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OREGON HEALTH AUTHORITY, DIVISION OF MEDICAL ASSISTANCE PROGRAMS




 

DIVISION 125
HOSPITAL SERVICES

410-125-0000
Determining When the Patient Has Medical Assistance
(1) The Medical Card gives the client’s name as listed with the Oregon Health Plan (OHP) and their alpha-numeric prime number.
(2) Eligibility may change on a monthly basis. In some instances, eligibility will change during the month. Eligibility should be verified each time services are provided in order to assure that the client is eligible for date(s) of service. For ways to verify client eligibility see General Rules OAR 410-120-1140.
Stat. Auth.: ORS 413.042

Stats. Implemented: ORS 413.042

Hist.: AFS 49-1989(Temp), f. 8-24-89, cert. ef. 9-1-89; AFS 72-1989, f. & cert. ef. 12-1-89; HR 21-1990, f. & cert. ef. 7-9-90, Renumbered from 461-015-0150; HR 42-1991, f. & cert. ef. 10-1-91; OMAP 70-2004, f. 9-15-04, cert. ef. 10-1-04; DMAP 19-2008, f. 6-13-08, cert. ef. 7-1-08
410-125-0020
Retroactive Eligibility
(1) The Division of Medical Assistance
Programs (Division) may pay for services provided to an individual who does not
have Medicaid coverage at the time services are provided if the individual is made
retroactively eligible for medical assistance and eligibility is extended back to
the date services were provided. Contact the local branch concerning possible retroactive
eligibility. In some cases, the date of branch contact may be considered the date
of application for eligibility.
(2) Authorization for payment
may be given after the service is provided under limited circumstances. For prior
authorization information see OAR 410-125-0124 (Hospital Services Program).
Stat. Auth.: ORS 413.042
Stats. Implemented: ORS 414.065
Hist.: AFS 49-1989(Temp),
f. 8-24-89, cert. ef. 9-1-89; AFS 72-1989, f. & cert. ef. 12-1-90; HR 21-1990,
f. & cert. ef. 7-9-90, Renumbered from 461-015-0160, 461-015-0230 & 461-015-0370;
HR 42-1991, f. & cert. ef. 10-1-91, Renumbered from 410-125-0160 & 410-125-0440;
OMAP 70-2004, f. 9-15-04, cert. ef. 10-1-04; DMAP 39-2008, f. 12-11-08, cert. ef.
1-1-09; 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
410-125-0030
Hospital Hold
(1) A hospital hold is a process which allows an in-state general hospital or an out-of-state contiguous general hospital to assist an individual who is admitted to the hospital for an inpatient hospital stay to secure a date of request when the individual is unable to apply for the Oregon Health Plan due to inpatient hospitalization.
(2) The Division of Medical Assistance Programs (Division) will accept hospital holds for inpatient stays. Hospitals must either submit a DMAP 3261 or a hospital generated form to the Division within 24 hours of the admission time or the next working day. If a hospital uses its own form, the form must contain all the information found on the DMAP 3261.
[ED. NOTE: Forms referenced are available from the agency.]
Stat. Auth.: ORS 413.042

Stats. Implemented: ORS 414.065

Hist.: OMAP 12-2000(Temp), f. 8-16-00, cert. ef. 8-17-00 thru 2-1-01; OMAP 39-2000, f. 11-14-00, cert. ef. 11-15-00; OMAP 12-2001, f. 3-30-01, cert. ef. 4-1-01; OMAP 70-2004, f. 9-15-04, cert. ef. 10-1-04
410-125-0040
Title XIX/Title XXI Clients
(1) Title XIX /Title XXI clients are eligible for medical assistance through programs established by the Federal government and for which the State receives federal assistance. Most Title XIX/Title XXI clients are eligible for the Plus or Standard Benefit packages. See the General rules (chapter 410 division 120) for more information on eligibility, benefit package, and covered services. Most Title XIX/Title XXI clients are enrolled in a FCHP, a MHO and a DCO. Some Title XIX clients are Medicare Beneficiaries.
(2) The Division of Medical Assistance Programs (Division) contracts with Prepaid Health Plans (PHPs): Fully-Capitated Health Plans (FCHPs), Mental Health Organizations (MHOs), and Dental Care Organizations (DCOs), to provide certain medical, mental health and dental services on a prepaid basis.
(a) FCHPs provide a comprehensive package of health care benefits including hospital, physician, laboratory, X-ray and other diagnostic imaging, Medicheck (EPSDT), pharmacy, physical therapy, speech-language therapy, occupational therapy, case management, and other services;
(b) MHOs provide mental health services. They can be fully-capitated health plans, community mental health programs, private behavioral organizations or a combination thereof;
(c) DCOs provide dental care;
(d) If the client is enrolled in a Prepaid Health Plan, the name, address and phone number of the plan will appear on the Medical Care Identification. Always check with the plan listed if there is a question about coverage;
(e) PHP clients receive most of their primary care services through the PHP or upon referral from the PHP. In emergency situations, all services may be provided without prior authorization or referral. However, all claims for emergency services must be sent to the prepaid health plan. The hospital must work with the client's prepaid health plan to arrange for billing and payment for emergency and non-emergency services;
(f) The Division will not reimburse for services that can be provided by the client's PHP and are included in the PHP's contract as covered services. Reimbursement is between the service provider and the PHP.
(3) Medicare clients: Some Title XIX clients also have Medicare coverage. Most Medicare beneficiaries who are also eligible for Medicaid will have the full range of covered benefits for both Medicare and Medicaid. However, a few individuals who are Medicare eligible are eligible for only partial coverage through Medicaid. Refer to the General rules (chapter 410 division 120) for information on eligibility.
Stat. Auth.: ORS 413.042

Stats. Implemented: ORS 414.065

Hist.: AFS 49-1989(Temp), f. 8-24-89, cert. ef. 9-1-89; AFS 72-1989, f. & cert. ef. 12-1-89; HR 21-1990, f. & cert. ef. 7-9-90, Renumbered from 461-015-0170 & 461-015-0180; HR 31-1990(Temp), f. & cert. ef. 9-11-90; HR 2-1991, f. & cert. ef. 1-4-91; HR 42-1991, f. & cert. ef. 10-1-91, Renumbered from 410-125-0060; HR 22-1992, f. 7-31-92, cert. ef. 8-1-92; OMAP 34-1999, f. & cert. ef. 10-1-99; OMAP 70-2004, f. 9-15-04, cert. ef. 10-1-04
410-125-0041
Non-Title XIX/XXI Clients
(1) State-funded clients are clients who have not qualified for medical assistance through a federal program but have access to medical benefits through state funded programs. There are two categories of clients who are in State-funded programs.
(2) Program General Assistance (GA) clients: Program GA clients are children in foster care, in Services to Children and Families (SCF) custody, who are not eligible for Title XIX/Title XXI programs. They have access to the full range of Medicaid covered services, but payment for services provided may be different from that for Title XIX/Title XXI clients. For additional reimbursement information see the Hospital Services Supplemental Information on the Division of Medical Assistance Programs (Division) web site.
(3) Program SF clients: Program SF clients are individuals who are receiving treatment in a state facility, such as Oregon State Hospital, or the Eastern Oregon Training Center. These clients may need to receive hospital care outside the state facility. They are entitled to the full range of Medicaid covered hospital services. These individuals will be referred by the state facility for services. They do not have Medical Care Identification cards. They are not enrolled in a Fully Capitated Health Plan. The state facility from which the client is transferred will contact the hospital regarding billing instructions for these clients.
Stat. Auth.: ORS 413.042

Stats. Implemented: ORS 414.065

Hist.: HR 42-1991, f. & cert. ef. 10-1-91; HR 22-1993(Temp), f. & cert. ef. 9-1-93; HR 36-1993, f. & cert. ef. 12-1-93; HR 5-1994, f. & cert. ef. 2-1-94; OMAP 34-1999, f. & cert. ef. 10-1-99; OMAP 70-2004, f. 9-15-04, cert. ef. 10-1-04; DMAP 39-2008, f. 12-11-08, cert. ef. 1-1-09
410-125-0045
Coverage and Limitations
In general, most medically appropriate
services are covered. There are, however, some restrictions and limitations. Please
refer to the Division of Medical Assistance Programs’ (Division) General Rules
Program for information on general scope of coverage and limitations. Some of the
limitations and restrictions that apply to hospital services are:
(1) Prior authorization (PA):
Some services require PA for the Oregon Health Plan (OHP) Plus Benefit Package check
OAR 410-125-0080.
(2) Non-covered services:
(a) Services that are not
medically appropriate, unproven medical efficacy or services that are the responsibility
of another Department of Human Services (Department) or Oregon Health Authority
(Authority) Division are not covered by the Division of Medical Assistance Programs;
(b) Service coverage is based
on the Health Evidence Review Commission's (HERC) Prioritized List of Services and
the client’s benefit package;
(c) See the General Rules
Program (chapter 410, division 120) and other program divisions in chapter 410 for
a list of not covered services. Further information on covered and non-covered services
is found in the Revenue Code section in the Hospital Services Supplemental Information.
(3) Limitations on hospital
benefit days: Clients have no hospital benefit day limitations for treatment of
covered services.
(4) Dental services: Clients
have dental/denturist services identified as covered on the HERC Prioritized List
(OAR 410-141-520).
(5) Services provided outside
of the hospital's licensed facilities; for example, in the client's home or in a
nursing home, are not covered by Division as hospital services. The only exceptions
to this are Maternity Case Management services and specific nursing or physician
services provided during a ground or air ambulance transport.
(6) Dialysis services require
a written physician prescription. The prescription must indicate the ICD-10 diagnosis
code and must be retained by the provider of dialysis services for the period of
time specified in the General Rules Program.
Stat. Auth.: ORS 413.042
Stats. Implemented: ORS 414.065
Hist.: HR 42-1991, f. &
cert. ef. 10-1-91; HR 36-1993, f. & cert. ef. 12-1-93; HR 5-1994, f. & cert.
ef. 2-1-94; HR 4-1995, f. & cert. ef. 3-1-95; HR 3-1997, f. 1-31-97, cert. ef.
2-1-97; OMAP 28-2000, f. 9-29-00, cert. ef. 10-1-00; OMAP 70-2004, f. 9-15-04, cert.
ef. 10-1-04; DMAP 39-2008, f. 12-11-08, cert. ef. 1-1-09; DMAP 37-2011, f. 12-13-11,
cert. ef. 1-1-12; DMAP 51-2015, f. 9-22-15, cert. ef. 10-1-15
410-125-0050
Client Copayments
Copayments may be required for
certain services and/or benefit package(s). See OAR 410-120-1230 for specific details.
Stat. Auth.: ORS 413.042

