportation
program rules (OAR chapter 410, division 136);
(mm) Vision services as described
in the Visual Services program rules (OAR chapter 410, division 140).
(3) Other Authority or Department,
divisions, units, or offices, including Vocational Rehabilitation, AMH, and APD
may offer services to Medicaid eligible clients, that are not reimbursed by or available
through the Division of Medical Assistance Programs.
[Publications: Publications
referenced are available from the agency.]
Stat. Auth.: ORS 413.042
Stats. Implemented: ORS 414.025,
414.065
Hist.: PWC 683, f. 7-19-74,
ef. 8-11-74; PWC 803(Temp), f. & ef. 7-1-76; PWC 812, f. & ef. 10-1-76;
AFS 14-1979, f. 6-29-79, ef. 7-1-79; AFS 73-1980(Temp), f. & ef. 10-1-80; AFS
5-1981, f. 1-23-81, ef. 3-1-81; AFS 71-1981, f. 9-30-81, ef. 10-1-81; Renumbered
from 461-013-0000, AFS 47-1982, f. 4-30-82 & AFS 52-1982, f. 5-28-82, ef. 5-1-82
for providers located in the geographical areas covered by the branch offices of
North Salem, South Salem, Dallas, Woodburn, McMinnville, Lebanon, Albany and Corvallis,
ef. 6-30-82 for remaining AFS branch offices; AFS 94-1982(Temp), f. & ef. 10-18-82;
AFS 103-1982, f. & ef. 11-1-82; AFS 117-1982, f. 12-30-82, ef. 1-1-83; AFS 42-1983,
f. 9-2-83, ef. 10-1-83; AFS 62-1983, f. 12-19-83, ef. 1-1-84; AFS 4-1984, f. &
ef. 2-1-84; AFS 12-1984, f. 3-16-84, ef. 4-1-84; AFS 25-1984, f. 6-8-84, ef. 7-1-84;
AFS 14-1985, f. 3-14-85, ef. 4-1-85; AFS 53-1985, f. 9-20-85, ef. 10-1-85; AFS 67-1986(Temp),
f. 9-26-86, ef. 10-1-86; AFS 76-1986(Temp), f. & ef. 12-8-86; AFS 16-1987(Temp),
f. & ef. 4-1-87; AFS 17-1987, f. 5-4-87, ef. 6-1-87; AFS 32-1987, f. 7-22-87,
ef. 8-1-87; AFS 6-1988, f. & cert. ef. 2-1-88; AFS 51-1988(Temp), f. & cert.
ef. 8-2-88; AFS 58-1988(Temp), f. & cert. ef. 9-27-88; AFS 69-1988, f. &
cert. ef. 12-5-88; AFS 70-1988, f. & cert. ef. 12-7-88; AFS 4-1989, f. 1-31-89,
cert. ef. 2-1-89; AFS 8-1989(Temp), f. 2-24-89, cert. ef. 3-1-89; AFS 14-1989(Temp),
f. 3-31-89, cert. ef. 4-1-89; AFS 47-1989, f. & cert. ef. 8-24-89; HR 2-1990,
f. 2-12-90, cert. ef. 3-1-90, Renumbered from 461-013-0102; HR 5-1990(Temp), f.
3-30-90, cert. ef. 4-1-90; HR 19-1990, f. & cert. ef. 7-9-90; HR 32-1990, f.
9-24-90, cert. ef. 10-1-90; HR 41-1991, f. & cert. ef. 10-1-91; HR 27-1992(Temp),
f. & cert. ef. 9-1-92; HR 33-1992, f. 10-30-92, cert. ef. 11-1-92; HR 22-1993(Temp),
f. & cert. ef. 9-1-93; HR 32-1993, f. & cert. ef. 11-1-93, Renumbered from
410-120-0440; HR 2-1994, f. & cert. ef. 2-1-94; HR 40-1994, f. 12-30-94, cert.
ef. 1-1-95; HR 21-1997, f. & cert. ef. 10-1-97; OMAP 10-1999, f. & cert.
ef. 4-1-99; OMAP 31-1999, f. & cert. ef. 10-1-99; OMAP 35-2000, f. 9-29-00,
cert. ef. 10-1-00; OMAP 62-2003, f. 9-8-03, cert. ef.10-1-03; OMAP 10-2004, f. 3-11-04,
cert. ef. 4-1-04; OMAP 67-2004, f. 9-14-04, cert. ef. 10-1-04; OMAP 39-2005, f.
9-2-05, cert. ef. 10-1-05; DMAP 36-2011, f. 12-13-11, cert. ef. 1-1-12; DMAP 49-2012,
f. 10-31-12, cert. ef. 11-1-12; DMAP 37-2013(Temp), f. 6-27-13, cert. ef. 7-1-13
thru 12-24-13; DMAP 71-2013, f. & cert. ef. 12-27-13; DMAP 57-2014, f. 9-26-14,
cert. ef. 10-1-14
410-120-1180
Medical Assistance
Benefits: Out-of-State Services
(1) Out-of-state
Providers must enroll with the Division as described in OARs 943-120-0320 and 410-120-1260,
Provider Enrollment. Out-of-state Providers must provide services and bill in compliance
with all of these Rules and the OARs for the appropriate type of service(s) provided.
(2) Payment
rates for out-of-state providers are established in the individual provider rules,
through contracts or service agreements and in accordance with OAR chapter 943 division
120 and OAR 410-120-1340, Payment.
(3) For enrolled
non-contiguous, out-of-state providers, the Division reimburses for covered services
under any of the following conditions:
(a) For clients
enrolled in a CCO or PHP:
(A) The service
was authorized by a CCO or PHP and payment to the out-of-State provider is the responsibility
of the CCO or PHP;
(B) If a
client has coverage through a CCO or PHP, the request for non-emergency services
must be referred to the CCO or PHP. Payment for these services is the responsibility
of the CCO or PHP;
(C) The service
or item is not available in the State of Oregon or provision of the service or item
by an out-of-State provider is cost effective, as determined by the CCO or PHP.
(b) For clients
not enrolled in a CCO or PHP:
(A) The service
to a Division client was emergent; or
(B) A delay
in the provision of services until the client is able to return to Oregon could
reasonably be expected to result in prolonged impairment, or in increased risk that
treatment will become more complex or hazardous, or in substantially increased risk
of the development of chronic illness;
(C) The Division
authorized payment for the service in advance of the provision of services or was
otherwise authorized in accordance with Payment Authorization requirements in the
individual provider rules or in the General Rules;
(D) The
service is being billed for Qualified Medicare Beneficiary (QMB) deductible or co-insurance
coverage.
(4) The Division
may give prior authorization (PA) for non-emergency out-of-state services provided
by a non-contiguous enrolled Provider, under the following conditions:
(a) The service
is being billed for Qualified Medicare Beneficiary (QMB) deductible or co-insurance
coverage, or
(b) The Division
covers the service or item under the specific client's benefit package; and
(c) The service
or item is not available in the State of Oregon or provision of the service or item
by an out-of-state provider is cost effective, as determined by the Division; and
(d) The service
or item is deemed medically appropriate and is recommended by a referring Oregon
physician;
(5) Laboratory
analysis of specimens sent to out-of-state independent or hospital-based Laboratories
is a covered service and does not require PA. The Laboratory must meet the same
certification requirements as Oregon Laboratories and must bill in accordance with
Division rules.
(6) The Division
makes no reimbursement for services provided to a Client outside the territorial
limits of the United States. For purposes of this provision the “United States”
includes the District of Columbia, Puerto Rico, the Virgin Islands, Guam, the Northern
Mariana Islands, and American Samoa.
(7) The Division
will reimburse, within limits described in these General rules and in individual
provider rules, all services provided by enrolled providers to children:
(a) Who the
Authority has placed in foster care;
(b) Who the
Department has placed in a subsidized adoption outside the State of Oregon; or
(c) Who are
in the custody of the Department and traveling with the consent of the Department.
(8) The Division
does not require authorization of non-emergency services for the children covered
by (7), except as specified in the individual provider rules.
(9) Payment
rates for out-of-state providers are established in the individual provider rules,
through contracts or service agreements and in accordance with OAR 943-120-0350
and 410-120-1340, Payment.
Stat. Auth.: ORS
413.042

Stats. Implemented:
ORS 414.065 & 414.025

Hist.: PWC
683, f. 7-19-74, ef. 8-11-74; PWC 803(Temp), f. & ef. 7-1-76; PWC 812, f. &
ef. 10-1-76; AFS 27-1978(Temp), f. 6-30-78, ef. 7-1-78; AFS 39-1978, f. 10-10-78,
ef. 11-1-78; AFS 33-1981, f. 6-23-81, ef. 7-1-81; Renumbered from 461-013-0130,
AFS 47-1982, f. 4-30-82 & AFS 52-1982, f. 5-28-82, ef. 5-1-82 for providers
located in the geographical areas covered by the branch offices of North Salem,
South Salem, Dallas, Woodburn, McMinnville, Lebanon, Albany and Corvallis, ef. 6-30-82
for remaining AFS branch offices; AFS 21-1985, f. 4-2-85, ef. 5-1-85; AFS 24-1985,
f. 4-24-85, ef. 6-1-85; HR 2-1990, f. 2-12-90, cert. ef. 3-1-90, Renumbered from
461-013-0045 & 461-013-0046; HR 41-1991, f. & cert. ef. 10-1-91; HR 32-1993,
f. & cert. ef. 11-1-93, Renumbered from 410-120-0120, 410-120-0140 & 410-120-0160;
HR 40-1994, f. 12-30-94, cert. ef. 1-1-95; HR 5-1997, f. 1-31-97, cert. ef. 2-1-97;
OMAP 20-1998, f. & cert. ef. 7-1-98; OMAP 10-1999, f. & cert. ef. 4-1-99;
OMAP 35-2000, f. 9-29-00, cert. ef. 10-1-00; OMAP 39-2005, f. 9-2-05, cert. ef.
10-1-05; OMAP 15-2006, f. 6-12-06, cert. ef. 7-1-06; DMAP 34-2008, f. 11-26-08,
cert. ef. 12-1-08; DMAP 49-2012, f. 10-31-12, cert. ef. 11-1-12
410-120-1190
Medically Needy Benefit Program
The Medically Needy Program is eliminated effective February 1, 2003. Although references to this benefit exist elsewhere in rule, the program currently is not funded and is not offered as a benefit.