Stats. Implemented: ORS 414.065

Hist.: OMAP 77-2002, f. 12-24-02,
cert. ef. 1-1-03; OMAP 70-2004, f. 9-15-04, cert. ef. 10-1-04
410-125-0080
Inpatient Services
(1) Elective (not urgent or emergent)
hospital admission:
(a) Coordinated Care Organization
(CCO), Fully-Capitated Health Plan (FCHP), and Mental Health Organization (MHO)
clients: Contact the client's CCO, FCHP, or MHO. The health plan may have different
prior authorization (PA) requirements than the Division of Medical Assistance Programs
(Division);
(b) Medicare clients: The
Division does not require PA for inpatient services provided to clients with Medicare
Part A or B coverage;
(c) Division clients: Oregon
Health Plan (OHP) clients covered by the OHP Plus Benefit Package:
(A) For a list of medical
and surgical procedures that require PA, see the Division’s Medical-Surgical
Services Program, rules OAR chapter 410, division 130, specifically OAR 410-130-0200,
table 130-0200-1, unless they are urgent or emergent defined in OAR 410-125-0401;
(B) For PA, contact the Division
unless otherwise indicated in the Medical-Surgical Service Program rules, specifically
OAR 410-130-0200, Table 130-0200-1.
(2) Transplant services:
(a) Complete rules for transplant
services are in the Division’s Transplant Services Program rules, OAR chapter
410, division 124;
(b) Clients are eligible
for transplants covered by the Oregon Health Evidence Review Commission's Prioritized
List of Health Services (Prioritized List). See the Transplant Services Program
administrative rules for criteria. For clients enrolled in a FCHP, contact the plan
for authorization. Clients not enrolled in a FCHP, contact the Division’s
Medical Director's office.
(3) Out-of-State non-contiguous
hospitals:
(a) All non-emergent and
non-urgent services provided by hospitals more than 75 miles from the Oregon border
require PA;
(b) Contact the Division’s
Medical Director's office for authorization for clients not enrolled in a Prepaid
Health Plan (PHP). For clients enrolled in a PHP, contact the plan.
(4) Out-of-State contiguous
hospitals: The Division prior authorizes services provided by contiguous-area hospitals,
less than 75 miles from the Oregon border, following the same rules and procedures
governing in-State providers.
(5) Transfers to another
hospital:
(a) Transfers for the purpose
of providing a service listed in the Medical-Surgical Service Program rules, specifically
OAR 410-130-0200, Table 130-0200-1, e.g., inpatient physical rehabilitation care,
require PA. Contact the Division-contracted Quality Improvement Organization (QIO);
(b) For transfers to a long-term,
acute-care hospital, skilled nursing facility, intermediate care facility or swing
bed, contact Aging and People with Disabilities (APD). APD reimburses nursing facilities
and swing beds through contracts with the facilities. For CCO and FCHP clients,
transfers require authorization and payment (for first 20 days) from the CCO or
FCHP;
(c) For transfers for the
same or lesser level inpatient care to a general acute-care hospital, the Division
shall cover transfers, including back transfers that are primarily for the purpose
of locating the patient closer to home and family, when the transfer is expected
to result in significant social or psychological benefit to the patient:
(A) The assessment of significant
benefit shall be based on the amount of continued care the patient is expected to
need (at least seven days) and the extent to which the transfer locates the patient
closer to familial support;
(B) Payment for transfers
not meeting these guidelines may be denied on the basis of post-payment review.
(d) Exceptions:
(A) Emergency transfers do
not require PA;
(B) In-State or contiguous
non-emergency transfers for the purpose of providing care that is unavailable in
the transferring hospital do not require PA unless the planned service is listed
in the Medical-Surgical Service Program rules, specifically OAR 410-130-0200, Table
130-0200-1;
(C) All non-urgent transfers
to out-of-State, non-contiguous hospitals require PA.
(6) Dental procedures provided
in a hospital setting:
(a) For prior authorization
requirements, see the Division’s Dental Services Program rules; specifically
OAR 410-123-1260 and 410-123-1490;
(b) Emergency dental services
do not require PA;
(c) For prior authorization
for fee-for-service clients, contact the Division’s Dental Services Program
analyst. (See the Division’s Dental Services Program Supplemental information,
http://www.oregon.gov/OHA/healthplan/pages/dental.aspx);
(d) For clients enrolled
in a CCO or FCHP, contact the client's health plan.
Stat. Auth.: ORS 413.042
Stats. Implemented: ORS 414.065
Hist.: AFS 14-1980, f. 3-27-80,
ef. 4-1-80; AFS 30-1982, f. 4-26-82 & AFS 51-1982, f. 5-28-82, ef. 5-1-82 for
providers located in the geographical areas covered by the AFS branch offices located
in North Salem, South Salem, Dallas, Woodburn, McMinnville, Lebanon, Albany and
Corvallis, ef. 6-30-82 for remaining AFS branch offices; AFS 11-1983, f. 3-8-83,
ef. 4-1-83; AFS 37-1983(Temp), f. & ef. 7-15-83; AFS 1-1984, f. & ef. 1-9-84;
AFS 6-1984(Temp), f. 2-28-84, ef. 3-1-84; AFS 36-1984, f. & ef. 8-20-84; AFS
22-1985, f. 4-23-85, ef. 6-1-85; AFS 38-1986, f. 4-29-86, ef. 6-1-86; AFS 46-1987,
f. & ef. 10-1-87; AFS 7-1989(Temp), f. 2-17-89, cert. ef. 3-1-89; AFS 36-1989(Temp),
f. & cert. ef. 6-30-89; AFS 45-1989, f. & cert. ef. 8-21-89; HR 9-1990(Temp),
f. 3-30-90, cert. ef. 4-1-90; HR 21-1990, f. & cert. ef. 7-9-90, Renumbered
from 461-015-0190; HR 31-1990(Temp), f. & cert. ef. 9-11-90; HR 2-1991, f. &
cert. ef. 1-4-91; HR 15-1991(Temp), f. & cert. ef. 4-8-91; HR 42-1991, f. &
cert. ef. 10-1-91; HR 39-1992, f. 12-31-92, cert. ef. 1-1-93; HR 36-1993, f. &
cert. ef. 12-1-93; HR 5-1994, f. & cert. ef. 2-1-94; HR 4-1995, f. & cert.
ef. 3-1-95; OMAP 34-1999, f. & cert. ef. 10-1-99; OMAP 7-2000, f. 3-31-00, cert.
ef. 4-1-00; OMAP 28-2000, f. 9-29-00, cert. ef. 10-1-00; OMAP 35-2001, f. 9-24-01,
cert. ef. 10-1-01; OMAP 9-2002, f. & cert. ef. 4-1-02; OMAP 22-2003, f. 3-26-03,
cert. ef. 4-1-03; OMAP 11-2004, f. 3-11-04, cert. ef. 4-1-04; OMAP 49-2004, f. 7-28-04
cert. ef. 8-1-04; OMAP 50-2005, f. 9-30-05, cert. ef. 10-1-05; DMAP 27-2007(Temp),
f. & cert. ef. 12-20-07 thru 5-15-08; DMAP 12-2008, f. 4-29-08, cert. ef. 5-1-08;
DMAP 19-2008, f. 6-13-08, cert. ef. 7-1-08; DMAP 39-2008, f. 12-11-08, cert. ef.
1-1-09; DMAP 17-2009 f. 6-12-09, cert. ef. 7-1-09; DMAP 32-2010, f. 12-15-10, cert.
ef. 1-1-11; DMAP 37-2011, f. 12-13-11, cert. ef. 1-1-12; 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
410-125-0085
Outpatient Services
(1) Outpatient services that may require
prior authorization (PA) include (see the individual program in the Division of
Medical Assistance Programs (Division), Oregon administrative rules (OARs or rules):
(a) Physical Therapy (chapter
410, division 131);
(b) Occupational Therapy
(chapter 410, division 131);
(c) Speech Therapy (chapter
410, division 129);
(d) Audiology (chapter 410,
division 129);
(e) Hearing Aids (chapter
410, division 129);
(f) Dental Procedures (chapter
410, division 123);
(g) Drugs (chapter 410, division
121);
(h) Apnea monitors, services,
and supplies (chapter 410, division 131);
(i) Home Parenteral/Enteral
Therapy (chapter 410, division 148);
(j) Durable Medical Equipment
and Medical supplies (chapter 410, division 122);
(k) Certain hospital services.
(2) The National Drug Code
(NDC) must be included on the electronic (837I) and paper (UB 04) claims for physician
administered drug codes required by the Deficit Reduction Act of 2005.
(3) Outpatient surgical procedures:
(a) Coordinated Care Organization
(CCO) and Fully-Capitated Health Plan (FCHP) clients: Contact the client's health
plan. The health plan may have different PA requirements than the Division. Some
services are not covered under FCHP contracts and require PA from the Division,
or the Division’s Dental Program analyst;
(b) Medicare clients enrolled
in a CCO or an FCHP: These services must be authorized by the plan even if Medicare
is the primary payer. Without this authorization, the provider shall not be paid
beyond any Medicare payments (see also OAR 410-125-0103);
(c) For Division clients
on the OHP Plus benefit package:
(A) Surgical procedures listed
in OAR 410-125-0080 require PA when performed in an outpatient or day surgery setting,
unless they are urgent or emergent;
(B) Contact the Division
for PA (unless indicated otherwise in OAR 410-125-0080).
(d) Out-of-State services:
Outpatient services provided by hospitals located less than 75 miles from the border
of Oregon do not require prior authorization unless specified in the Division’s
Hospital Services Program rules. All non-urgent or non-emergent services provided
by hospitals located more than 75 miles from the border of Oregon require PA. For
clients enrolled in a CCO or an FCHP, contact the health plan for authorization.
For clients not enrolled in a health plan, contact the Division’s Medical
Unit.
Stat. Auth.: ORS 413.042
Stats. Implemented: ORS 414.065
Hist.: HR 42-1991, f. &
cert. ef. 10-1-91; HR 39-1992, f. 12-31-92, cert. ef. 1-1-93; HR 36-1993, f. &
cert. ef. 12-1-93; HR 5-1994, f. & cert. ef. 2-1-94; HR 4-1995, f. & cert.
ef. 3-1-95; OMAP 34-1999, f. & cert. ef. 10-1-99; OMAP 70-2004, f. 9-15-04,
cert. ef. 10-1-04; DMAP 39-2008, f. 12-11-08, cert. ef. 1-1-09; DMAP 32-2010, f.
12-15-10, cert. ef. 1-1-11; DMAP 37-2011, f. 12-13-11, cert. ef. 1-1-12; 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
410-125-0086
Prior Authorization for FCHP/MHO Clients
Most non-emergent inpatient and outpatient services require prior authorization by a Fully Capitated Health Plan (FCHP) or a Mental Health Organization (MHO). Emergency hospital services must be covered by an FCHP or MHO without regard to prior authorization or the emergency care provider's contractual relationship with the FCHP or MHO. Emergency hospital services are defined as covered inpatient and outpatient services that are needed to evaluate or stabilize an emergency medical condition. Once a client's condition is considered stabilized, or a medical screening examination has determined that the client's medical condition is not emergent, an FCHP or MHO may require prior authorization for hospital admission, follow-up care, or further treatment. Failure to obtain prior authorization from the FCHP or MHO may result in a denial of payment for services. Contact the client's FCHP or MHO for further information on prior authorization.
Stat. Auth.: ORS 413.042

Stats. Implemented: ORS 414.065

Hist.: HR 42-1991, f. & cert. ef. 10-1-91; HR 36-1993, f. & cert. ef. 12-1-93; OMAP 34-1999, f. & cert. ef. 10-1-99; OMAP 12-2001, f. 3-30-01, cert. ef. 4-1-01
410-125-0090
Inpatient Rate Calculations -- Type A, Type B, and Critical Access Oregon Hospitals
(1) The Office of Rural Health designates Type A, Type B, and Critical Access Oregon Hospitals.
(2) Reimbursement to Type A, Type B, and Critical Access Oregon Hospitals for covered inpatient services is as follows:
(a) Interim reimbursement for inpatient covered services is the hospital specific cost to charge percentage from the last finalized cost settlement, except Laboratory and Radiology services are based on the Division of Medical Assistance Programs (DMAP) fee schedule;
(b) Retrospective cost-based reimbursement is made during the annual cost settlement period for all covered inpatient services, except for the hospitals that have payment contracts with managed care plans;
(c) Cost-based reimbursement is derived from the most recent audited Medicare Cost Report and adjusted to reflect the Medicaid mix of services.
(3) Type A, Type B, and Critical Access Hospitals are:
(a) Eligible for disproportionate share reimbursements, but must meet the same criteria as other hospitals. See OAR 410-125-0150 for eligibility criteria and reimbursement calculation;
(b) Type A, Type B, and Critical Access Hospitals do not receive cost outlier, capital, or medical education payments.
(4) Notwithstanding subsection (2) of this rule, this subsection becomes effective for dates of service on and after January 1, 2006, but will not be operative as the basis for payments until the Division determines all necessary federal approvals have been obtained. Reimbursement to Type A, Type B, and Critical Access Oregon Hospitals for covered inpatient services is as follows:
(a) Interim reimbursement for inpatient-covered services is the hospital specific cost to charge percentage from the last finalized cost settlement, except clinical laboratory services which are based on the Division fee schedule;
(b) Retrospective cost-based reimbursement is made for all fee-for-service covered inpatient services during the annual cost settlement period;
(c) Cost-based reimbursement is derived from the most recent audited Medicare Cost Report and adjusted to reflect the Medicaid mix of services.
Stat. Auth.: ORS 413.042

Stats. Implemented: ORS 414.065

Hist.: AFS 14-1980, f. 3-27-80, ef. 4-1-80; AFS 57-1980, f. 8-29-80, ef. 9-1-80; AFS 68-1981, f. 9-30-81, ef. 10-1-82; AFS 18-1982(Temp), f. & ef. 3-1-82; AFS 60-1982, f. & ef. 7-1-82; Renumbered from 461-015-0120(5); AFS 37-1983(Temp), f. & ef. 7-15-83; AFS 1-1984, f. & ef. 1-9-84; AFS 45-1984, f. & ef. 10-1-84; AFS 6-1985, f. 1-28-85, ef. 2-1-85; AFS 52-1985, f. 9-3-85, ef. 10-1-85; AFS 46-1986(Temp), f. 6-25-86, ef. 7-1-86; AFS 61-1986, f. 8-12-86, ef. 9-1-86; AFS 33-1987(Temp), f. & ef. 7-22-87; AFS 46-1987, f. & ef. 10-1-87; AFS 62-1987(Temp), f. 12-30-87, ef. 1-1-88; AFS 12-1988, f. 2-10-88, cert. ef. 6-1-88; AFS 26-1988, f. 3-31-88, cert. ef. 4-1-88; AFS 47-1988(Temp), f. 7-13-88, cert. ef. 7-1-88; AFS 63-1988, f. 10-3-88, cert. ef. 12-1-88; AFS 7-1989(Temp), f. 2-17-89, cert. ef. 3-1-89; AFS 15-1989(Temp), f. 3-31-89, cert. ef. 4-1-89; AFS 36-1989(Temp), f. & cert. ef. 6-30-89; AFS 37-1989(Temp), f. 6-30-89, cert. ef. 7-1-89; AFS 45-1989, f. & cert. ef. 8-21-89; AFS 49-1989(Temp), f. 8-24-89, cert. ef. 9-1-89; AFS 72-1989, f. & cert. ef. 12-1-89, Renumbered from 461-015-0006, 461-015-0036, 461-015-0065 & 461-015-0124; HR 21-1990, f. & cert. ef. 7-9-90, Renumbered from 461-015-0580; HR 31-1990(Temp), f. & cert. ef. 9-11-90; HR 2-1991, f. & cert. ef. 1-4-91; HR 15-1991(Temp), f. & cert. ef. 4-8-91; HR 28-1991(Temp), f. & cert. ef. 7-1-91; HR 32-1991(Temp), f. & cert. ef. 7-29-91; HR 53-1991, f. & cert. ef. 11-18-91, Renumbered from 410-125-0860; HR 36-1993, f. & cert. ef. 12-1-93; OMAP 35-2001, f. 9-24-01, cert. ef. 10-1-01; OMAP 73-2005, f. 12-29-05, cert. ef. 1-1-06
410-125-0095
Hospitals Providing Specialized Inpatient Services
(1) Some hospitals provide specific highly specialized inpatient services by arrangement with the Division of Medical Assistance Programs (Division).
(2) Reimbursement is made according to the terms of a contract between the Division and the hospital.
Stat. Auth.: ORS 413.042

Stats. Implemented: ORS 414.065

Hist.: AFS 14-1980, f. 3-27-80, ef. 4-1-80; AFS 57-1980, f. 8-29-80, ef. 9-1-80; AFS 68-1981, f. 9-30-81, ef. 10-1-82; AFS 18-1982(Temp), f. & ef. 3-1-82; AFS 60-1982, f. & ef. 7-1-82; Renumbered from 461-015-0120(5); AFS 37-1983(Temp), f. & ef. 7-15-83; AFS 1-1984, f. & ef. 1-9-84; AFS 45-1984, f. & ef. 10-1-84; AFS 6-1985, f. 1-28-85, ef. 2-1-85; AFS 52-1985, f. 9-3-85, ef. 10-1-85; AFS 46-1986(Temp), f. 6-25-86, ef. 7-1-86; AFS 61-1986, f. 8-12-86, ef. 9-1-86; AFS 33-1987(Temp), f. & ef. 7-22-87; AFS 46-1987, f. & ef. 10-1-87; AFS 62-1987(Temp), f. 12-30-87, ef. 1-1-88; AFS 12-1988, f. 2-10-88, cert. ef. 6-1-88; AFS 26-1988, f. 3-31-88, cert. ef. 4-1-88; AFS 47-1988(Temp), f. 7-13-88, cert. ef. 7-1-88; AFS 63-1988, f. 10-3-88, cert. ef. 12-1-88; AFS 7-1989(Temp), f. 2-17-89, cert. ef. 3-1-89; AFS 15-1989(Temp), f. 3-31-89, cert. ef. 4-1-89; AFS 36-1989(Temp), f. & cert. ef. 6-30-89; AFS 37-1989(Temp), f. 6-30-89, cert. ef. 7-1-89; AFS 45-1989, f. & cert. ef. 8-21-89; AFS 49-1989(Temp), f. 8-24-89, cert. ef. 9-1-89; AFS 72-1989, f. & cert. ef. 12-1-89, Renumbered from 461-015-0006, 461-015-0036, 461-015-0065 & 461-015-0124; HR 21-1990, f. & cert. ef. 7-9-90, Renumbered from 461-015-0580; HR 31-1990(Temp), f. & cert. ef. 9-11-90; HR 2-1991, f. & cert. ef. 1-4-91; HR 15-1991(Temp), f. & cert. ef. 4-8-91; HR 28-1991(Temp), f. & cert. ef. 7-1-91; HR 32-1991(Temp), f. & cert. ef. 7-29-91; HR 53-1991, f. & cert. ef. 11-18-91, Renumbered from 410-125-0860
410-125-0101
Hospital-Based Nursing Facilities and Medicaid Swing Beds
To receive reimbursement for hospital-based long-term care nursing facility services or Medicaid swing beds, the hospital must enter into an agreement with Aging and People with Disabilities (APD). These services must be provided, billed, and accounted for separately from other hospital services and in accordance with APD rules. Contact APD client's branch office for further information.
Stat. Auth.: ORS 413.042

Stats. Implemented: ORS 414.065

Hist.: AFS 14-1980, f. 3-27-80, ef. 4-1-80; AFS 57-1980, f. 8-29-80, ef. 9-1-80; AFS 68-1981, f. 9-30-81, ef. 10-1-82; AFS 18-1982(Temp), f. & ef. 3-1-82; AFS 60-1982, f. & ef. 7-1-82; Renumbered from 461-015-0120(5); AFS 37-1983(Temp), f. & ef. 7-15-83; AFS 1-1984, f. & ef. 1-9-84; AFS 45-1984, f. & ef. 10-1-84; AFS 6-1985, f. 1-28-85, ef. 2-1-85; AFS 52-1985, f. 9-3-85, ef. 10-1-85; AFS 46-1986(Temp), f. 6-25-86, ef. 7-1-86; AFS 61-1986, f. 8-12-86, ef. 9-1-86; AFS 33-1987(Temp), f. & ef. 7-22-87; AFS 46-1987, f. & ef. 10-1-87; AFS 62-1987(Temp), f. 12-30-87, ef. 1-1-88; AFS 12-1988, f. 2-10-88, cert. ef. 6-1-88; AFS 26-1988, f. 3-31-88, cert. ef. 4-1-88; AFS 47-1988(Temp), f. 7-13-88, cert. ef. 7-1-88; AFS 63-1988, f. 10-3-88, cert. ef. 12-1-88; AFS 7-1989(Temp), f. 2-17-89, cert. ef. 3-1-89; AFS 15-1989(Temp), f. 3-31-89, cert. ef. 4-1-89; AFS 36-1989(Temp), f. & cert. ef. 6-30-89; AFS 37-1989(Temp), f. 6-30-89, cert. ef. 7-1-89; AFS 45-1989, f. & cert. ef. 8-21-89; AFS 49-1989(Temp), f. 8-24-89, cert. ef. 9-1-89; AFS 72-1989, f. & cert. ef. 12-1-89, Renumbered from 461-015-0006, 461-015-0036, 461-015-0065 & 461-015-0124; HR 21-1990, f. & cert. ef. 7-9-90, Renumbered from 461-015-0580; HR 31-1990(Temp), f. & cert. ef. 9-11-90; HR 2-1991, f. & cert. ef. 1-4-91; HR 15-1991(Temp), f. & cert. ef. 4-8-91; HR 28-1991(Temp), f. & cert. ef. 7-1-91; HR 32-1991(Temp), f. & cert. ef. 7-29-91; HR 53-1991, f. & cert. ef. 11-18-91, Renumbered from 410-125-0860; OMAP 70-2004, f. 9-15-04, cert. ef. 10-1-04
410-125-0102
Medically Needy Clients
(1) The QIO can give prior authorization for non-emergency inpatient services for clients who are in the Medically Needy Program but have not yet met their spend-down. Only Medically Needy Program clients under age 21 and pregnant women have coverage for inpatient services if enrolled in the Medically Needy Program.
(2) Prior authorization cannot be granted for outpatient services, which require prior authorization. However, you may contact the Division of Medical Assistance Programs (Division) Medical/ Dental Group once the client has been made eligible and request retroactive authorization.
Stat. Auth.: ORS 413.042

Stats. Implemented: ORS 414.065

Hist.: HR 42-1991, f. & cert. ef. 10-1-91; OMAP 70-2004, f. 9-15-04, cert. ef. 10-1-04
410-125-0103
Medicare Clients
When Medicare is the primary payer, services provided in the inpatient or out-patient setting do not require prior authorization. However, if the Division of Medical Assistance Programs (Division) is the primary payer because the service is not covered by Medicare; the prior authorization requirements listed in chapter 410 division 125 would apply.
Stat. Auth.: ORS 413.042

Stats. Implemented: ORS 414.065

Hist.: HR 42-1991, f. & cert. ef. 10-1-91; OMAP 70-2004, f. 9-15-04, cert. ef. 10-1-04
410-125-0115
Non-Contiguous Area Out-of-State Hospitals -- Effective for services rendered on or after October 1, 2003
Non-contiguous area hospitals are out-of-state hospitals located more than 75 miles outside the Oregon border. Unless such hospitals have an agreement or contract with Division of Medical Assistance Programs (Division) for specialized services, non-contiguous area out-of-state hospitals will receive DRG reimbursement or billed charges whichever is less. The unit value for non-contiguous out-of-state hospitals will be set at the final unit value for the 50th percentile of Oregon hospitals (see Inpatient Rate Calculations from Other Hospitals, DRG Rate Methodology, OAR 410-125-0141 for the methodology used to calculate the unit value at the 50th percentile). No cost outlier, capital or medical education payments will be made. The hospital will receive a disproportionate share reimbursement if eligible (see OAR 410-125-0150).
Stat. Auth.: ORS 413.042