Stat. Auth.: ORS 413.042

Stats. Implemented: ORS 414.025 & 414.065

Hist,: OMAP 2-2003, f. 1-31-03, cert. ef. 2-1-03
410-120-1195
SB 5548 Population
Effective for services rendered on or after January 1, 2004.
(1) Certain individuals previously participating in the OSIP-MN Medically Needy Program as of January 31, 2003, and who are identified by the Authority with specific health-related conditions as outlined in the Joint Ways and Means budget note accompanying Senate Bill 5548 (2003) shall be referred to as SB 5548 clients.
(2) SB 5548 clients are eligible for a State-funded, limited, prescription drug benefit for covered drugs described in subsection (3) of this rule.
(3) Eligibility for and access to covered drugs for SB 5548 clients:
(a) SB 5548 clients must have been participating in the former OSIP-MN Medically Needy Program as of January 31, 2003, and as of that date had a medical diagnosis of HIV or organ transplant status;
(b) SB 5548 clients receiving anti-retroviral and other prescriptions necessary for the direct support of HIV symptoms:
(A) Must agree to participate in the Authority’s CareAssist Program in order to obtain access to this limited prescription drug benefit; and
(B) Prescriptions are limited to those listed on the CareAssist Formulary which can be found at http://www.oregon.gov/oha/pharmacy/CAREAssist/Pages/providers.aspx;
(c) SB 5548 clients receiving prescriptions necessary for the direct support of organ transplants are limited:
(A) Drug coverage includes any Medicaid reimbursable immunosuppressive, anti-infective or other prescriptions necessary for the direct support of organ transplants;
(B) Some drug classes are subject to restrictions or limitations based upon the Practitioner-Managed Prescription Drug Plan, OAR 410-121-0030.
(4) Reimbursement for covered prescription drugs is limited by the terms and conditions described in this rule. This limited drug benefit provides State-funded reimbursement to pharmacies choosing to participate according to the terms and conditions of this rule:
(a) The Authority will send SB 5548 clients a letter from the Authority, instead of a Medical Care Identification, which will document their eligibility for this limited drug benefit;
(b) Retail pharmacies choosing to participate will be reimbursed for covered prescription drugs for the direct support of organ transplants described in subsection (3)(c) of this rule based upon Oregon Medicaid reimbursement levels as specified in the Division’s Pharmaceutical Services Program administrative rules 410-121-0155 and 410-121-0160.
(c) The Authority pharmacy benefits manager, will process retail pharmacy drug benefit reimbursement claims for SB 5548 clients;
(d) Mail order reimbursement will be subject to the Authority contract rates;
(e) Prescription drugs through the CareAssist program will be subject to the Authority contract rates;
(f) Reimbursement for this limited drug benefit is not subject to the following rules:
(A) 410-120-1230, Client Copayments;
(B) 410-121-0300, Federal Upper Limit (FUL) for prescription drugs.
Stat. Auth.: ORS 413.042

Stats. Implemented: ORS 414.025 & 414.065

Hist.: OMAP 28-2003(Temp), f. & cert. ef. 4-1-03 thru 9-1-03; OMAP 44-2003, f. & cert. ef. 6-30-03; OMAP 45-2003(Temp), f. & cert. ef. 7-1-03 thru 12-15-03; OMAP 56-2003, f. 8-28-03, cert. ef. 9-1-03; OMAP 89-2003, f. 12-30-03 cert. ef. 1-1-04; OMAP 39-2005, f. 9-2-05, cert. ef. 10-1-05; DMAP 34-2008, f. 11-26-08, cert. ef. 12-1-08; DMAP 39-2010, f. 12-28-10, cert. ef. 1-1-11
410-120-1200
Excluded Services and Limitations
(1) Certain services or items are not
covered under any program or for any group of eligible clients. Service limitations
are subject to the Health Evidenced Review Commission (HERC) Prioritized List of
Health Services as referenced in 410-141-0520 and the individual program chapter
410 OARs. If the client accepts financial responsibility for a non-covered service,
payment is a matter between the provider and the client subject to the requirements
of OAR 410-120-1280.
(2) The Division of Medical
Assistance Programs (Division) shall make no payment for any expense incurred for
any of the following services or items that are:
(a) Not expected to significantly
improve the basic health status of the client as determined by Division staff or
its contracted entities; for example, the Division’s medical director, medical
consultants, dental consultants, or Quality Improvement Organizations (QIO);
(b) Determined not medically
or dentally appropriate by Division staff or authorized representatives, including
DMAP’s contracted utilization review organization, or are not covered by the
Health Evidence Review Commission Prioritized List of Health Services;
(c) Not properly prescribed
as required by law or administrative rule by a licensed practitioner practicing
within his or her scope of practice or licensure;
(d) For routine checkups
or examinations for individuals age 21 or older in connection with participation,
enrollment, or attendance in a program or activity not related to the improvement
of health and rehabilitation of the client. Examples include exams for employment
or insurance purposes;
(e) Provided by friends or
relatives of eligible clients or members of his or her household, except when the
friend, relative or household member:
(A) Is a health professional
acting in a professional capacity; or
(B) Is directly employed
by the client under the Department of Human Services (Department) Aging and People
with Disabilities division (APD) Home and Community Based Services or the APD administrative
rules, OAR 411-034-0000 through 411-034-0090, governing Personal Care Services covered
by the State Plan; or
(C) Is directly employed
by the client under the Department Child Welfare administrative rules, OAR 413-090-0100
through 413-090-0220, for services to children in the care and custody of the Department
who have special needs inconsistent with their ages. A family member of a minor
client (under the age of 18) must not be legally responsible for the client in order
to be a provider of personal care services;
(f) For services or items
provided to a client who is in the custody of a law enforcement agency or an inmate
of a non-medical public institution, including juveniles in detention facilities,
except such services as designated by federal statute or regulation as permissible
for coverage under the Division’s administrative rules (i.e., inpatient hospitalizations);
(g) Needed for purchase,
repair, or replacement of materials or equipment caused by adverse actions of adult
clients age 21 and over to personally owned goods or equipment or to items or equipment
that the Division rented or purchased;
(h) Related to a non-covered
service; some exceptions are identified in the individual provider rules. If the
Division determines the provision of a service related to a non-covered service
is cost effective, the related medical service may, at the discretion of the Division
and with Division prior authorization (PA), be covered;
(i) Considered experimental
or investigational, including clinical trials and demonstration projects, or that
deviates from acceptable and customary standards of medical practice or for which
there is insufficient outcome data to indicate efficacy;
(j) Identified in the appropriate
program rules including the Division’s Hospital Services program administrative
rules, Revenue Codes Section, as non- covered services.
(k) Requested by or for a
client whom the Division has determined to be non-compliant with treatment and who
is unlikely to benefit from additional related, identical, or similar services;
(l) For copying or preparing
records or documents, except those Administrative Medical Reports requested by
the branch offices or the Division for casework planning or eligibility determinations;
(m) Whose primary intent
is to improve appearances, exceptions subject to the HERC coverage and guidelines;
(n) Similar or identical
to services or items that will achieve the same purpose at a lower cost and where
it is anticipated that the outcome for the client will be essentially the same;
(o) For the purpose of establishing
or reestablishing fertility or pregnancy;
(p) Items or services that
are for the convenience of the client and are not medically or dentally appropriate;
(q) The collection, processing,
and storage of autologous blood or blood from selected donors unless a physician
certifies that the use of autologous blood or blood from a selected donor is medically
appropriate and surgery is scheduled;
(r) Educational or training
classes that are not intended to improve a medical condition;
(s) Outpatient social services
except maternity case management services and other social services described as
covered in the individual provider rules;
(t) Post-mortem exams or
burial costs;
(u) Radial keratotomies
(v) Recreational therapy;
(w) Telephone calls except
for:
(A) Tobacco cessation counseling
as described in OAR 410-130-0190;
(B) Maternity case management
as described in OAR 410-130-0595;
(C) Telemedicine as described
in OAR 410-130-0610; and
(D) Services specifically
identified as allowable for telephonic delivery when appropriate in the mental health
and substance use disorder procedure code and reimbursement rates published by the
Addiction and Mental Health division;
(x) Services that have no
standard code set as established according to 45 CFR 162.1000 to 162.1011, unless
the Division has assigned a procedure code to a service authorized in rule;
(y) Whole blood (Whole blood
is available at no cost from the Red Cross.); The processing, storage, and costs
of administering whole blood are covered;
(z) Immunizations prescribed
for foreign travel;
(aa) Services that are requested
or ordered but not provided to the client, unless specified otherwise in individual
program rules;
(bb) Missed appointments,
an appointment that the client fails to keep. Refer to 410-120-1280;
(cc) Transportation to meet
a client's personal choice of a provider;
(dd) Alcoholics Anonymous
(AA) and other self-help programs;
(ee) Medicare Part D covered
prescription drugs or classes of drugs and any cost sharing for those drugs for
Medicare-Medicaid Fully Dual Eligible clients, even if the Fully Dual Eligible client
is not enrolled in a Medicare Part D plan. See OAR 410-120-1210 for benefit package;
(ff) Services provided outside
of the United States. Refer to OAR 410-120-1180.