Stats. Implemented: ORS 414.065

Hist.: AFS 14-1980, f. 3-27-80, ef. 4-1-80; AFS 57-1980, f. 8-29-80, ef. 9-1-80; AFS 18-1982(Temp), f. & ef. 3-1-82; AFS 60-1982, f. & ef. 7-1-82; Renumbered from 461-015-0120(5); AFS 37-1983(Temp), f. & ef. 7-15-83; AFS 1-1984, f. & ef. 1-9-84; AFS 45-1984, f. & ef. 10-1-84; AFS 6-1985, f. 1-28-85, ef. 2-1-85; AFS 52-1985, f. 9-3-85, ef. 10-1-85; AFS 46-1986(Temp), f. 6-25-86, ef. 7-1-86; AFS 61-1986, f. 8-12-86, ef. 9-1-86; AFS 33-1987(Temp), f. & ef. 7-22-87; AFS 46-1987, f. & ef. 10-1-87; AFS 62-1987(Temp), f. 12-30-87, ef. 1-1-88; AFS 12-1988, f. 2-10-88, cert. ef. 6-1-88; AFS 26-1988, f. 3-31-88, cert. ef. 4-1-88; AFS 47-1988(Temp), f. 7-13-88, cert. ef. 7-1-88; AFS 63-1988, f. 10-3-88, cert. ef. 12-1-88; AFS 7-1989(Temp), f. 2-17-89, cert. ef. 3-1-89; AFS 15-1989(Temp), f. 3-31-89, cert. ef. 4-1-89; AFS 36-1989(Temp), f. & cert. ef. 6-30-89; AFS 37-1989(Temp), f. 6-30-89, cert. ef. 7-1-89; AFS 45-1989, f. & cert. ef. 8-21-89; AFS 49-1989(Temp), f. 8-24-89, cert. ef. 9-1-89; AFS 72-1989, f. & cert. ef. 12-1-89, Renumbered from 461-015-0006, 461-015-0020 & 461-015-0124; HR 18-1990(Temp), f. 6-29-90, cert. ef. 7-1-90; HR 21-1990, f. & cert. ef. 7-9-90, Renumbered from 461-015-0570; HR 31-1990(Temp), f. & cert. ef. 9-11-90; HR 36-1990(Temp), f. 10-29-90, cert. ef. 11-1-90; HR 3-1991, f. & cert. ef. 1-4-91; HR 28-1991(Temp), f. & cert. ef. 7-1-91; HR 32-1991(Temp), f. & cert. ef. 7-29-91; HR 53-1991, f. & cert. 11-18-91, Renumbered from 410-125-0840; OMAP 58-2003, f. 9-5-03, cert. ef. 10-1-03; OMAP 16-2004(Temp), f. & cert. ef. 3-15-04 thru 8-15-04; OMAP 27-2004, f. 4-22-04 cert. ef. 5-1-04
410-125-0120
Transportation To and From Medical Services
(1) Transportation to and from
medical services, including hospital services, is a covered service. However, all
non-emergency transports require prior authorization in order for the transportation
provider to be paid.
(2) The transportation must
be the least expensive obtainable under existing conditions and appropriate to the
client's needs.
(3) Contact the Division of
Medical Assistance Program (Division) -contracted regional Transportation Brokerage
(Brokerage) for prior authorization for the transport or instruct the transportation
provider to contact the Brokerage. Brokerage map and contact information is available
at http://www.oregon.gov/oha/healthplan/Pages/medical-transportation.aspx.
(4) Hospitals must follow the
after hours procedures for the Brokerages and contact the appropriate after hours
providers for non-emergent transportation for hospital discharges.
(5) No prior authorization is
required when the client's condition requires emergency transport.
(6) When a hospital sends a
patient to another facility or provider during the course of an inpatient stay and
the client is returned to the admitting hospital within 24 hours, the hospital must
arrange for and pay for the transportation. See billing instructions contained in
the Hospital Supplemental Information on the Division website for additional information.
Stat. Auth.: ORS 413.042

Stats. Implemented: ORS 414.065

Hist.: AFS 49-1989(Temp), f.
8-24-89, cert. ef. 9-1-89; AFS 72-1989, f. & cert. ef. 12-1-89; HR 21-1990,
f. & cert. ef. 7-9-90, Renumbered from 461-015-0210; HR 42-1991, f. & cert.
ef. 10-1-91; OMAP 70-2004, f. 9-15-04, cert. ef. 10-1-04; DMAP 32-2012, f. 6-29-12,
cert. ef. 7-1-12
410-125-0121
Contiguous Area Out-of-State Hospitals -- Effective for services rendered on or after October 1, 2003
Contiguous area hospitals are out-of-state hospitals located less than 75 miles outside the Oregon border. Unless such hospitals have an agreement or contract with Division of Medical Assistance Programs (Division) for specialized services, contiguous area out-of-state hospitals will receive DRG reimbursement or billed charges whichever is less. The unit value for contiguous out-of-state hospitals will be set at the final unit value for the 50th percentile of Oregon hospitals (see Inpatient Rate Calculations for Other Hospitals, DRG Rate Methodology OAR 410-125-0141 for the methodology). Contiguous area out-of-state hospitals are also eligible for cost outlier payments. No capital or medical education payments will be made. The hospital will receive a disproportionate share reimbursement if eligible (see OAR 410-125-0150).
Stat. Auth.: ORS 413.042

Stats. Implemented: ORS 414.065

Hist.: AFS 14-1980, f. 3-27-80, ef. 4-1-80; AFS 57-1980, f. 8-29-80, ef. 9-1-80; AFS 18-1982(Temp), f. & ef. 3-1-82; AFS 60-1982, f. & ef. 7-1-82; Renumbered from 461-015-0120(5); AFS 37-1983(Temp), f. & ef. 7-15-83; AFS 1-1984, f. & ef. 1-9-84; AFS 45-1984, f. & ef. 10-1-84; AFS 6-1985, f. 1-28-85, ef. 2-1-85; AFS 52-1985, f. 9-3-85, ef. 10-1-85; AFS 46-1986(Temp), f. 6-25-86, ef. 7-1-86; AFS 61-1986, f. 8-12-86, ef. 9-1-86; AFS 33-1987(Temp), f. & ef. 7-22-87; AFS 46-1987, f. & ef. 10-1-87; AFS 62-1987(Temp), f. 12-30-87, ef. 1-1-88; AFS 12-1988, f. 2-10-88, cert. ef. 6-1-88; AFS 26-1988, f. 3-31-88, cert. ef. 4-1-88; AFS 47-1988(Temp), f. 7-13-88, cert. ef. 7-1-88; AFS 63-1988, f. 10-3-88, cert. ef. 12-1-88; AFS 7-1989(Temp), f. 2-17-89, cert. ef. 3-1-89; AFS 15-1989(Temp), f. 3-31-89, cert. ef. 4-1-89; AFS 36-1989(Temp), f. & cert. ef. 6-30-89; AFS 37-1989(Temp), f. 6-30-89, cert. ef. 7-1-89; AFS 45-1989, f. & cert. ef. 8-21-89; AFS 49-1989(Temp), f. 8-24-89, cert. ef. 9-1-89; AFS 72-1989, f. & cert. ef. 12-1-89, Renumbered from 461-015-0006, 461-015-0020 & 461-015-0124; HR 18-1990(Temp), f. 6-29-90, cert. ef. 7-1-90; HR 21-1990, f. & cert. ef. 7-9-90, Renumbered from 461-015-0570; HR 31-1990(Temp), f. & cert. ef. 9-11-90; HR 36-1990(Temp), f. 10-29-90, cert. ef. 11-1-90; HR 3-1991, f. & cert. ef. 1-4-91; HR 28-1991(Temp), f. & cert. ef. 7-1-91; HR 32-1991(Temp), f. & cert. ef. 7-29-91; HR 53-1991, f. & cert. ef. 11-18-91, Renumbered from 410-125-0840; OMAP 58-2003, f. 9-5-03, cert. ef. 10-1-03; OMAP 16-2004(Temp), f. & cert. ef. 3-15-04 thru 8-15-04; OMAP 27-2004, f. 4-22-04 cert. ef. 5-1-04
410-125-0124
Retroactive Authorization
Retroactive authorization for payment can be granted after the service is provided only in the following circumstances:
(1) The person was not yet eligible for Medicaid/CHIP at the time the services were provided. Payment can be made if the services are covered Medicaid/CHIP services and the client's eligibility is extended back to the date the hospital provided services. See: the Hospital Services Supplemental Information on the Division of Medical Assistance Programs (Division) website for additional billing information.
(2) If another insurer denied the claim because the service is not covered by that insurer, and the hospital did not seek prior authorization because it had good reason to believe the service was covered by the insurer. Payment can be made by the Division if the services are covered by Medicaid. See: the Hospital Services Supplemental Information on the Division website for additional billing information.
Stat. Auth.: ORS 413.042

Stats. Implemented: ORS 414.065

Hist.: HR 42-1991, f. & cert. ef. 10-1-91; OMAP 34-1999, f. & cert. ef. 10-1-99; OMAP 70-2004, f. 9-15-04, cert. ef. 10-1-04
410-125-0125
Free-Standing Inpatient Psychiatric Facilities
Free-standing inpatient psychiatric facilities (institutions for mental diseases), including Oregon's state-operated psychiatric and training facilities, are reimbursed according to the terms of an agreement between the Addictions and Mental Health, Aging and People with Disabilities, and the hospital.
Stat. Auth.: ORS 413.042

Stats. Implemented: ORS 414.065

Hist.: AFS 14-1980, f. 3-27-80, ef. 4-1-80; AFS 57-1980, f. 8-29-80, ef. 9-1-80; AFS 68-1981, f. 9-30-81, ef. 10-1-82; AFS 18-1982(Temp), f. & ef. 3-1-82; AFS 60-1982, f. & ef. 7-1-82; Renumbered from 461-015-0120(5); AFS 37-1983(Temp), f. & ef. 7-15-83; AFS 1-1984, f. & ef. 1-9-84; AFS 45-1984, f. & ef. 10-1-84; AFS 6-1985, f. 1-28-85, ef. 2-1-85; AFS 52-1985, f. 9-3-85, ef. 10-1-85; AFS 46-1986(Temp), f. 6-25-86, ef. 7-1-86; AFS 61-1986, f. 8-12-86, ef. 9-1-86; AFS 33-1987(Temp), f. & ef. 7-22-87; AFS 46-1987, f. & ef. 10-1-87; AFS 62-1987 (Temp), f. 12-30-87, ef. 1-1-88; AFS 12-1988, f. 2-10-88, cert. ef. 6-1-88; AFS 26-1988, f. 3-31-88, cert. ef. 4-1-88; AFS 47-1988(Temp), f. 7-13-88, cert. ef. 7-1-88; AFS 63-1988, f. 10-3-88, cert. ef. 12-1-88; AFS 7-1989(Temp), f. 2-17-89, cert. ef. 3-1-89; AFS 15-1989(Temp), f. 3-31-89, cert. ef. 4-1-89; AFS 36-1989(Temp), f. & cert. ef. 6-30-89; AFS 37-1989 (Temp), f. 6-30-89, cert. ef. 7-1-89; AFS 45-1989, f. & cert. ef. 8-21-89; AFS 49-1989(Temp), f. 8-24-89, cert. ef. 9-1-89; AFS 72-1989, f. & cert. ef. 12-1-89, Renumbered from 461-015-0006, 461-015-0036, 461-015-0065 & 461-015-0124; HR 21-1990, f. & cert. ef. 7-9-90, Renumbered from 461-015-0580; HR 31-1990(Temp), f. & cert. ef. 9-11-90; HR 2-1991, f. & cert. ef. 1-4-91; HR 15-1991(Temp), f. & cert. ef. 4-8-91; HR 28-1991 (Temp), f. & cert. ef. 7-1-91; HR 32-1991(Temp), f. & cert. ef. 7-29-91; HR 53-1991, f. & cert. ef. 11-18-91, Renumbered from 410-125-0860; DMAP 34-2008, f. 11-26-08, cert. ef. 12-1-08
410-125-0140
Prior Authorization Does Not Guarantee Payment
(1) Prior authorization (PA)
is valid for the date range approved only as long as the client remains eligible
for services. For example, a client may become ineligible after the PA has been
granted but before the actual date of service, or a client's hospital benefit days
may be used prior to the time the claim for the prior
authorized service is submitted to the Division of Medical Assistance Programs (Division)
for payment.
(2) All prior authorized treatment are
subject to retrospective review. If the information provided to obtain PA cannot
be validated in a retrospective review, payment shall be denied or recovered.
(3) Hospitals should develop
their own internal monitoring system to determine if the admitting physician has
received PA for the service from the Division.
(4) For the Plus Benefit Package
PA information refer to the PA chart in the Hospital Services Program OAR 410-125-0080.
(5) Hospitals may also verify
PA requirements by calling the Division’s Provider Services Unit or the RN
Benefit Hotline (contact phone numbers are located on the Division’s website).
Stat. Auth.: ORS 413.042