Stat. Auth.: ORS 413.042
Stats. Implemented: ORS 414.065,
414.025
Hist.: PWC 683, f. 7-19-74,
ef. 8-11-74; PWC 803(Temp), f. & ef. 7-1-76; PWC 812, f. & ef. 10-1-76,
Renumbered from 461-013-0030; AFS 47-1982, f. 4-30-82 & AFS 52-1982, f. 5-28-82,
ef. 5-1-82 for providers located in the geographical areas covered by the branch
offices of North Salem, South Salem, Dallas, Woodburn, McMinnville, Lebanon, Albany
and Corvallis, ef. 6-30-82 for remaining AFS branch offices; AFS 103-1982, f. &
ef. 11-1-82; AFS 15-1983(Temp), f. & ef. 4-20-83; AFS 31-1983(Temp), f. 6-30-83,
ef. 7-1-83; AFS 43-1983, f. 9-2-83, ef. 10-1-83; AFS 61-1983, f. 12-19-83, ef. 1-1-84;
AFS 24-1985, f. 4-24-85, ef. 6-1-85; AFS 57-1986, f. 7-25-86, ef. 8-1-86; AFS 78-1986(Temp),
f. 12-16-86, ef. 1-1-87; AFS 10-1987, f. 2-27-87, ef. 3-1-87; AFS 29-1987(Temp),
f. 7-15-87, ef. 7-17-87; AFS 54-1987, f. 10-29-87, ef. 11-1-87; AFS 51-1988(Temp),
f. & cert. ef. 8-2-88; AFS 53-1988(Temp), f. 8-23-88, cert. ef. 9-1-88; AFS
58-1988(Temp), f. & cert. ef. 9-27-88; AFS 70-1988, f. & cert. ef. 12-7-88;
HR 2-1990, f. 2-12-90, cert. ef. 3-1-90, Renumbered from 461-013-0055; 461-013-0103,
461-013-0109 & 461-013-0112; HR 5-1990(Temp), f. 3-30-90, cert. ef. 4-1-90;
HR 19-1990, f. & cert. ef. 7-9-90; HR 23-1990(Temp), f. & cert. ef. 7-20-90;
HR 32-1990, f. 9-24-90, cert. ef. 10-1-90; HR 27-1991 (Temp), f. & cert. ef.
7-1-91; HR 41-1991, f. & cert. ef. 10-1-91; HR 22-1993(Temp), f. & cert.
ef. 9-1-93; HR 32-1993, f. & cert. ef. 11-1-93, Renumbered from 410-120-0420,
410-120-0460 & 410-120-0480; HR 2-1994, f. & cert. ef. 2-1-94; HR 31-1994,
f. & cert. ef. 11-1-94; HR 40-1994, f. 12-30-94, cert. ef. 1-1-95; HR 6-1996,
f. 5-31-96 & cert. ef. 6-1-96; HR 5-1997, f. 1-31-97, cert. ef. 2-1-97; HR 21-1997,
f. & cert. ef. 10-1-97; OMAP 12-1998(Temp), f. & cert. ef. 5-1-98 thru 9-1-98;
OMAP 20-1998, f. & cert. ef. 7-1-98; OMAP 10-1999, f. & cert. ef. 4-1-99;
OMAP 31-1999, f. & cert. ef. 10-1-99; OMAP 35-2000, f. 9-29-00, cert. ef. 10-1-00;
OMAP 22-2002, f. 6-14-02 cert. ef. 7-1-02; OMAP 42-2002, f. & cert. ef. 10-1-02;
OMAP 3-2003, f. 1-31-03, cert. ef. 2-1-03; OMAP 8-2003, f. 2-28-03, cert. ef. 3-1-03;
OMAP 17-2003(Temp), f. 3-13-03, cert. ef. 3-14-03 thru 8-15-03; OMAP 46-2003(Temp),
f. & cert. ef. 7-1-03 thru 12-15-03; OMAP 56-2003, f. 8-28-03, cert. ef. 9-1-03;
OMAP 10-2004, f. 3-11-04, cert. ef. 4-1-04; OMAP 10-2005, f. 3-9-05, cert. ef. 4-1-05;
OMAP 39-2005, f. 9-2-05, cert. ef. 10-1-05; OMAP 65-2005, f. 11-30-05, cert. ef.
1-1-06; OMAP 15-2006, f. 6-12-06, cert. ef. 7-1-06; DMAP 24-2007, f. 12-11-07 cert.
ef. 1-1-08; DMAP 15-2008, f. 6-13-08, cert. ef. 7-1-08; DMAP 38-2009, f. 12-15-09,
cert. ef. 1-1-10; DMAP 39-2010, f. 12-28-10, cert. ef. 1-1-11; DMAP 36-2011, f.
12-13-11, cert. ef. 1-1-12; DMAP 37-2013(Temp), f. 6-27-13, cert. ef. 7-1-13 thru
12-24-13; DMAP 71-2013, f. & cert. ef. 12-27-13; DMAP 57-2014, f. 9-26-14, cert.
ef. 10-1-14
410-120-1210
Medical Assistance
Benefit Packages and Delivery System
(1) The services clients are eligible
to receive are based on their benefit package. Not all packages receive the same
benefits.
(2) The Division of Medical
Assistance Programs (Division) benefit package description, codes, eligibility criteria,
coverage, limitations and exclusions are identified in these rules.
(3) The limitations and exclusions
listed here are in addition to those described in OAR 410-120-1200 and in any chapter
410 OARs.
(4) Benefit package descriptions:
(a) Oregon Health Plan (OHP)
Plus:
(A) Benefit package identifier:
BMH;
(B) Eligibility criteria:
As defined in federal regulations and in the 1115 OHP waiver demonstration, a client
is categorically eligible for medical assistance if he or she is eligible under
a federally defined mandatory, selected, optional Medicaid program or the Children's
Health Insurance Program (CHIP) and also meets Oregon Health Authority (Authority)
adopted income and other eligibility criteria;
(C) Coverage includes:
(i) Services above the funding
line on the Health Evidence Review Commission (HERC) Prioritized List of Health
Services (Prioritized List), (OAR 410-141-0480 through 410-141-0520);
(ii) Ancillary services,
(OAR 410-141-0480);
(iii) Substance use disorder
treatment and recovery services provided through local substance use disorder treatment
and recovery providers;
(iv) Mental health services
based on the Prioritized List to be provided through Community Mental Health Programs
or their subcontractors;
(v) Hospice;
(vi) Post-hospital extended
care benefit up to a 20-day stay in a nursing facility for non-Medicare Division
clients who meet Medicare criteria for a post-hospital skilled nursing placement.
This benefit requires prior authorization by pre-admission screening (OAR 411-070-0043)
or by the Fully Capitated Health Plan (FCHP) for clients enrolled in an FCHP;
(vii) Cost sharing (e.g.,
copayments) may apply to some covered services.
(D) Limitations: The following
services have limited coverage for non-pregnant adults age 21 and older. (Refer
to the cited OAR chapters and divisions for details):
(i) Selected dental (OAR
chapter 410, division 123);
(ii) Vision services such
as frames, lenses, contacts corrective devices and eye exams for the purpose of
prescribing glasses or contacts (OAR chapter 410, division 140).
(b) OHP with Limited Drug:
(A) Benefit Package identifier:
BMM, BMD;
(B) Eligibility criteria:
Eligible clients are eligible for Medicare and Medicaid benefits;
(C) Coverage includes: Services
covered by Medicare and OHP Plus as described in this rule;
(D) Limitations:
(i) The same as OHP Plus,
as described in this rule;
(ii) Drugs excluded from
Medicare Part D coverage that are also covered under the medical assistance programs,
subject to applicable limitations for covered prescription drugs (Refer to OAR chapter
410, division 121 for specific limitations). These drugs include but are not limited
to:
(I) Over-the-counter (OTC)
drugs;
(II) Barbiturates (except
for dual eligible individuals when used in the treatment of epilepsy, cancer or
a chronic mental health disorder as Part D will cover those indications).
(E) Exclusions: Drugs or
classes of drugs covered by Medicare Part D Prescription Drug;
(F) Payment for services
is limited to the Medicaid-allowed payment less the Medicare payment up to the amount
of co-insurance and deductible;
(G) Cost sharing may apply
to some covered services; however, cost sharing related to Medicare Part D is not
covered since drugs covered by Part D are excluded from the benefit package.
(c) Qualified Medicare Beneficiary
(QMB)-Only:
(A) Benefit Package identifier
code MED;
(B) Eligibility criteria:
Eligible clients are Medicare Part A and B beneficiaries who have limited income
but do not meet the income standard for full medical assistance coverage;
(C) Coverage: Is limited
to the co-insurance or deductible for the Medicare service. Payment is based on
the Medicaid-allowed payment less the Medicare payment up to the amount of co-insurance
and deductible but no more than the Medicare allowable;
(D) Providers may not bill
QMB-only clients for the deductible and coinsurance amounts due for services that
are covered by Medicare.
(d) Citizen/Alien-Waived
Emergency Medical (CAWEM):
(A) Benefit Package identifier
CWM;
(B) Eligibility criteria:
Eligible clients are non-qualified aliens that are not eligible for other Medicaid
programs pursuant to Oregon Administrative Rules (OAR) 461-135-1070;
(C) Coverage is limited to:
(i) Emergency medical services
as defined by 42 CFR 440.255. Sudden onset of a medical condition manifesting itself
by acute symptoms of sufficient severity (including severe pain) such that the absence
of immediate medical attention could reasonably be expected to result in: placing
the patient's health in serious jeopardy, serious impairment to bodily functions,
or serious dysfunction of any bodily organ or part (the “prudent layperson
standard” does not apply to the CAWEM emergency definition);
(ii) Labor and Delivery.
(D) Exclusions: The following
services are not covered even if they are sought as emergency services:
(i) Prenatal or postpartum
care;
(ii) Sterilization;
(iii) Family Planning;
(iv) Preventive care;
(v) Organ transplants and
transplant-related services;
(vi) Chemotherapy;
(vii) Hospice;
(viii) Home health;
(ix) Private duty nursing;
(x) Dialysis;
(xi) Dental services provided
outside of an emergency department hospital setting;
(xii) Outpatient drugs or
over-the-counter products;
(xiii) Non-emergency medical
transportation;
(xiv) Therapy services;
(xv) Durable medical equipment
and medical supplies;
(xvi) Rehabilitation services.
(e) CAWEM Plus:
(A) Benefit Package identifier
code CWX;
(B) Eligibility criteria:
As defined in federal regulations and in the Children's Health Insurance Program
(CHIP) state plan eligible clients are CAWEM pregnant women not eligible for Medicaid
at or below 185 percent of the Federal Poverty Level (FPL);
(C) Coverage includes: Services
covered by OHP Plus as described above;
(D) Exclusions: The following
services are not covered for this program:
(i) Postpartum care (except
when provided and billed as part of a global obstetric package code that includes
the delivery procedure);
(ii) Sterilization;
(iii) Abortion;
(iv) Death with dignity services;
(v) Hospice.
(E) The day after pregnancy
ends, eligibility for medical services shall be based on eligibility categories
established in OAR chapter 461.
(5) Division clients are
enrolled for covered health services to be delivered through one of the following
means:
(a) Coordinated Care Organization
(CCO):
(A) These clients are enrolled
in a CCO that provides integrated and coordinated health care;
(B) CCO services are obtained
from the CCO or by referral from the CCO that is responsible for the provision and
reimbursement for physical health, substance use disorder treatment and recovery,
mental health services or dental care.
(b) Prepaid Health Plan (PHP):
(A) These clients are enrolled
in a PHP for their medical, dental or mental health care;
(B) Most non-emergency services
are obtained from the PHP or require a referral from the PHP that is responsible
for the provision and reimbursement for the medical, dental or mental health service;
(c) Physician Care Organization
(PCO):
(A) These clients are enrolled
in a PCO for their medical care;
(B) Inpatient hospital services
are not the responsibility of the PCO and are governed by the Division’s Hospital
Services Program rule (OAR chapter 410, division 125).
(d) Fee-for-service (FFS):
(A) These clients are not
enrolled in a CCO, PHP or PCO;
(B) Subject to limitations
and restrictions in the Division’s individual program rules, the client can
receive health care from any Division-enrolled provider that accepts FFS clients.
The provider shall bill the Division directly for any covered service and shall
receive a fee for the service provided.
Stat. Auth.: ORS 413.042
Stats. Implemented: ORS 414.025,
414.065, 414.329, 414.706 & 414.710
Hist.: OMAP 46-2003(Temp),
f. & cert. ef. 7-1-03 thru 12-15-03; OMAP 56-2003, f. 8-28-03, cert. ef. 9-1-03;
OMAP 49-2004, f. 7-28-04 cert. ef. 8-1-04; OMAP 39-2005, f. 9-2-05, cert. ef. 10-1-05;
OMAP 65-2005, f. 11-30-05, cert. ef. 1-1-06; OMAP 15-2006, f. 6-12-06, cert. ef.
7-1-06; DMAP 38-2009, f. 12-15-09, cert. ef. 1-1-10; DMAP 36-2011, f. 12-13-11,
cert. ef. 1-1-12; DMAP 49-2012, f. 10-31-12, cert. ef. 11-1-12; DMAP 63-2012(Temp),
f. 12-27-12, cert. ef. 1-1-13 thru 6-29-13; DMAP 31-2013, f. & cert. ef. 6-27-13;
DMAP 37-2013(Temp), f. 6-27-13, cert. ef. 7-1-13 thru 12-24-13; DMAP 71-2013, f.
& cert. ef. 12-27-13; DMAP 75-2013(Temp), f. 12-31-13, cert. ef. 1-1-14 thru
6-30-14; DMAP 23-2014, f. & cert. ef. 4-4-14
410-120-1230
Client Co-payment
(1) Oregon Health Plan (OHP) Plus clients
shall be responsible for paying a co-payment for some services. This co-payment
shall be paid directly to the provider. A co-payment applies regardless of location
of services rendered, i.e., provider’s office or client’s residence.
(2) The following services
are exempt from co-payment:
(a) Emergency medical services
as defined in OAR 410-120-0000;
(b) Family planning services
and supplies;
(c) Prescription drug products
for nicotine replacement therapy (NRT);
(d) Prescription drugs ordered
through the Division of Medical Assistance Programs’ (Division’s) Mail
Order (a.k.a., Home-Delivery) Pharmacy program;
(e) Services to treat “health
care-acquired conditions” (HCAC) and “other provider preventable conditions”
(OPPC) services as defined in OAR 410-125-0450.
(3) The following clients
are exempt from co-payments:
(a) Pregnant women;
(b) Children under age 19;
(c) Young adults in substitute
care and in the former Foster Care Youth Medical program;
(d) Clients receiving services
under the Medicaid-funded home and community-based services program;
(e) Inpatients in a hospital,
nursing facility, or Intermediate Care Facility for Intellectually or Developmentally
Disabled (ICF/IDD);
(f) American Indian/Alaska
Native (AI/AN) clients who are members of a federally recognized Indian tribe or
receive services through Indian Health Services (IHS), a tribal organization, or
services provided at an Urban Tribal Health Clinic as provided under Public Law
93-638;
(g) Individuals receiving
hospice care;
(h) Individuals eligible
for the Breast and Cervical Cancer program.
(4) Co-payment for services
is due and payable at the time the service is provided unless exempted in sections
(2) and (3) above. Services to a client may not be denied solely because of an inability
to pay an applicable co-payment. This does not relieve the client of the responsibility
to pay the applicable co-payment, nor does it prevent the provider from attempting
to collect any applicable co-payments from the client. The co-payment is a legal
debt and is due and payable to the provider of service.
(5) Except for prescription
drugs, one co-payment is assessed per provider/per visit/per day unless otherwise
specified in other Division’s program administrative rules.
(6) Fee-for-service co-payment
requirements:
(a) The provider may not
deduct the co-payment amount from the usual and customary billed amount submitted
on the claim. Except as provided in section (2) and (3) of this rule, the Division
shall deduct the co-payment from the amount the Division pays to the provider (whether
or not the provider collects the co-payment from the client);
(b) If the Division’s
payment is less than the required co-payment, then the co-payment amount is equal
to the Division’s lesser required payment, unless the client or services are
exempt according to exclusions listed in section (2) and (3) above. The client’s
co-payment shall constitute payment-in-full;
(c) Unless specified otherwise
in individual program rules and to the extent permitted under 42 CFR 1001.951–1001.952,
the Division does not require providers to bill or collect a co-payment from the
Medicaid client. The provider may choose not to bill or collect a co-payment from
a Medicaid client; however, the Division shall still deduct the co-payment amount
from the Medicaid reimbursement made to the provider.
(7) CCO, PHP, or PCO co-payment
requirements:
(a) Unless specified otherwise
in individual program rules and to the extent permitted under 42 CFR 447.58 and
447.60, the Division does not require CCOs, PHPs, or PCOs to bill or collect a co-payment
from the Medicaid client. The CCO, PHP, or PCO may choose not to bill or collect
a co-payment from a Medicaid client; however, the Division shall still deduct the
co-payment amount from the Medicaid reimbursement made to the CCO, PHP, or PCO;
(b) When a CCO, PHP, or PCO
is operating within the scope of the safe harbor regulation outlined in 42 CFR 1001.952(l),
a CCO, PHP, or PCO may elect to assess a co-payment on some of the services outlined
in Table 120-1230-1 but not all. The CCO, PHP, or PCO must assure they are working
within the provisions of 42 CFR 1003.102(b) (13). [Table not included. See ED. NOTE.]
(8) Services that require
co-payments are listed in Table 120-1230-1. [Table not included. See ED. NOTE.]
(9) Table 120-1230-1. [Table
not included. See ED. NOTE.]
[ED. NOTE: Tables referenced are available
from the agency.]
Stat. Auth.: ORS 413.042
Stat. Implemented: ORS 414.025,
414.065
Hist.: OMAP 73-2002, f. 12-24-02,
cert. ef. 1-1-03; OMAP 73-2003, f. & cert. ef. 10-1-03; OMAP 39-2004(Temp),
f. 6-14-04 cert. ef. 6-19-04 thru 11-30-04; OMAP 49-2004, f. 7-28-04 cert. ef. 8-1-04;
OMAP 39-2005, f. 9-2-05, cert. ef. 10-1-05; OMAP 15-2006, f. 6-12-06, cert. ef.
7-1-06; DMAP 5-2008, f. 2-28-08, cert. ef. 3-1-08; DMAP 38-2009, f. 12-15-09, cert.
ef. 1-1-10; DMAP 39-2010, f. 12-28-10, cert. ef. 1-1-11; DMAP 49-2012, f. 10-31-12,
cert. ef. 11-1-12; DMAP 75-2013(Temp), f. 12-31-13, cert. ef. 1-1-14 thru 6-30-14;
DMAP 23-2014, f. & cert. ef. 4-4-14; DMAP 57-2014, f. 9-26-14, cert. ef. 10-1-14
410-120-1260
Provider Enrollment
(1) This rule applies to providers enrolled
with or seeking to enroll with the Division of Medical Assistance Programs (Division).
(2) Providers signing the
Provider Enrollment Agreement constitute agreement to comply with all applicable
Division provider rules and federal and state laws and regulations.
(3) Providers enrolled by
the Division include:
(a) A non-payable provider,
meaning a provider who is issued a provider number for purposes of data collection
or non-claims-use such as, but not limited to:
(A) Ordering or referring
providers whose only relationship with the Division is to order, refer, or prescribe
services for Division clients;
(B) A billing agent or billing
service submitting claims or providing other business services on behalf of a provider
but not receiving payment in the name of or on behalf of the provider;
(C) An encounter only provider:
A provider contracted with a PHP or CCO.
(b) A payable provider, meaning
a provider who is issued a provider number for the purpose of submitting health
care claims for reimbursement from the Division. A payable provider may be:
(A) The rendering provider;
(B) An individual, agent,
business, corporation, clinic, group, institution, or other entity that, in connection
with the submission of claims, receives or directs the payment on behalf of a rendering
provider;
(4) When an entity is receiving
or directing payment on behalf of the rendering provider, the billing provider must:
(a) Meet one of the following
standards as applicable:
(A) Have a relationship with
the rendering provider described in 42 CFR 447.10(g) and have the authority to submit
the rendering provider enrollment application and supporting documentation on behalf
of the rendering provider;
(B) Is a contracted billing
agent or billing service that has enrolled with the Division to provide services
in connection with the submission of claims and to receive or direct payment in
the name of the rendering provider pursuant to 42 CFR 447.10(f).
(b) Maintain and make available
to the Division upon request records indicating the billing provider's relationship
with the rendering provider. This includes:
(A) Identify all rendering
providers for whom they bill or receive or direct payments at the time of enrollment;
(B) Notify the Division within
30 days of a change to the rendering provider’s name, date of birth, address,
Division provider numbers, NPIs, Social Security Number (SSN), or the Employer Identification
Number (EIN).