Stats. Implemented: ORS 414.065

Hist.: AFS 49-1989(Temp), f.
8-24-89, cert. ef. 9-1-89; AFS 72-1989, f. & cert. ef. 12-1-89; HR 21-1990,
f. & cert. ef. 7-9-90, Renumbered from 461-015-0220; HR 42-1991, f. & cert.
ef. 10-1-91; HR 39-1992, f. 12-31-92, cert. ef. 1-1-93; OMAP 70-2004, f. 9-15-04,
cert. ef. 10-1-04; DMAP 32-2010, f. 12-15-10, cert. ef. 1-1-11; DMAP 37-2011, f.
12-13-11, cert. ef. 1-1-12
410-125-0141
DRG Rate Methodology
(1) Diagnosis Related Groups:
(a) Diagnosis Related Groups
(DRG) is a system of classification of diagnoses and procedures based on the International
Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM);
(b) The DRG classification
methodology assigns a DRG category to each inpatient service, based on the patient's
diagnoses, age, procedures performed, length of stay, and discharge status.
(2) Medicare Grouper: The
Medicare Grouper is the software used to assign an individual claim to a DRG category.
Medicare revises the Grouper program each year in October. The Division of Medical
Assistance Programs (Division) uses the Medicare Grouper program in the assignment
of inpatient hospital claims. The most recent version of the Medicare grouper will
be installed each year within 90 days of the date it is implemented by Medicare.
Where better assignment of claims is achieved through changes to the grouper logic,
the Division may modify the logic of the grouper program. The Division will work
with representatives of hospitals that may be affected by grouper logic changes
in reaching a cooperative decision regarding changes. The Division DRG weight tables
can be found on the Division web site.
(3) DRG Relative Weights:
(a) Relative weights are
a measure of the relative resources required in the treatment of the average case
falling within a specific DRG category;
(b) For most DRGs, the Division
establishes a relative weight based on federal Medicare DRG weights. For state-specific
Rehabilitation, Neonate, and Adolescent Psychiatric DRGs, Oregon Title XIX fee-for-service
claims history is used. To determine whether enough claims exist to establish a
reasonable weight for each state-specific Rehabilitation, Neonate, and Adolescent
Psychiatric DRG, the Division uses the following methodology: Using the formula
N = where Z = 1.15 (a 75% confidence level), S is the standard deviation, and R
= 10% of the mean. The Division determines the minimum number of claims required
to set a stable weight for each DRG (N must be at least 5). For state-specific Rehabilitation,
Neonate, and Adolescent Psychiatric DRGs lacking sufficient volume, the Division
sets a relative weight using:
(A) Division non-Title XIX
claims data; or
(B) Data from other sources
expected to reflect a population similar to the Division Title XIX caseload;
(c) When a test shows at
the 90% confidence level that an externally derived weight is not representative
of the average cost of services provided to the Division Title XIX population in
that DRG, the weight derived from the Division Title XIX claims history is used
instead of the externally derived weight for that DRG;
(d) Those relative weights
based on Federal Medicare DRG weights, will be established when changes are made
to the DRG Grouper logic. State specific relative weights shall be adjusted, as
needed, as determined by the Division. When relative weights are recalculated, the
overall Case Mix Index (CMI) will be kept constant. Reweighing of DRGs or the addition
or modification of the grouper logic will not result in a reduction of overall payments
or total relative weights.
(4) Case Mix Index: The hospital-specific
case mix index is the total of all relative weights for all services provided by
a hospital during a period, divided by the number of discharges.
(5) Unit Value: Hospitals
larger than fifty (50) beds are reimbursed using the Diagnosis Related Grouper (DRG)
as described in (2). Effective for services on or after:
(a) August 15, 2005, the
operating unit payment is 100% of 2004 Medicare and related data published in Federal
Register/Vol. 68, No. 148, August 1, 2003. The unit value is also referred to as
the operating unit per discharge.
(b) May 1, 2009, the operating
unit payment is 108.5% of the 2004 Medicare and related data published in Federal
Register/Vol. 68, No. 148, August 1, 2003. The unit value is also referred to as
the operating unit per discharge.
(c) Effective October 1,
2009 the operating unit payment is 100% of the most recent version of the Medicare
base payment rates. The Division will revise the base payment rates each year in
October when Medicare posts the rates.
(6) DRG Payment: The DRG
payment to each Oregon DRG hospital is calculated by adding the unit value to the
capital amount, then multiplied by the claim assigned DRG relative weight (out of
state hospitals do not receive the capital amount).
(7) Cost Outlier Payments:
(a) Cost outlier payments
are an additional payment made to in-state and contiguous hospitals for exceptionally
costly services or exceptionally long lengths of stay provided to Title XIX and
SF (State Facility) clients;
(b) For dates of service
on and after March 1, 2004 the calculation to determine the cost outlier payment
for Oregon DRG hospitals is as follows:
(A) Non-covered services
(such as ambulance charges) are deducted from billed charges;
(B) The remaining billed
charges are converted to hospital-specific costs using the hospital's cost-to-charge
ratio derived from the most recent audited Medicare cost report and adjusted to
the Medicaid caseload;
(C) If the hospital's net
costs as determined above are greater than 270 percent of the DRG payment for the
admission and are greater than $25,000, an additional cost outlier payment is made;
(D) Costs which exceed the
threshold ($25,000 or 270% of the DRG payment, whichever is greater) are reimbursed
using the following formula:
(i) Billed charges less non-covered
charges, multiplied by;
(ii) Hospital-specific cost-to-charge
ratio equals;
(iii) Net Costs, minus;
(iv) 270% of the DRG or $25,000
(whichever is greater), equals;
(v) Outlier Costs, multiplied
by;
(vi) Cost Outlier Percentage,
(cost outlier percentage is 50%), equals;
(vii) Cost Outlier Payment;
(E) Third party reimbursements
are deducted from the Division calculation of the payable amount;
(F) When hospital cost reports
are audited during the cost settlement process, an adjustment will be made to cost
outlier payments to reflect the actual Medicaid hospital-specific cost-to-charge
ratio during the time cost outlier claims were incurred. The cost-to-charge ratio
in effect for that period of time will be determined from the audited Medicare Cost
Report and DMAP 42, adjusted to reflect the Medicaid mix of services.
(8) Capital:
(a) The capital payment is
a reimbursement to in-state hospitals for capital costs associated with the delivery
of services to Title XIX, non-Medicare persons. The Division uses the Medicare definition
and calculation of capital costs. These costs are taken from the Hospital Statement
of Reimbursable Cost (Medicare Report);
(b) For the dates of service
on and after March 1, 2004 the Capital cost per discharge is one hundred (100) percent
of the published Medicare capital rate for fiscal year 2004, see (5). The capital
cost is added to the Unit Value and paid per discharge.
(c) Effective October 1,
2009 the Capital cost per discharge is one hundred (100) percent of the current
year Medicare capital rate and updated every October thereafter, see (5). The capital
cost is added to the Unit Value and paid per discharge.
(9) Direct Medical Education:
(a) The direct medical education
payment is a reimbursement to in-state hospitals for direct medical education costs
associated with the delivery of services to Title XIX eligible persons. The Division
uses the Medicare definition and calculation of direct medical education costs.
These costs are taken from the Hospital Statement of Reimbursable Cost (Medicare
Report);
(b) Direct medical education
cost per discharge is calculated as follows:
(A) The direct medical education
cost proportional to the number of Title XIX non-Medicare discharges during the
period from July 1, 1986 through June 30, 1987 are divided by the number of Title
XIX non-Medicare discharges. This is the Title XIX direct medical education cost
per discharge;
(B) The Title XIX direct
medical education cost per discharge for this period is inflated forward to January
1, 1992, using the compounded HCFA-DRI market basket adjustment;
(c) Direct medical education
payment per discharge:
(A) The number of Title XIX
non-Medicare discharges from each hospital for the quarterly period is multiplied
by the inflated Title XIX cost per discharge. This determines the current quarter's
Direct Medical Education costs. This amount is then multiplied by 85%. Payment is
made within thirty days of the end of the quarter;
(B) The Direct Medical Education
Payment per Discharge will be adjusted at an inflation factor determined by the
Department in consideration of inflationary trends, hospital productivity and other
relevant factors.
(C) Notwithstanding subsection
(9) of this rule, this subsection becomes effective for dates of service:
(i) On July 1, 2006 and thereafter
direct medical education payments will not be made to hospitals; and
(ii) On July 1, 2008 and
thereafter direct medical education payments will be made to hospitals, but will
not be operative as the basis for payments until the Division determines all necessary
federal approvals have been obtained.
(10) Indirect Medical Education:
(a) The indirect medical
education payment is a reimbursement made to instate hospitals for indirect medical
education costs associated with the delivery of services to Title XIX non-Medicare
clients;
(b) Indirect medical education
costs are those indirect costs identified by Medicare as resulting from the effect
of teaching activity on operating costs;
(c) Indirect medical education
payments are made to in-state hospitals determined by Medicare to be eligible for
such payments. The indirect medical education factor in use by Medicare for each
of these eligible hospitals at the beginning of the State's fiscal year is the Division
indirect medical education factor. This factor is used for the entire Oregon fiscal
year;
(d) For dates of service
on and after March 1, 2004 the calculation for the Indirect Medical Education quarterly
payment is as follows: Total paid discharges during the quarter multiplied by the
Case Mix Index, multiplied by the hospital specific February 29, 2004 Unit Value,
multiplied by the Indirect Factor equals the Indirect Medical Education Payment;
(e) Effective October 1,
2009, the calculation of the Indirect Medical Education quarterly payment is as
follows: Total paid discharges during the quarter multiplied by the Case Mix Index,
multiplied by the hospital unit value, see (5)(c), multiplied by the indirect factor
equals the Indirect Medical Education Payment.
(f) This determines the current
quarter's Indirect Medical Education Payment. Indirect medical education payments
are made quarterly to each eligible hospital. Payment for indirect medical education
costs will be made within thirty days of the end of the quarter.
(g) Notwithstanding subsection
(10) of this rule, this subsection becomes effective for dates of service:
(A) On July 1, 2006 and thereafter
Indirect Medical Education payment will not be made to hospitals; and
(B) On July 1, 2008 and thereafter
Indirect Medical Education payments will be made to hospitals, but will not be operative
as the basis for payments until the Division determines all necessary federal approvals
have been obtained.
[Publications: Publications referenced
are available from the agency.]
Stat. Auth.: ORS 413.042
Stats. Implemented: ORS 414.065
Hist.: AFS 14-1980, f. 3-27-80,
ef. 4-1-80; AFS 57-1980, f. 8-29-80, ef. 9-1-80; AFS 18-1982(Temp), f. & ef.
3-1-82; AFS 60-1982, f. & ef. 7-1-82; Renumbered from 461-015-0120(5); AFS 37-1983(Temp),
f. & ef. 7-15-83; AFS 1-1984, f. & ef. 1-9-84; AFS 45-1984, f. & ef.
10-1-84; AFS 6-1985, f. 1-28-85, ef. 2-1-85; AFS 52-1985, f. 9-3-85, ef. 10-1-85;
AFS 46-1986(Temp), f. 6-25-86, ef. 7-1-86; AFS 61-1986, f. 8-12-86, ef. 9-1-86;
AFS 33-1987(Temp), f. & ef. 7-22-87; AFS 46-1987, f. & ef. 10-1-87; AFS
62-1987(Temp), f. 12-30-87, ef. 1-1-88; AFS 12-1988, f. 2-10-88, cert. ef. 6-1-88;
AFS 26-1988, f. 3-31-88, cert. ef. 4-1-88; AFS 47-1988(Temp), f. 7-13-88, cert.
ef. 7-1-88; AFS 63-1988, f. 10-3-88, cert. ef. 12-1-88; AFS 7-1989(Temp), f. 2-17-89,
cert. ef. 3-1-89; AFS 15-1989(Temp), f. 3-31-89, cert. ef. 4-1-89; AFS 36-1989(Temp),
f. & cert. ef. 6-30-89; AFS 37-1989(Temp), f. 6-30-89, cert. ef. 7-1-89; AFS
45-1989, f. & cert. ef. 8-21-89; AFS 49-1989(Temp), f. 8-24-89, cert. ef. 9-1-89;
AFS 72-1989, f. & cert. ef. 12-1-89, Renumbered from 461-015-0006, 461-015-0020
& 461-015-0124; HR 18-1990(Temp), f. 6-29-90, cert. ef. 7-1-90; HR 21-1990,
f. & cert. ef. 7-9-90, Renumbered from 461-015-0570, 461-015-0590, 461-015-0600
& 461-015-0610; HR 31-1990(Temp), f. & cert. ef. 9-11-90; HR 36-1990(Temp),
f. 10-29-90, cert. ef. 11-1-90; HR 42-1990, f. & cert. ef. 11-30-90; HR 3-1991,
f. & cert. ef. 1-4-91; HR 28-1991(Temp), f. & cert. ef. 7-1-91; HR 32-1991(Temp),
f. & cert. ef. 7-29-91; HR 53-1991, f. & cert. ef. 11-18-91, Renumbered
from 410-125-0840, 410-125-0880, 410-125-0900, 410-125-0920, 410-125-0960 &
410-125-0980; HR 35-1993(Temp), f. & cert. ef. 12-1-93; HR 23-1994, f. 5-31-94,
cert. ef. 6-1-94; HR 11-1996(Temp), f. & cert. ef. 7-1-96; HR 22-1996, f. 11-29-96,
cert. ef. 12-1-96; OMAP 45-1998, f. & cert. ef. 12-1-98; OMAP 34-1999, f. &
cert. ef. 10-1-99; OMAP 35-2001, f. 9-24-01, cert. ef. 10-1-01; OMAP 13-2003, f.
2-28-03, cert. ef. 3-1-03; OMAP 16-2003(Temp), f. & cert. ef. 3-10-03 thru 8-1-03;
OMAP 37-2003, f. & cert. ef. 5-1-03; OMAP 90-2003, f. 12-30-03 cert. ef. 1-1-04;
OMAP 78-2004(Temp), f. & cert. ef. 10-1-04 thru 3-15-05; Administrative correction,
3-18-05; OMAP 21-2005, f. 3-21-05, cert. ef. 4-1-05; OMAP 37-2005(Temp) f. &
cert. ef. 8-15-05 thru 1-15-06; OMAP 70-2005, f. 12-21-05, cert. ef. 1-1-06; OMAP
17-2006, f. 6-12-06, cert. ef. 7-1-06; DMAP 19-2008, f. 6-13-08, cert. ef. 7-1-08;
DMAP 10-2009(Temp), f. 4-29-09, cert. ef. 5-1-09 thru 10-28-09; DMAP 31-2009, f.
9-22-09, cert. ef. 10-1-09; DMAP 51-2015, f. 9-22-15, cert. ef. 10-1-15
410-125-0142
Graduate Medical Education Reimbursement for Public Teaching Hospitals
(1) Graduate Medical Education (GME) payment is reimbursement made to an institution for the costs of an approved medical training program. The State makes GME payments to any in-state public acute care hospital providing a major teaching program, defined as a hospital with more than 200 residents or interns. Funding for public teaching hospital GME is not included in the "capitation rates" paid to managed care plans under the Oregon Health Plan resulting in hospitals with medical teaching programs not being able to capture GME costs when contracting with managed care plans.
(2) For each qualifying public hospital, the payment amount is initially determined based on hospital specific costs for medical education as reported in the Medicare Cost Report for the most recent completed reporting year (becomes base year).
(3) The GME payment is calculated as follows:
(a) Total Direct Medical Education (DME) costs consist of the costs for medical residency and the paramedical education programs. Title XIX DME costs are determined based on the ratio of Title XIX days to total days applied to the total DME.
(b) Indirect Medical Education (IME) costs are derived by first computing the percent of IME to total Medicare inpatient payments. This is performed by dividing the IME Adjustment reported in the Medicare Cost Report by the sum of this amount and Medicare payments for DRG amount -- other than outlier payments, inpatient program capital, and organ acquisition. The resulting percent is then applied to net allowable costs (total allowable costs less Total DME costs, computed as discussed in the previous paragraph). Title XIX IME costs are then determined based upon the ratio of Title XIX days to total days.
(c) The total net Title XIX GME is the sum of Title XIX IME and DME costs. The GME reimbursement is made quarterly. Reimbursement is limited to the availability of public funds, specifically, the amount of public funds available for GME attributable to the Title XIX patient population. GME is rebased yearly.
(4) Total GME payments will not exceed that determined by using Medicare reimbursement. The Medicare upper limit will be determined from the most recent Medicare Cost Report and performed for all inpatient acute hospitals and separately for State operated inpatient acute hospitals in accordance with 42 CFR 447.272(a) and (b). The upper limit review will be performed before the GME payment is made.
Stat. Auth.: ORS 413.042

Stats. Implemented: ORS 414.065

Hist.: OMAP 30-1999(Temp), f. & cert. ef. 6-15-99 thru 11-1-99; OMAP 34-1999, f. & cert. ef. 10-1-99; OMAP 35-2001, f. 9-24-01, cert. ef. 10-1-01; OMAP 17-2006, f. 6-12-06, cert. ef. 7-1-06
410-125-0146
Supplemental Reimbursement for Public Academic Teaching University Medical Practitioners
(1) Effective for dates of service on or after November 17, 2005, physician and other practitioner services provided by practitioners affiliated with a public academic medical center that meets the following eligibility standards shall be eligible for a supplemental teaching practitioner's payment for these services provided to eligible Medicaid recipients and paid for directly on a fee-for-service basis, subject to subsections (3) and (4) of this rule. This supplemental payment shall be equal to the difference between the Medicare allowable and Medicaid reimbursement received.
(2) Eligible academic medical centers must be:
(a) The hospital must be located within the State of Oregon (border hospitals are excluded); and
(b) The hospital provides a major medical teaching program, defined as a hospital with more than 200 residents or interns.
(3) Payments under this rule shall be made only to the eligible academic medical centers in accordance with the terms of an intergovermental agreement between the eligible academic medical center and Division of Medical Assistance Programs (Division). Such payments may be made quarterly, but shall be at least paid annually, at the end of each federal fiscal year. Calculation of the payment amount will be based on the annual difference between the practitioners' Medicare allowable and the Medicaid allowable payments to eligible practitioners for the Medicaid claims paid during the most recently completed state fiscal year. Services included are physician and other practitioners' services with RVU weights and physician-administered drugs. The RVU rates used for the payment calculation are the Division fee established in rule for the date of service payment period.
(4) Allowable Medicaid payments including this supplemental payment remain subject to OAR 410-125-0220(12) and 410-130-0225. For purposes of this rule, the allowable Medicaid payments used to calculate the supplemental payment shall be limited to the services that are billed fee-for-service to the Division on the electronic 837P or the paper CMS-1500, and as to which the physician or practitioner is receiving no reimbursement from the eligible academic medical center and the cost of their service is not reported as a direct medical education cost on the Medicare and the Division cost report.
Stat. Auth.: ORS 413.042