(c) Prior to submission of
any claims or receipt or direction of any payment from the Division, obtain signed
confirmation from the rendering provider that the billing entity or provider has
been authorized by the rendering provider to submit claims or receive or direct
payment on behalf of the rendering provider. This authorization, and any limitations
or termination of such authorization, must be maintained in the provider's files
for at least five years following the submission of claims or receipt or direction
of funds from the Division.
(5) In order to facilitate
timely claims processing and claims payment consistent with applicable privacy and
security requirements for providers:
(a) The Division requires
non-payable and payable providers to be enrolled consistent with the provider enrollment
process described in this rule;
(b) If the rendering provider
uses electronic media to conduct transactions with the Division or authorizes a
non-payable provider, e.g. billing service or billing agent, to conduct such electronic
transactions, the rendering provider must comply with the Authority Electronic Data
Interchange (EDI) rules, OAR 943-120-0100 through 943-120-0200. Enrollment as a
payable or non-payable provider is a necessary requirement for submitting electronic
claims, but the provider must also register as an EDI trading partner and identify
the EDI submitter in order to submit electronic claims.
(6) To be enrolled and able
to bill as a provider, an individual or organization must:
(a) Meet applicable licensing
and regulatory requirements set forth by federal and state statutes, regulations,
and rules;
(b) Comply with all Oregon
statutes and regulations for provision of Medicaid and CHIP services;
(c) If providing services
within the State of Oregon, have a valid Oregon business license if such a license
is a requirement of the state, federal, county, or city government to operate a
business or to provide services.
(7) An Indian Health Service
facility meeting enrollment requirements will be accepted on the same basis as any
other qualified provider. However, when state licensure is normally required, the
facility need not obtain a license but must meet all applicable standards for licensure.
(8) An individual or organization
that is currently subject to sanction by the Division, another state’s Medicaid
program, or the federal government is not eligible for enrollment (see OAR 410-120-1400,
943-120-0360, Provider Sanctions).
(9) Required information:
All providers must meet the following requirements before the Division can issue
or renew a provider number and must provide documentation at any time upon written
request by the Division:
(a) Disclosure requirements:
The provider must disclose to the Division:
(A) The identity of any person
employed by the provider who has been convicted of a criminal offense related to
that person’s involvement in any program under Medicare, Medicaid, or CHIP
program in the last ten years;
(B) If the provider is an
entity other than an individual practitioner or group of practitioners, disclose
the following:
(i) The name, date of birth,
address, and tax identification number of each person with an ownership or control
interest in the provider or in any subcontractor in which the provider has a direct
or indirect ownership interest of 5 percent or more. When disclosing tax identification
numbers:
(I) For corporations, use
the federal Tax Identification Number;
(II) For individuals in a
solo practice or billing as an individual practitioner, use the Social Security
Number (SSN);
(III) All other providers
use the Employer Identification Number (EIN);
(IV) The SSN or EIN of the
rendering provider cannot be the same as the Tax Identification Number of the billing
provider;
(V) Pursuant to 42 CFR 433.37,
including federal tax laws at 26 USC 6041, SSN’s and EIN’s provided
are used for the administration of federal, state, and local tax laws and the administration
of this program for internal verification and administrative purposes including
but not limited to identifying the provider for payment and collection activities;
(ii) Whether any of the persons
so named:
(I) Is related to another
as spouse, parent, child, sibling, or other family members by marriage or otherwise;
and
(II) Has an ownership or
control interest in any other entity.
(C) A provider must submit
within 35 days of the date of a request full and complete information about the
ownership of any subcontractor with whom the provider has had business transactions
totaling more than $25,000 during the 12-month period ending on the date of the
request and any significant business transactions between the provider and any wholly
owned supplier or between the provider and any subcontractor during the five-year
period ending on the date of the request;
(b) Provider screening and
enrollment requirements: The provider must submit the following information to the
Division:
(A) For non-payable providers,
a complete Non-Paid Provider Enrollment Request;
(B) For payable providers,
a complete Provider Enrollment Request, Provider Enrollment Attachment, Disclosure
Statement, and Provider Enrollment Agreement;
(C) Application fee if required
under 42 CFR 455.460;
(D) Consent to criminal background
check when required;
(E) To fulfill federal provider
screening requirements pursuant to 42 CFR 455.436 and upon request, the name, date
of birth, address, Division provider numbers, NPIs, and Social Security Number (SSN)
of any provider who is enrolled or seeking enrollment with the Division.
(c) Verification of licensing
or certification: Loss of the appropriate licensure or certification will result
in immediate disenrollment of the provider and recovery of payments made subsequent
to the loss of licensure or certification;
(d) Required updates: Enrolled
providers must notify the Division in writing of material changes in any status
or condition that relates to their qualifications or eligibility to provide medical
assistance services including, but not limited to, those listed in this subsection:
(A) Failure to notify the
Division of a change of Federal Tax Identification Number for entities or a Social
Security Number or Employer Identification Number for individual rendering providers
may result in the imposition of a $50 fine:
(i) If the Division notifies
a provider about an error in their Federal Tax Identification, including Social
Security Numbers or Employer Identification Numbers for individual rendering providers,
the provider must supply the appropriate valid Federal Tax Identification Number
within 30 calendar days of the date of the Division’s notice.
(ii) Failure to comply with
this requirement may result in the Division imposing a fine of $50 for each such
notice. Federal Tax Identification requirements described in this rule refer to
any such requirements established by the Internal Revenue Service;
(B) Changes in business affiliation,
ownership, NPI and Federal Tax Identification Number, ownership and control information,
or criminal convictions may require the submission of a provider enrollment form,
provider enrollment agreement, provider certification, or other related documentation.
(C) In the event of bankruptcy
proceedings, the provider shall immediately notify the Division administrator in
writing;
(D) Claims submitted by or
payments made to providers who have not furnished the notification required by this
rule or to a provider that has failed to submit a new application as required by
the Division under this rule may be denied or recovered.
(10) Rendering providers
may be enrolled retroactive to the date services were provided to a Division client
only if:
(a) The provider was appropriately
licensed, certified, and otherwise met all Division requirements for providers at
the time services were provided;
(b) Services were provided
fewer than 12 months prior to the date the application for provider status was received
by the Division as evidenced by the first date stamped on the paper claim submitted
with the application materials for those services, either manually or electronically;
(11) The Division reserves
the right to retroactively enroll the provider prior to the 12-month period based
upon extenuating circumstances outside the control of the provider, consistent with
federal Medicaid regulations, and with approval of the Division’s Provider
Enrollment Unit Manager.
(12) There are two types
of provider numbers:
(a) Oregon Medicaid provider
number: The Division issues provider numbers to establish an individual or organization’s
enrollment as an Oregon Medicaid provider.
(A) This number designates
specific categories of services covered by the Division Provider Enrollment Attachment.
For example, a pharmacy provider number applies to pharmacy services but not to
durable medical equipment, which requires a separate provider application attachment
and establishes a separate Oregon Medicaid provider number;
(B) For providers not subject
to NPI requirements, this number is the provider identifier for billing the Division;
(b) National Provider Identifier
(NPI) and taxonomy: The Division requires compliance with NPI requirements in 45
CFR Part 162. For providers subject to NPI requirements:
(A) The NPI and taxonomy
codes are the provider identifier for billing the Division;
(B) Currently enrolled providers
that obtain a new NPI are required to update their records with the Division's Provider
Enrollment Unit;
(C) Provider applicants must
obtain an NPI and include it in their provider enrollment request to the Division.
(13) Enrollment of out-of-state
providers: Providers of services outside the State of Oregon will be enrolled as
a provider if they comply with the requirements in OAR 410-120-1260 and under the
following conditions:
(a) The provider is appropriately
licensed or certified and meets standards for participation in the Medicaid program.
Disenrollment or sanction from other states’ Medicaid program or exclusion
from any other federal or state health care program is a basis for disenrollment,
termination, or suspension from participation as a provider in Oregon’s medical
assistance programs;
(b) Noncontiguous out-of-state
pharmacy providers must be licensed by the Oregon Board of Pharmacy to provide pharmacy
services in Oregon. In instances where clients are out of the state due to travel
or other circumstances that prevent them from using a pharmacy licensed in Oregon
and prescriptions need to be filled, the pharmacy is required to be licensed in
the state they are doing business where the client filled the prescription and must
be enrolled with the Division in order to submit claims. Out-of-state Internet or
mail order, except the Division’s mail order vendor, prescriptions are not
eligible for reimbursement;
(c) The provider bills only
for services provided within the provider's scope of licensure or certification;
(d) For noncontiguous out-of-state
providers, the services provided must be authorized in the manner required under
these rules for out-of-state services (OAR 410-120-1180) or other applicable Authority
rules:
(A) The services provided
are for a specific Oregon Medicaid client who is temporarily outside Oregon or the
contiguous area of Oregon; or
(B) Services provided are
for foster care or subsidized adoption children placed out of state; or
(C) The provider is seeking
Medicare deductible or coinsurance coverage for Oregon Qualified Medicare Beneficiaries
(QMB) clients;
(D) The services for which
the provider bills are covered services under the Oregon Health Plan (OHP).
(e) Facilities including
but not restricted to hospitals, rehabilitative facilities, institutions for care
of individuals with mental retardation, psychiatric hospitals, and residential care
facilities will be enrolled as providers only if the facility is enrolled as a Medicaid
provider in the state in which the facility is located or is licensed as a facility
provider of services by the State of Oregon;
(f) Out-of-state providers
may provide contracted services per OAR 410-120-1880.
(g) Out-of-state billing
providers may need to register with the Secretary of State and the Department of
Revenue to transact business in Oregon pursuant to 943-120-0320(15)(f).
(14) Absentee Physicians:
When a substitute physician is retained to take over another physician's professional
practice while he or she is absent or unavailable, the following shall apply:
(a) The Division recognizes
that absentee physicians may retain substitute physicians as a locum tenens or as
part of a reciprocal billing arrangement. For purposes of this rule:
(A) A “locum tenens”
means a substitute physician retained to take over another physician's professional
practice while he or she is absent (i.e., absentee physician) for reasons such as
illness, vacation, continuing medical education, pregnancy, etc.;
(B) A locum tenens cannot
be retained to take over a deceased physician’s professional practice without
becoming enrolled with the Division;
(C) A “reciprocal billing
arrangement” means a substitute physician retained on an occasional basis;
(b) Substitute physicians
are not required to enroll with the Division; however, the Division may enroll such
providers at the discretion of the Division’s provider enrollment manager
if the provider submits all information required for provider enrollment as described
in this rule;
(c) In no instance may an
enrolled absentee physician utilize a substitute physician who is, at that time,
excluded from participation in or under sanction by Medicaid or federally funded
or federally assisted health programs;
(d) The absentee physician
must be an enrolled Division provider and must bill with their individual Division
assigned provider number and receive payment for covered services provided by the
substitute physician:
(A) Services provided by
the locum tenens must be billed with a modifier Q6;
(B) Services provided in
a reciprocal billing arrangement by the substitute physician must be billed with
a modifier Q5;
(C) In entering the Q5 or
Q6 modifier, the absentee physician is certifying that the services are provided
by a substitute physician identified in a record of the absentee physician that
is available for inspection and are services for which the absentee physician is
authorized to submit a claim;
(D) A physician or other
person who falsely certifies that the requirements of this section are met may be
subject to possible civil and criminal penalties for fraud, and the enrolled provider’s
right to receive payment or to submit claims may be revoked.
(e) These requirements do
not apply to substitute arrangements among physicians in the same medical practice
when claims are submitted in the name of the practice or group name.
(f) Nothing in this rule
prohibits physicians sharing call responsibilities from opting out of the substitute
provider arrangement described in this rule and submitting their own claims for
services provided, as long as all such physicians are themselves enrolled rendering
providers and as long as duplicate claims for services are not submitted.
(15) Provider termination:
(a) The provider may terminate
enrollment at any time. The request must be in writing and signed by the provider.
The notice shall specify the Division assigned provider number to be terminated
and the effective date of termination. Termination of the provider enrollment does
not terminate any obligations of the provider for dates of services during which
the enrollment was in effect;
(b) The Division may terminate
or suspend providers when a provider fails to meet one or more of the requirements
governing a provider’s participation in Oregon’s medical assistance
programs such as, but not limited to:
(A) Breaches of provider
agreement;
(B) Failure to submit timely
and accurate information as requested by the Division;
(C) Failure to submit fingerprints
in a form determined by the Division within 30 days of request;
(D) Failure to permit access
to provider locations for site visits;
(E) Failure to comply with
federal or state statutes and regulations or policies of the Division that are applicable
to the provider;
(F) No claims have been submitted
in an 18-month period. The provider must reapply for enrollment;
(G) Any person who has an
ownership or control interest in the provider or who is an agent or managing employee
of the provider and has been convicted of a criminal offense related to that person’s
involvement in any program established under Medicare, Medicaid CHIP, or the Title
XX services program in the last 10 years;
(H) Failure to fully and
accurately make any disclosure required under this section (9) of this rule.
(16) If a provider’s
enrollment in the OHP program is denied, suspended, or terminated or a sanction
is imposed under this rule, the providers may request a contested case hearing pursuant
to OAR 410-120-1600 and 410-120-1860.
(17) The provision of health
care services or items to Division clients is a voluntary action on the part of
the provider. Providers are not required to serve all Division clients seeking service.
[Publications: Publications referenced
are available from the agency.]
Stat. Auth.: ORS 413.042
Stats. Implemented: ORS 414.025
& 414.065
Hist.: PWC 683, f. 7-19-74,
ef. 8-11-784; PWC 803(Temp), f. & ef. 7-1-76; PWC 812, f. & ef. 10-1-76;
AFS 5-1981, f. 1-23-81, ef. 3-1-81, Renumbered from 461-013-0060; AFS 33-1981, f.
6-23-81, ef. 7-1-81; AFS 47-1982, f. 4-30-82, f. 4-30-82 & AFS 52-1982, f. 5-28-82,
ef. 5-1-82 for providers located in the geographical areas covered by the branch
offices of North Salem, South Salem, Dallas, Woodburn, McMinnville, Lebanon, Albany
and Corvallis, ef. 6-30-82 for remaining AFS branch offices; AFS 57-1982, f. 6-28-82,
ef. 7-1-82; AFS 117-1982, f. 12-30-82, ef. 1-1-83; AFS 42-1983, f. 9-2-83, ef. 10-1-83;
AFS 38-1986, f. 4-29-86, ef. 6-1-86; AFS 73-1989, f. & cert. ef. 12-7-89; HR
2-1990, f. 2-12-90, cert. ef. 3-1-90, Renumbered from 461-013-0063, 461-013-0075
& 461-013-0180; HR 19-1990, f. & cert. ef. 7-9-90; HR 41-1991, f. &
cert. ef. 10-1-91; HR 51-1991(Temp), f. 11-29-91, cert. ef. 12-1-91; HR 5-1992,
f. & cert. ef. 1-16-92; HR 32-1993, f. & cert. ef. 11-1-93, Renumbered from
410-120-0020, 410-120-0040 & 410-120-0060; HR 31-1994, f. & cert. ef. 11-1-94;
HR 5-1997, f. 1-31-97, cert. ef. 2-1-97; OMAP 20-1998, f. & cert ef. 7-1-98;
OMAP 10-1999, f. & cert. ef. 4-1-99; OMAP 9-2001, f. 3-30-01, cert. ef. 4-1-01;
OMAP 42-2002, f. & cert. ef. 10-1-02; OMAP 62-2003, f. 9-8-03, cert. ef.10-1-03;
OMAP 67-2004, f. 9-14-04, cert. ef. 10-1-04; OMAP 10-2005, f. 3-9-05, cert. ef.
4-1-05; OMAP 39-2005, f. 9-2-05, cert. ef. 10-1-05; OMAP 15-2006, f. 6-12-06, cert.
ef. 7-1-06; DMAP 34-2008, f. 11-26-08, cert. ef. 12-1-08; DMAP 28-2012, f. 6-21-12,
cert. ef. 7-1-12; DMAP 57-2014, f. 9-26-14, cert. ef. 10-1-14
410-120-1280
Billing
(1) A provider enrolled with the Authority
or providing services to a client in a CCO or PHP under the Oregon Health Plan (OHP)
may not seek payment, from the client for any services covered by Medicaid fee-for-service
or through contracted health care plans:
(a) A client may not be billed
for missed appointments. A missed appointment is not considered to be a distinct
Medicaid service by the federal government and as such is not billable to the client
or the Division;
(b) A client may not be billed
for services or treatments that have been denied due to provider error (e.g., required
documentation not submitted, prior authorization not obtained, etc.).
(2) For Medicaid covered
services the provider may not bill the Division more than the provider's usual charge
(see definitions) or the reimbursement specified in the applicable Division program
rules.
(3) Providers shall only
bill a client or a financially responsible relative or representative of that client
in the following situations:
(a) For any applicable coinsurance,
copayments and deductibles expressly authorized in OAR chapter 410, divisions 120
and 141, or any other Division program rules;
(b) The client did not inform
the provider of their OHP coverage, enrollment in a PHP or CCO, or third party insurance
coverage at the time of or after a service was provided, therefore, the provider
could not bill the appropriate payer for reasons including, but not limited to,
the lack of prior authorization, or the time limit to submit the claim for payment
has passed. The provider must verify eligibility, pursuant to OAR 410-120-1140,
and document attempts to obtain coverage information prior to billing the client;
(c) The client became eligible
for benefits retroactively but did not meet all of the other criteria required to
receive the service);
(d) A third party payer made
payments directly to the client for services provided;
(e) The client has the limited
Citizen Alien Waived Emergency Medical benefit package. CAWEM clients have the benefit
package identifier of CWM. Clients receiving CAWEM benefits may be billed for services
that are not part of the CAWEM benefits. (See OAR 410-120-1210 for coverage.) The
provider must document that the client was informed in advance that the service
or item would not be covered by the Division. A DMAP 3165 is not required for these
services;
(f) The client has requested
a continuation of benefits during the contested case hearing process and the final
decision was not in favor of the client. The client shall pay for any charges incurred
for the denied service, on or after the effective date on the Notice of Action or
Notice of Appeal Resolution. The provider must complete the DMAP 3165 pursuant to
section (3)(h) of this rule before providing these services;
(g) In exceptional circumstances,
a client may decide to privately pay for a covered service. In this situation, the
provider may bill the client if the provider informs the client in advance of all
of the following:
(A) The requested service
is a covered service, and the appropriate payer (the Division, PHP, CCO or third
party payer) would pay the provider in full for the covered service; and
(B) The estimated cost of
the covered service, including all related charges, the amount that the appropriate
payer would pay for the service, and that the provider cannot bill the client for
an amount greater than the amount the appropriate payer would pay; and
(C) That the client knowingly
and voluntarily agrees to pay for the covered service;
(D) The provider documents
in writing, signed by the client or the client's representative, indicating that
the provider gave the client the information described in section (3)(g)(A-C); and
that the client had an opportunity to ask questions, obtain additional information
and consult with the client's caseworker or client representative; and the client
agreed to privately pay for the service by signing an agreement incorporating all
of the information described above. The provider must give a copy of the signed
agreement to the client. A provider may not submit a claim for payment for covered
services to the Division or to the client's PHP, CCO or third party payer that is
subject to the agreement.
(h) A provider may bill a
client for services that are not covered by the Division, PHP, or CCO (see definition
of non-covered services). Before providing the non-covered service, the client must
sign the provider-completed Agreement to Pay (DMAP 3165), or a facsimile containing
all of the information and elements of the DMAP 3165 as shown in Table 3165 of this
rule. The completed DMAP 3165, or facsimile, is valid only if the estimated fee
does not change and the service is scheduled within 30 days of the client’s
signature. Providers must make a copy of the completed DMAP 3165, or facsimile,
available to the Division, PHP or CCO upon request.