Stats. Implemented: 414.065

Hist.: OMAP 33-2006, f. 8-31-06, cert. ef. 9-1-06; OMAP 43-2006, f. 12-15-06, cert. ef. 1-1-07
410-125-0150
Disproportionate Share
(1) The Disproportionate-share
hospital (DSH) payment is an additional reimbursement made to hospitals that serve
a disproportionate share of low-income patients with special needs.
(a) To receive DSH payments,
a hospital must have at least two obstetricians with staff privileges at the hospital
who have agreed to provide non-emergency obstetrical services to Medicaid patients.
For hospitals in a rural area (outside of a Metropolitan Statistical Area, as defined
by the Executive Office of Management and Budget), the term "obstetrician" includes
any physician with staff privileges at the hospital that performs non-emergency
obstetric procedures. This requirement does not apply to a hospital in which a majority
of inpatients are under 18 years of age, or a hospital that had discontinued or
did not offer non-emergency obstetric services as of December 21, 1987. No hospital
may qualify for disproportionate share payments unless the hospital has, at a minimum,
a Medicaid utilization rate of 1 percent. The Medicaid utilization rate is the ratio
of total paid Medicaid (Title XIX, non-Medicare) days to total inpatient days. Newborn
days, days in specialized wards, and administratively necessary days are included.
Days attributable to individuals eligible for Medicaid in another State are also
accounted for;
(b) Information on total inpatient
days is taken from the most recent Medicare Cost Report.
(2) A hospital's eligibility
for DSH payments is determined at the beginning of each fiscal year. Hospitals that
are not eligible under Criteria 1 may apply for eligibility at any time during the
year under Criteria 2. A hospital may be determined eligible under Criteria 2 only
after being determined ineligible under Criteria 1.
(3) Eligibility under Criteria
2 is effective from the beginning of the quarter in which eligibility is approved.
Out-of-state hospitals are eligible for DSH payments if they have been designated
by their state Title XIX Medicaid program as eligible for DSH payments within that
state:
(a) Criteria 1: One or more
standard deviation above the mean
(A) The ratio of total paid
Medicaid inpatient (Title XIX, non-Medicare) days for hospital services (regardless
of whether the services were furnished on a fee-for-service basis or through a managed
care entity) to total inpatient days is one or more standard deviations above the
mean for all Oregon hospital;
(B) Information on total inpatient
days is taken from the most recent audited Medicare Cost Report. The total paid
Medicaid inpatient days is based on Division of Medical Assistance Programs’
(Division) records for the same cost reporting period;
(C) Information on total paid
Medicaid days is taken from Division reports of paid claims for the same fiscal
period as the Medicare Cost Report.
(b) Criteria 2: A low-income
utilization rate exceeding 25 percent
(A) The Low income utilization
rate is the sum of percentages (3)(b)(A)(i) and (3)(b)(A)(ii) below:
(i) The Medicaid percentage:
The total of Medicaid inpatient and outpatient revenues paid to the hospital for
hospital services (regardless of whether the services were furnished on a fee-for-service
basis or through a managed care entity) plus any cash subsidies received directly
from State and local governments in the most recent Medicare cost reporting period.
This amount is divided by the total amount of inpatient and outpatient revenues
and cash subsidies of the hospital for patient services in the most recent Medicare
cost reporting period. The result is expressed as a percentage;
(ii) The charity care percentage:
The total hospital charges for inpatient hospital services for charity care in the
most recent Medicare cost reporting period, minus any cash subsidies received directly
from State and local government in the same period is divided by the total amount
of the hospital's charges for inpatient services in the same period. The result
is expressed as a percentage;
(iii) Charity care is provided
to individuals who have no source of payment, including third party and personal
resources.
(B) Charity care shall not include
deductions from revenues or the amount by which inpatient charges are reduced due
to contractual allowances and discounts to other third party payers, such as Fully-Capitated
Health Plans (FCHPs), Medicare, Medicaid, etc;
(C) The information used to
calculate the low income utilization rate is taken from the following sources:
(i) The most recent Medicare
Cost Reports;
(ii) The Division’s records
of payments made during the same reporting period;
(iii)
Hospital-provided financial statements, prepared and certified for accuracy by a
licensed public accounting firm for the same reporting period;
(iv) Hospital-provided official records
from state and county agencies of any cash subsidies paid to the hospital during
the same reporting period;
(v) Any other information that
the Division, working in conjunction with representatives of Oregon hospitals, determines
is necessary to establish eligibility.
(D) The Division determines
within 30 days of receipt of all required information if a hospital is eligible
under the low income utilization rate criteria.
(c) Disproportionate-share
payment calculations:
(A) All hospitals that have
been deemed DSH hospitals will always qualify for DSH payments under criteria 1
or criteria 2. Hospital ranking is done on an annual basis for all hospitals.
Once eligible hospitals are determined Division calculates the standard deviations
for the hospitals to determine if they will be eligible under criteria 1 or criteria
2.
(B) Criteria 1:one or more deviations
above the mean The quarterly DSH payment to hospitals eligible under criteria 1
is the sum of Diagnosis Related Groups (DRG) weights for paid Title XIX non-Medicare
claims for the quarter multiplied by a percentage of the hospital-specific Unit
Value; this determines the hospital's DSH payment for the current quarter. The Unit
Value used for eligible Type A, Type B, and Critical Access Hospitals is set at
the same rate as for out-of-state hospitals. The calculation is as follows:
(i) For eligible hospitals more
than one standard deviation and less than two standard deviations above the mean,
the disproportionate share percentage is 5%. The total of all relative weights is
multiplied by the hospital's unit value. This amount is multiplied by 5% to determine
the DSH payment;
(ii) For eligible hospitals
more than two and less than three standard deviations above the mean, the percentage
is 10%. The total of all relative weights is multiplied by the hospital's unit value.
The amount is multiplied by 0.10 to determine the DSH payment.
(iii) For eligible hospitals
more than three standard deviations above the mean, the percentage is 25%. The total
of all relative weights is multiplied by the hospital's unit value. This amount
is multiplied by 0.25 to determine the DSH payment.
(C) Eligibility under Criteria
2 — For hospitals eligible under Criteria 2 (low income utilization rate),
the payment is the sum of DRG weights for claims paid by the Division in the quarter,
multiplied by the hospital's disproportionate share adjustment percentage established
under Section 1886(d)(5)(F)(iv) of the Social Security Act multiplied by the hospital's
unit value;
(D) For out-of-state hospitals,
the quarterly DSH payment is 5% of the out-of-state unit value multiplied by the
sum of the Oregon Medicaid DRG weights for the quarter. Out-of-state hospitals that
have entered into agreements with the Division for payment are reimbursed according
to the terms of the agreement or contract.
(d) Public Academic Medical
Center Disproportionate Share adjustments:
(A) Public academic medical
centers that meet the following eligibility standards shall be deemed eligible for
additional DSH payments up to 100% of their cost for serving Medicaid fee for service
clients and indigent and uninsured patients:
(i) The hospital must have at
least two obstetricians with staff privileges at the hospital who have agreed to
provide obstetric services to individuals who are entitled to medical assistance
for such services; and
(ii) The hospital must be located
within the State of Oregon (border hospitals are excluded); and
(iii) The hospital provides
a major medical teaching program, defined as a hospital with more than 200 residents
or interns.
(B) 100% of the costs for hospitals
qualifying for this DSH payment will be determined from the following sources:
(i) The most recent Medicare
Cost Reports; or
(ii) The Division’s record
of payments made during the same reporting period; or
(iii) Hospital provided official
records from state and county agencies of any cash subsidies paid to the hospital
during the same reporting period; or
(iv) Any information which the
Division, working in conjunction with representatives of Oregon hospitals, determines
necessary to establish cost.
(e) Additional Disproportionate
Adjustments:
(A) For all hospitals with a
Medicaid utilization rate above one percent of all payer utilization, the DSH payment
is the ratio of the hospital’s low income shortfall to the low income shortfall
for all eligible hospitals multiplied by the total Federal disproportionate share
allotment remaining after disproportionate payments have been made.(B) The low income
shortfall is the Medicaid costs for inpatient and outpatient hospitals services
plus uncompensated care for the uninsured cost for inpatient and outpatient hospital
services less total Medicaid and self-pay payments for inpatient and outpatient
hospital services.
(f) Disproportionate-share payment
schedule:
(A) Hospitals qualifying for
DSH payments under section (3) (c) above will receive quarterly payments based on
claims paid during the preceding quarter. Hospitals that were eligible during one
fiscal year but are not eligible for disproportionate share status during the next
fiscal year will receive DSH payments based on claims paid in the quarter in which
they were eligible. Hospitals qualifying for DSH payments under section (3) (e)
above will receive quarterly payments of 25 percent of the amount determined under
this section;
(B) Effective October 1, 1994,
and in accordance with the Omnibus Budget Reconciliation Act of 1993, DSH payments
to hospitals will not exceed 100 percent of the "basic limit" which is:
(i) The inpatient and outpatient
costs for services to Medicaid patients, less the amounts paid by the State under
the non-DSH payment provisions of the State plan, plus;
(ii) The inpatient and outpatient
costs for services to uninsured indigent patients, less any payments for such services.
An uninsured indigent patient is defined as an individual who has no other resources
to cover the costs of services delivered. The costs attributable to uninsured patients
are determined through disclosures in the Medicare (HCFA-2552) cost report and state
records on indigent care.
(C) The State has a contingency
plan to assure that disproportionate share hospital payments will not exceed the
State disproportionate share hospital allotment (allotment). A reduction in payments
in proportion to payments received will be effected to meet the requirements of
section 1923(f) of the Social Security Act. DSH payments are made quarterly. Before
payments are made for the last quarter of the Federal fiscal year, payments for
the first three quarters and the anticipated payment for the last quarter are cumulatively
compared to the allotment.
(i) If the allotment will be
exceeded, the DSH payments for the last quarter will be adjusted proportionately
for each hospital qualifying for payments under section (3)(d).
(ii) If the allotment will still
be exceeded after this adjustment, DSH payments to out-of-state hospitals will be
adjusted in proportion to DSH payments received during the previous three quarters.
(iii) If this second adjustment
still results in the allotment being exceeded, hospitals qualifying for payments
under section (3)(c) (Criteria 1 and 2) will be adjusted by applying each hospital's
proportional share of payments during the previous three quarters to total DSH payments
to all hospitals for that period.
(D) Similar monitoring, using
a predetermined limit based on the most recent audited costs, and including the
execution of appropriate adjustments to DSH payments are in effect to meet the hospital
specific limit provisions detailed in section 1923(g) of the Social Security Act.
Stat. Auth.: ORS 413.042

Stats. Implemented: ORS 414.065

Hist.: AFS 14-1980, f. 3-27-80,
ef. 4-1-80; AFS 57-1980, f. 8-29-80, ef. 9-1-80; AFS 18-1982(Temp), f. & ef.
3-1-82; AFS 60-1982, f. & ef. 7-1-82; Renumbered
from 461-015-0120(5); AFS 37-1983(Temp), f. & ef. 7-15-83; AFS 1-1984, f. &
ef. 1-9-84; AFS 45-1984, f. & ef. 10-1-84; AFS 6-1985, f. 1-28-85, ef. 2-1-85;
AFS 52-1985, f. 9-3-85, ef. 10-1-85; AFS 46-1986(Temp), f. 6-25-86, ef. 7-1-86;
AFS 61-1986, f. 8-12-86, ef. 9-1-86; AFS 33-1987(Temp), f. & ef. 7-22-87; AFS
46-1987, f. & ef. 10-1-87; AFS 62-1987(Temp), f. 12-30-87, ef. 1-1-88; AFS 12-1988,
f. 2-10-88, cert. ef. 6-1-88; AFS 26-1988, f. 3-31-88, cert. ef. 4-1-88; AFS 47-1988(Temp),
f. 7-13-88, cert. ef. 7-1-88; AFS 63-1988, f. 10-3-88, cert. ef. 12-1-88; AFS 7-1989(Temp),
f. 2-17-89, cert. ef. 3-1-89; AFS 15-1989(Temp), f. 3-31-89, cert. ef. 4-1-89; AFS
36-1989(Temp), f. & cert. ef. 6-30-89; AFS 37-1989(Temp), f. 6-30-89, cert.
ef. 7-1-89; AFS 45-1989, f. & cert. ef. 8-21-89; AFS 49-1989(Temp), f. 8-24-89,
cert. ef. 9-1-89; AFS 72-1989, f. & cert. ef. 12-1-89, Renumbered from 461-015-0006
& 461-015-0124; HR 21-1990, f. & cert. ef. 7-9-90, Renumbered from 461-015-0620;
HR 31-1990(Temp), f. & cert. ef. 9-11-90; HR 2-1991, f. & cert. ef. 1-4-91;
HR 28-1991(Temp), f. & cert. ef. 7-1-91; HR 32-1991(Temp), f. & cert. ef.
7-29-91; HR 53-1991, f. & cert. ef. 11-18-91, Renumbered from 410-125-0940;
HR 36-1993, f. & cert. ef. 12-1-93; HR 24-1995, f. 12-29-95, cert. ef. 1-1-96;
OMAP 6-1998(Temp), f. & cert. ef. 2-11-98 thru 7-15-98; OMAP 23-1998, f. &
cert. ef. 7-15-98; OMAP 35-2001, f. 9-24-01, cert. ef. 10-1-01; OMAP 70-2004, f.
9-15-04, cert. ef. 10-1-04; DMAP 32-2012, f. 6-29-12, cert. ef. 7-1-12
410-125-0155
Upper Limits on Payment
of Hospital Claims
(1) Supplemental payments:
(a) Private Hospital Supplemental
Payments:
(A) From the private Upper Payment
Limit (UPL) gap, payments shall be made to all private Diagnosis Related Groups
(DRG) hospitals in the form of a per discharge payment applied to hospital specific
Medicaid fee-for-service discharges from the quarter preceding the month of the
payment;
(B) This payment will be equal
to one quarter of the gap amount divided by the total private DRG hospital Medicaid
fee-for-service discharges from the quarter proceeding the month of payment;
(C) The supplemental payments
for Private Hospitals will not exceed the UPL for inpatient hospital services.
(b) Non-State Government Owned
Hospital Supplemental Payments:
(A) From the non-state government
owned hospital upper payment limit gap, payments shall be made to all non-state
government owned DRG hospitals in the form of a per discharge payment applied to
hospital specific Medicaid fee-for-service discharges from the quarter preceding
the month of the payment;
(B) This payment will be equal
to one quarter of the gap amount divided by the total non-state government owned
DRG hospital Medicaid fee-for-service discharges from the quarter proceeding the
month of payment;
(C) The supplemental payments
for non-state government owned Hospitals will not exceed the UPL for inpatient hospital
services.
(2) For Type A, Type B and Critical
Access Hospitals, reimbursement shall be limited to the lesser of allowable costs
or billed charges. This limitation shame be applied separately to inpatient and
outpatient services.
(3) Payments will not exceed
final approved plan:
(a) Total reimbursements to
a state-operated facility made during the Division of Medical Assistance Program
(Division) fiscal year (July 1 through June 30) may not exceed any limit imposed
under federal law in the final approved plan;
(b) Total aggregate inpatient
and outpatient reimbursements to all hospitals made during the Division’s
fiscal year (July 1 through June 30) may not exceed any limit imposed under federal
law in the final approved plan.
Stat. Auth.: ORS 413.042