(4) Code Set requirements:
(a) Federal Code Set requirements
(45 CFR 162) apply to all Medicaid Code Set requirements, including the use of diagnostic
or procedure codes for prior authorization, claims submissions and payments. Code
Set has the meaning set forth in 45 CFR 162.103, and it includes the codes and the
descriptors of the codes. Federal Code Set requirements are mandatory, and the Division
lacks any authority to delay or alter their application or effective dates as established
by the U.S. Department of Health and Human Services;
(b) The Division shall adhere
to the Code Set requirements in 45 CFR 162.1000–162.1011;
(c) Periodically, the Division
shall update its provider rules and tables to conform to national codes. In the
event of an alleged variation between a Division-listed code and a national code,
the Division shall apply the national code in effect on the date of request or date
of service;
(d) Only codes with limitations
or requiring prior authorization are noted in rules. National Code Set issuance
alone should not be construed as coverage or a covered service by the Division;
(e) The Division adopts by
reference the National Code Set revisions, deletions, and additions issued and published
by the American Medical Association (Current Procedural Terminology — CPT)
and on the CMS website (Healthcare Common Procedural Coding System — HCPCS).
This code adoption should not be construed as coverage or as a covered service by
the Division.
(5) Claims:
(a) Upon submission of a
claim to the Division for payment, the provider agrees that it has complied with
all Division program rules. Submission of a claim, however, does not relieve the
provider from the requirement of a signed provider agreement;
(b) A provider enrolled with
the Division must bill using the Authority assigned provider number, or the National
Provider Identification (NPI) number if the NPI is available, pursuant to OAR 410-120-1260;
(c) The provider may not
bill the Division more than the provider's usual charge (see definitions) or the
reimbursement specified in the applicable Division program rules;
(d) Claims must be submitted
on the appropriate form as described in the individual Division program rules or
electronically in a manner authorized in OAR chapter 943, division 120;
(e) Claims must be for services
provided within the provider's licensure or certification;
(f) Unless otherwise specified,
claims must be submitted after:
(A) Delivery of service;
or
(B) Dispensing, shipment
or mailing of the item.
(g) The provider must submit
true and accurate information when billing the Division. Use of a billing provider
does not abrogate the performing provider's responsibility for the truth and accuracy
of submitted information;
(h) A claim is considered
a valid claim only if all required data is entered on or attached to the claim form.
See the appropriate provider rules and supplemental information for specific instructions
and requirements;
(i) A provider or its contracted
agency, including billing providers, may not submit or cause to be submitted:
(A) Any false claim for payment;
(B) Any claim altered in
such a way as to result in a payment for a service that has already been paid;
(C) Any claim upon which
payment has been made or is expected to be made by another source unless the amount
paid or to be paid by the other party is clearly entered on the claim form;
(D) Any claim for furnishing
specific care, items, or services that has not been provided.
(j) The provider is required
to submit an Individual Adjustment Request or to refund the amount of the overpayment
on any claim where the provider identifies an overpayment made by the Division;
(k) A provider who, after
having been previously warned in writing by the Division or the Department of Justice
about improper billing practices, is found to have continued improper billing practices
and has had an opportunity for a contested case hearing shall be liable to the Division
for up to triple the amount of the Division established overpayment received as
a result of the violation.
(6) Diagnosis code requirement:
(a) A primary diagnosis code
is required on all claims, using the ICD-10-CM diagnosis code set, unless specifically
excluded in individual Division program rules;
(b) The primary diagnosis
code must be the code that most accurately describes the client’s condition;
(c) All diagnosis codes are
required to the highest degree of specificity;
(d) Hospitals must follow
national coding guidelines and bill using the 7th digit where applicable in accordance
with methodology used in the Medicare Diagnosis Related Groups.
(7) Procedure code requirement:
(a) For claims requiring
a procedure code the provider must bill as instructed in the appropriate Division
program rules and must use the appropriate HIPAA procedure code set such as CPT,
HCPCS, ICD-10-PCS, ADA CDT, NDC, established according to 45 CFR 162.1000 to 162.1011,
which best describes the specific service or item provided;
(b) For claims that require
the listing of a procedure code as a condition of payment, the code listed on the
claim must be the code that most accurately describes the services provided. Hospitals
must follow national coding guidelines;
(c) When there is no appropriate
descriptive procedure code to bill the Division, the provider must use the code
for “unlisted services.” Instructions on the specific use of unlisted
services are contained in the individual provider rules. A complete and accurate
description of the specific care, item, or service must be documented on the claim;
(d) Where there is one CPT,
CDT, or HCPCS code that according to CPT, CDT, and HCPCS coding guidelines or standards
describes an array of services, the provider must bill the Division using that code
rather than itemizing the services under multiple codes. Providers may not “unbundle”
services in order to increase the payment.
(8) Third party Liability
(TPL):
(a) Federal law requires
that state Medicaid agencies take all reasonable measures to ensure that in most
instances the Division shall be the payer of last resort;
(b) Providers must make reasonable
efforts to obtain payment first from other resources. For the purposes of this rule
“reasonable efforts” include determining the existence of insurance
or other resources on each date of service by:
(A) Using an insurance database
such as Electronic Verification System (EVS) available to the provider;
(B) Using the Automated Voice
Response (AVR) or secure provider web portal on each date of service and at the
time of billing.
(c) Except as noted in section
(8)(d)(A through E) below, when third party coverage is known to the provider prior
to billing the Division the provider must:
(A) Bill the TPL; and
(B) Except for pharmacy claims
billed through the Division’s point-of-sale system, the provider must wait
30 days from submission date of a clean claim and have not received payment from
the third party; and
(C) Comply with the insurer's
billing and authorization requirements; and
(D) Appeal a denied claim
when the service is payable in whole or in part by an insurer.
(d) In accordance with federal
regulations the provider must bill the TPL prior to billing the Division, except
under the following circumstances:
(A) The covered health service
is provided by an Intermediate Care Facility for Individuals with Intellectual Disabilities
(ICF/ID);
(B) The covered health service
is provided by institutional services for the mentally and emotionally disturbed;
(C) The covered health services
are prenatal and preventive pediatric services;
(D) Services are covered
by a third party insurer through an absent parent where the medical coverage is
administratively or court ordered;
(E) When another party may
be liable for an injury or illness (see definition of Liability Insurance), the
provider may bill the insurer, the liable party, place a lien against a settlement,
or bill the Division. The provider may not both place a lien against a settlement
and bill the Division. The provider may withdraw the lien and bill the Division
within 12 months of the date of service. If the provider bills the Division, the
provider must accept payment made by the Division as payment in full.
(e) The provider may not
return the payment made by the Division in order to accept payment from a liability
settlement or liability insurer or place a lien against that settlement:
(A) In the circumstances
outlined in section (8)(d)(A) through (E) above, the provider may choose to bill
the primary insurance prior to billing the Division. Otherwise, the Division shall
process the claim and, if applicable, pay the Division’s allowable rate for
these services and seek reimbursement from the liable third party insurance plan;
(B) In making the decision
to bill the Division the provider should be cognizant of the possibility that the
third party payer may reimburse the service at a higher rate than the Division,
and that, once the Division makes payment no additional billing to the third party
is permitted by the provider.
(f) The provider may bill
the Division directly for services that are never covered by Medicare or another
insurer on the appropriate form identified in the relevant provider rules. Documentation
must be on file in the provider's records indicating this is a non-covered service
for purposes of Third Party Resources. See the individual provider rules for further
information on services that must be billed to Medicare first;
(g) Providers shall submit
an Individual Adjustment Request showing the amount of the third party payment or
to refund the amount received from another source within 30 days of the date the
payment is received. Failure to submit the Individual Adjustment Request within
30 days of receipt of the third party payment or to refund the appropriate amount
within this time frame is considered concealment of material facts and grounds for
recovery and sanction:
(A) When a provider receives
a payment from any source prior to the submission of a claim to the Division, the
amount of the payment must be shown as a credit on the claim in the appropriate
field;
(B) Any provider who accepts
third party payment for furnishing a service or item to a Division client after
having billed the Division shall:
(i) Submit an Individual
Adjustment Request indicating the amount of the third party payment. Follow instructions
in the individual Division program rules and supplemental billing; or
(ii) When the provider has
already accepted payment from the Division for the service or item, the provider
shall make direct payment of the amount of the third party payment to the Division.
The check to repay the Division shall include the reason the payment is being made
and either:
(I) An Individual Adjustment
Request that identifies the original claim, name and number of the client, date
of service and items or services for which the repayment is made; or
(II) A copy of the Remittance
Advice showing the original Division payment.
(C) Any provider who accepts
payment from a client, or client’s representative and is subsequently paid
for the service by the Division shall reimburse the client or their representative
the full amount of their payment.
(h) The Division may make
a claim against any third party payer after making payment to the provider of service.
The Division may pursue alternate resources following payment if it deems this a
more efficient approach. Pursuing alternate resources includes, but is not limited
to, requesting the provider to bill the third party and to refund the Division in
accordance with this rule;
(i) For services provided
to a Medicare and Medicaid dual eligible client, the Division may request the provider
to submit a claim for Medicare payment, and the provider must honor that request.
Under federal regulation, a provider may not charge a beneficiary (or the state
as the beneficiary's subrogee) for services for which a provider failed to file
a timely claim (42 CFR 424) with Medicare despite being requested to do so;
(j) If Medicare is the primary
payer and Medicare denies payment, Medicare appeals must be timely pursued, and
Medicare denial must be obtained prior to submitting the claim for payment to the
Division. Medicare denial on the basis of failure to submit a timely appeal may
result in the Division reducing from the amount of the claim any amount the Division
determines could have been paid by Medicare.
(9) Full use of alternate
resources:
(a) The Division shall generally
make payment only when other resources are not available for the client's medical
needs. Full use must be made of reasonable alternate resources in the local community;
(b) Except as provided in
subsection (10) of this rule, alternate resources may be available:
(A) Under a federal or state
worker's compensation law or plan;
(B) For items or services
furnished by reason of membership in a prepayment plan;
(C) For items or services
provided or paid for directly or indirectly by a health insurance plan or as health
benefits of a governmental entity such as:
(i) Armed Forces Retirees
and Dependents Act (CHAMPVA);
(ii) Armed Forces Active
Duty and Dependents Military Medical Benefits Act (CHAMPUS); or
(iii) Medicare Parts A and
B.
(D) To residents of another
state under that state's Title XIX or state funded medical assistance programs;
or
(E) Through other reasonably
available resources.
(10) Exceptions:
(a) Indian Health Services
or Tribal Health Facilities. Pursuant to 42 CFR 136.61 subpart G and the Memorandum
of Agreement in OAR 310-146-0000, Indian Health Services facilities and tribal facilities
operating under Public Law 93, Section 638 agreement are payers of last resort and
are not considered an alternate resource or TPL;
(b) Veterans Administration.
Veterans who are also eligible for Medicaid benefits are encouraged to utilize Veterans’
Administration facilities whenever possible. Veterans’ benefits are prioritized
for service related conditions and as such are not considered an alternate or TPL.
(11) Table 120-1280 –
TPR codes.
(12) Table – OHP Client
Agreement to Pay for Health Services, DMAP 3165.
[ED. NOTE:
Tables referenced are not included in rule text. Click here for PDF copy of table(s).]
Stat. Auth.: ORS 413.042
Stats. Implemented: ORS 414.025,
414.065
Hist.: PWC 683, f. 7-19-74,
ef. 8-11-74; PWC 803(Temp), f. & ef. 7-1-76; PWC 812, f. & ef. 10-1-76;
AFS 5-1981, f. 1-23-81, ef. 3-1-81, Renumbered from 461-013-0050, 461-013-0060,
461-013-0090 & 461-013-0020; AFS 47-1982, f. 4-30-82, & AFS 52-1982, f.
5-28-82, ef. 5-1-82 for providers located in the geographical areas covered by the
branch offices of North Salem, South Salem, Dallas, Woodburn, McMinnville, Lebanon,
Albany and Corvallis, ef. 6-30-82 for remaining AFS branch offices; AFS 117-1982,
f. 12-30-82, ef. 1-1-83; AFS 42-1983, f. 9-2-83, ef. 10-1-83; AFS 45-1983, f. 9-19-83,
ef. 10-1-83; AFS 6-1984(Temp), f. 2-28-84, ef. 3-1-84; AFS 36-1984, f. & ef.
8-20-84; AFS 24-1985, f. 4-24-85, cert. ef. 6-1-85; AFS 33-1986, f. 4-11-86, ef.
6-1-86; AFS 43-1986, f. 6-13-86, ef. 7-1-86; AFS 57-1986, f. 7-25-86, ef. 8-1-86;
AFS 14-1987, f. 5-31-87, ef. 4-1-87; AFS 38-1988, f. 5-17-88, cert. ef. 6-1-88;
HR 2-1990, f. 2-12-90, cert. ef. 3-1-90, Renumbered from 461-013-0140, 461-013-0150,
461-013-0175 & 461-013-0180; HR 19-1990, f. & cert. ef. 7-9-90; HR 41-1991,
f. & cert. ef. 10-1-91; HR 32-1993, f. & cert. ef. 11-1-93, Renumbered from
410-120-0040, 410-120-0260, 410-120-0280, 410-120-0300 & 410-120-0320; HR 31-1994,
f. & cert. ef. 11-1-94; HR 5-1997, f. 1-31-97, cert. ef. 2-1-97; HR 21-1997,
f. & cert. ef. 10-1-97; OMAP 20-1998, f. & cert. ef. 7-1-98; OMAP 10-1999,
f. & cert. ef. 4-10-99; OMAP 31-1999, f. & cert. ef. 10-1-99; OMAP 35-2000,
f. 9-29-00, cert. ef. 10-1-00; OMAP 30-2001, f. 9-24-01, cert. ef 10-1-01; OMAP
23-2002, f. 6-14-02 cert. ef. 8-1-02; OMAP 42-2002, f. & cert. ef. 10-1-02;
OMAP 73-2002, f. 12-24-02, cert. ef. 1-1-03; OMAP 3-2003, f. 1-31-03, cert. ef.
2-1-03; OMAP 62-2003, f. 9-8-03, cert. ef.10-1-03; OMAP 10-2004, f. 3-11-04, cert.
ef. 4-1-04; OMAP 10-2005, f. 3-9-05, cert. ef. 4-1-05; OMAP 39-2005, f. 9-2-05,
cert. ef. 10-1-05; OMAP 67-2005, f. 12-21-05, cert. ef. 1-1-06; OMAP 15-2006, f.
6-12-06, cert. ef. 7-1-06; OMAP 45-2006, f. 12-15-06, cert. ef. 1-1-07; DMAP 34-2008,
f. 11-26-08, cert. ef. 12-1-08; DMAP 39-2010, f. 12-28-10, cert. ef. 1-1-11; DMAP
49-2012, f. 10-31-12, cert. ef. 11-1-12; DMAP 61-2013, f. 10-31-13, cert. ef. 11-1-13;
DMAP 40-2015, f. & cert. ef. 7-1-15; DMAP 51-2015, f. 9-22-15, cert. ef. 10-1-15
410-120-1295
Non-Participating
Provider
(1) For purposes
of this rule, a provider enrolled with the Division of Medical Assistance Programs
(Division) that does not have a contract with a Division-contracted Coordinated
Care Organization (CCO) or Prepaid Health Plan (PHP) is referred to as a non-participating
provider.
(2) For covered
services that are subject to reimbursement from the CCO or PHP, a non-participating
provider, other than a hospital governed by (3) below, must accept from the Division-contracted
CCO or PHP, as payment in full, the amount that the provider would be paid from
the Division if the client was fee-for-service (FFS).
(3) For covered
services provided on and after October 1, 2011, the Division-contracted CCO or Fully
Capitated Health Plan (FCHP) that does not have a contract with a hospital, is required
to reimburse, and hospitals are required to accept as payment in full, the following
reimbursement:
(a) Non-participating
Type A and Type B hospital: The CCO or FCHP shall reimburse a non-participating
Type A and Type B hospital fully for the cost of covered services based on the cost-to-charge
ratio used for each hospital in setting the global payments to the CCO for the contract
period or for the capitation rates paid to the FCHP for the contract period.(ORS
414.727);
(b) All other
non-participating hospitals (not designated as a rural access or Type A and Type
B hospital): As specified in ORS 414.743, the CCO or FCHP shall reimburse inpatient
and outpatient services using a Medicare payment methodology at a specified percentage
point less than the percentage of Medicare costs used by the Oregon Health Authority
(Authority) when calculating the base hospital capitation payment to the CCO or
FCHP’s, excluding any supplemental payments.
(i) Effective
for services on or after October 1, 2011, for a hospital providing 10 percent or
more of the hospital admissions and outpatient hospital services to enrollees of
the plan, the percentage of the Medicare reimbursement shall be equal to 64 percent;
(ii) Effective
for services on or after October 1, 2011, for a hospital providing less than 10
percent of the hospital admissions and outpatient hospital services to enrollees
of the plan, the percentage of the Medicare reimbursement shall be equal to 66 percent.
(4) A non-participating
hospital must notify the CCO or FCHP within 2 business days of an CCO or FCHP patient
admission when the CCO or FCHP is the primary payer. Failure to notify does not,
in and of itself, result in denial for payment. The CCO or FCHP is required to review
the hospital claim for:
(a) Medical
appropriateness;
(b) Compliance
with emergency admission or prior authorization policies;
(c) Member’s
benefit package;
(d) The CCO
or FCHP contract and the Division’s administrative rules.
(5) After
notification from the non-participating hospital, the CCO or FCHP may:
(a) Arrange
for a transfer to a contracted facility, if the patient is medically stable and
the CCO or FCHP has secured another facility to accept the patient;
(b) Perform
concurrent review; and/or
(c) Perform
case management activities.
(6) In the
event of a disagreement between the CCO or FCHP and hospital, the provider may appeal
the decision by asking for an administrative review as specified in OAR 410-120-1580.
Stat. Auth.: ORS
413.042 & 414.065

Stats. Implemented:
ORS 414.025, 414.065 & 414.743

Hist.: OMAP
10-2001, f. 3-30-01, cert. ef. 4-1-01; OMAP 22-2004, f. & cert. ef. 3-22-04;
OMAP 23-2004(Temp), f. & cert. ef. 3-23-04 thru 8-15-04; OMAP 33-2004, f. 5-26-04,
cert. ef. 6-1-04; OMAP 75-2004(Temp), f. 9-30-04, cert. ef. 10-1-04 thru 3-15-05;
OMAP 4-2005(Temp), f. & cert. ef. 2-9-05 thru 7-1-05; OMAP 33-2005, f. 6-21-05,
cert. ef. 7-1-05; OMAP 35 2005, f. 7-21-05, cert. ef. 7-22-05; OMAP 49-2005(Temp),
f. 9-15-05, cert. ef. 10-1-05 thru 3-15-06; OMAP 63-2005, f. 11-29-05, cert. ef.
1-1-06; OMAP 66-2005(Temp), f. 12-13-05, cert. ef. 1-1-06 thru 6-28-06; OMAP 72-2005(Temp),
f. 12-29-05, cert. ef. 1-1-06 thru 6-28-06; OMAP 28-2006, f. 6-22-06, cert. ef.
6-23-06; OMAP 42-2006(Temp), f. 12-15-06, cert. ef. 1-1-07 thru 6-29-07; DMAP 2-2007,
f. & cert. ef. 4-5-07; DMAP 24-2007, f. 12-11-07 cert. ef. 1-1-08; DMAP 28-2009(Temp),
f. 9-11-09, cert. ef. 10-1-09 thru 3-25-10; DMAP 35-2009(Temp), f. & cert. ef.
12-4-09 thru 3-25-10; DMAP 38-2009, f. 12-15-09, cert. ef. 1-1-10; DMAP 38-2009,
f. 12-15-09, cert. ef. 1-1-10; DMAP 4-2010, f. & cert. ef. 3-26-10; DMAP 39-2010,
f. 12-28-10, cert. ef. 1-1-11; DMAP 30-2011(Temp), f. & cert. ef. 10-20-11 thru
3-25-12; DMAP 15-2012, f. & cert. ef. 3-22-12; DMAP 49-2012, f. 10-31-12, cert.
ef. 11-1-12
CONTINUE TO OARs 410-120-1300 through 410-120-1980

The official copy of an Oregon Administrative Rule is
contained in the Administrative Order filed at the Archives Division,
800 Summer St. NE, Salem, Oregon 97310. Any discrepancies with the
published version are satisfied in favor of the Administrative Order.
The Oregon Administrative Rules and the Oregon Bulletin are
copyrighted by the Oregon Secretary of State. Terms
and Conditions of Use