Stats. Implemented: ORS 414.065

Hist.: HR 28-1991(Temp), f.
& cert. ef. 7-1-91; HR 53-1991, f. & cert. ef. 11-18-91; HR 36-1993, f.
& cert. ef. 12-1-93; OMAP 35-2001, f. 9-24-01, cert. ef. 10-1-01; OMAP 17-2006,
f. 6-12-06, cert. ef. 7-1-06; DMAP 39-2008, f. 12-11-08,
cert. ef. 1-1-09; DMAP 32-2012, f. 6-29-12, cert. ef.
7-1-12
410-125-0162
Hospital Transformation Performance Program
(1) The Hospital Transformation Performance
Program (HTPP) is established by the Oregon Health Authority (Authority) to allow
hospitals to earn incentive payments by meeting specific performance standards that
advance health systems transformation, reduce hospital costs, and improve patient
safety.
(a) The total amount of funds
available through the program is equal to the federal financial participation received
from one-percentage point of the assessment. Hospitals that pay an assessment on
their net patient revenue, as required by OAR 410-050-0870, are eligible to participate.
(b) The performance standards
shall be established by the Authority based on recommendations of the Hospital Performance
Advisory Committee (Committee) and as approved by the Centers for Medicare and Medicaid
Services (CMS). The Committee shall be appointed by the Authority director and comprise
four hospital representatives, two Coordinated Care Organization (CCO) representatives,
and three members with expertise in measuring health outcomes.
(2) To qualify for incentive
payments, eligible hospitals must meet the performance standards and measures as
determined by the Authority.
(3) The Authority will:
(a) Establish baselines and
targets for performance measures;
(b) Post the data specs and
formats, forms to be used, schedule and frequency of data submission, frequency
of incentive distributions, and other technical information on the Authority’s
website once determined;
(c) Analyze performance data
submitted by hospitals;
(d) Determine if hospitals
achieve targeted goals or demonstrate sufficient improvement to qualify for incentive
payments; and
(e) Distribute incentive
payments to performing hospitals.
Stat. Auth.: 2013 OL Ch. 608, Sec. 1, 13 & 25
Stats. Implemented: 2013 OL Ch. 608, Sec. 1, 13 & 25
Hist.: DMAP 59-2014, f. 10-3-14,
cert. ef. 10-7-14
410-125-0165
Transfers and Reimbursement
(1) When a patient is transferred between hospitals, the transferring hospital is paid on the basis of the number of inpatient days spent at the transferring hospital multiplied by the Per Diem Inter-Hospital Transfer Payment rate.
(2) The per diem inter-hospital transfer payment rate = the DRG payment divided by the geometric mean length of stay for the DRG. The geometric mean length of stay is reported in the DRG tables on the Division website.
(3) Payment to the transferring hospital will not exceed the DRG payment.
(4) The final discharging hospital receives the full DRG payment.
Stat. Auth.: ORS 413.042

Stats. Implemented: ORS 414.065

Hist.: AFS 44-1985, f. & ef. 7-1-85; AFS 46-1987, f. & ef. 10-1-87; AFS 49-1989(Temp), f. 8-24-89, cert. ef. 9-1-89; AFS 72-1989, f. & cert. ef. 12-1-89, Renumbered from 461-015-0135; HR 21-1990, f. & cert. ef. 7-9-90, Renumbered from 461-015-0390; HR 31-1990(Temp), f. & cert. ef. 9-11-90; HR 2-1991, f. & cert. ef. 1-4-91; HR 42-1991, f. & cert. ef. 10-1-91, Renumbered from 410-125-0480; HR 53-1991, f. & cert. ef. 11-18-91; OMAP 34-1999, f. & cert. ef. 10-1-99; OMAP 70-2004, f. 9-15-04, cert. ef. 10-1-04
410-125-0170
Death Occurring on Day of Admission
A hospital receiving DRG reimbursements will receive the DRG reimbursement for the inpatient stay when death occurs on the day of admission as long as at least one hospital benefit day is available.
Stat. Auth.: ORS 413.042

Stats. Implemented: ORS 414.065

Hist.: AFS 14-1980, f. 3-27-80, ef. 4-1-80; AFS 57-1980, f. 8-29-80, ef. 9-1-80; AFS 18-1982(Temp), f. & ef. 3-1-82; AFS 60-1982, f. & ef. 7-1-82; Renumbered from 461-015-0120(5); AFS 37-1983(Temp), f. & ef. 7-15-83; AFS 1-1984, f. & ef. 1-9-84; AFS 45-1984, f. & ef. 10-1-84; AFS 6-1985, f. 1-28-85, ef. 2-1-85; AFS 52-1985, f. 9-3-85, ef. 10-1-85; AFS 46-1986(Temp), f. 6-25-86, ef. 7-1-86; AFS 61-1986, f. 8-12-86, ef. 9-1-86; AFS 33-1987(Temp), f. & ef. 7-22-87; AFS 46-1987, f. & ef. 10-1-87; AFS 62-1987(Temp), f. 12-30-87, ef. 1-1-88; AFS 12-1988, f. 2-10-88, cert. ef. 6-1-88; AFS 26-1988, f. 3-31-88, cert. ef. 4-1-88; AFS 47-1988(Temp), f. 7-13-88, cert. ef. 7-1-88; AFS 63-1988, f. 10-3-88, cert. ef. 12-1-88; AFS 7-1989(Temp), f. 2-17-89, cert. ef. 3-1-89; AFS 15-1989(Temp), f. 3-31-89, cert. ef. 4-1-89; AFS 36-1989(Temp), f. & cert. ef. 6-30-89; AFS 37-1989(Temp), f. 6-30-89, cert. ef. 7-1-89; AFS 45-1989, f. & cert. ef. 8-21-89; AFS 49-1989(Temp), f. 8-24-89, cert. ef. 9-1-89; AFS 72-1989, f. & cert. ef. 12-1-89, Renumbered from 461-015-0006, 461-015-0020 & 461-015-0124; HR 18-1990(Temp), f. 6-29-90, cert. ef. 7-1-90; HR 21-1990, f. & cert. ef. 7-9-90, Renumbered from 461-015-0570; HR 31-1990(Temp), f. & cert. ef. 9-11-90; HR 36-1990(Temp), f. 10-29-90, cert. ef. 11-1-90; HR 3-1991, f. & cert. ef. 1-4-91; HR 28-1991(Temp), f. & cert. ef. 7-1-91; HR 32-1991(Temp), f. & cert. ef. 7-29-91; HR 53-1991, f. & cert. ef. 11-18-91, Renumbered from 410-125-0840
410-125-0175
Hospitals Providing Specialized Outpatient Services
Some hospitals provide specific highly specialized outpatient services by arrangement with the Division. Reimbursement is made according to the terms of a written agreement or contract.
Stat. Auth.: ORS 413.042

Stats. Implemented: ORS 414.065

Hist.: HR 28-1991(Temp), f. & cert. ef. 7-1-91; HR 53-1991, f. & cert. ef. 11-18-91
410-125-0180
Public Rates
Rates billed to Division of Medical Assistance Programs (Division) cannot exceed the facility's public billing rate.
Stat. Auth.: ORS 413.042

Stats. Implemented: ORS 414.065

Hist.: AFS 14-1980, f. 3-27-80, ef. 4-1-80; AFS 30-1982, f. 4-26-82 & AFS 51-1982, f. 5-28-82, ef. 5-1-82 for providers located in the geographical areas covered by the AFS branch offices located in North Salem, South Salem, Dallas, Woodburn, McMinnville, Lebanon, Albany and Corvallis, ef. 6-30-82 for remaining AFS branch offices; AFS 37-1983(Temp), f. & ef. 7-15-83; AFS 1-1984, f. & ef. 1-9-84; AFS 46-1987, f. & ef. 10-1-87; AFS 49-1989(Temp), f. 8-24-89, cert. ef. 9-1-89; AFS 72-1989, f. & cert. ef. 12-1-89, Renumbered from 461-015-0015; HR 21-1990, f. & cert. ef. 7-9-90, Renumbered from 461-015-0240; HR 42-1991, f. & cert. ef. 10-1-91
410-125-0181
Non-Contiguous and Contiguous Area Out-of-State Hospitals -- Outpatient Services
Non-contiguous area hospitals are out-of-state hospitals located more than 75 miles outside the Oregon border. Contiguous area hospitals are out-of state hospitals located less than 75 miles outside the Oregon border. Unless such hospitals have an agreement with the Division of Medical Assistance Programs (Division) regarding reimbursement for specialized services, these hospitals will be reimbursed as follows:
(1) Laboratory, diagnostic and therapeutic radiology, nuclear medicine, CT scans, MRI services, other imaging services, and maternity case management services will be reimbursed under a Division fee schedule.
(2) All other outpatient services will be reimbursed at 50 percent of billed charges. There is no cost settlement.
(3) Notwithstanding subsections (1)-(2) of this rule, this subsection becomes effective for dates of service on and after January 1, 2006, but will not be operative as the basis for payments until the Division determines all necessary federal approvals have been obtained. Non-contiguous area hospitals are out-of-state hospitals located more than 75 miles outside the Oregon border. Contiguous area hospitals are out-of-state hospitals located less than 75 miles outside the Oregon border. Unless such hospitals have an agreement with the Division regarding reimbursement for specialized services, these hospitals will be reimbursed as follows:
(a) Clinical laboratory services will be reimbursed under a Division fee schedule;
(b) All other outpatient services will be reimbursed at 50 percent of billed charges. There is no cost settlement.
(4) The National Drug Code (NDC) must be included on the electronic (837I) and paper (UB 04) claims for physician administered drug codes required by the Deficit Reduction Act of 2005.
Stat. Auth.: ORS 413.042

Stats. Implemented: ORS 414.065

Hist.: AFS 14-1980, f. 3-27-80, ef. 4-1-80; AFS 57-1980, f. 8-29-80, ef. 9-1-80; AFS 18-1982(Temp), f. & ef. 3-1-82; AFS 60-1982, f. & ef. 7-1-82; Renumbered from 461-015-0120(5); AFS 37-1983(Temp), f. & ef. 7-15-83; AFS 1-1984, f. & ef. 1-9-84; AFS 45-1984, f. & ef. 10-1-84; AFS 6-1985, f. 1-28-85, ef. 2-1-85; AFS 52-1985, f. 9-3-85, ef. 10-1-85; AFS 46-1986(Temp), f. 6-25-86, ef. 7-1-86; AFS 61-1986, f. 8-12-86, ef. 9-1-86; AFS 33-1987(Temp), f. & ef. 7-22-87; AFS 46-1987, f. & ef. 10-1-87; AFS 62-1987(Temp), f. 12-30-87, ef. 1-1-88; AFS 12-1988, f. 2-10-88, cert. ef. 6-1-88; AFS 26-1988, f. 3-31-88, cert. ef. 4-1-88; AFS 47-1988(Temp), f. 7-13-88, cert. ef. 7-1-88; AFS 63-1988, f. 10-3-88, cert. ef. 12-1-88; AFS 7-1989(Temp), f. 2-17-89, cert. ef. 3-1-89; AFS 15-1989(Temp), f. 3-31-89, cert. ef. 4-1-89; AFS 36-1989(Temp), f. & cert. ef. 6-30-89; AFS 37-1989(Temp), f. 6-30-89, cert. ef. 7-1-89; AFS 45-1989, f. & cert. ef. 8-21-89; AFS 49-1989(Temp), f. 8-24-89, cert. ef. 9-1-89; AFS 72-1989, f. & cert. ef. 12-1-89, Renumbered from 461-015-0124; HR 18-1990(Temp), f. 6-29-90, cert. ef 7-1-90; HR 21-1990, f. & cert. ef. 7-9-90, Renumbered from 461-015-0540; HR 31-1990(Temp), f. & cert. ef. 9-11-90; HR 2-1991, f. & cert. ef. 1-4-91; HR 15-1991(Temp), f. & cert. ef. 4-8-91; HR 28-1991(Temp), f. & cert. ef. 7-1-91; HR 32-1991(Temp), f. & cert. ef. 7-29-91; HR 53-1991, f. & cert. ef. 11-18-91, Renumbered from 410-125-0780; OMAP 13-2003, f. 2-28-03, cert. ef. 3-1-03; OMAP 58-2003, f. 9-5-03, cert. ef. 10-1-03; OMAP 90-2003, f. 12-30-03 cert. ef. 1-1-04; OMAP 16-2004(Temp), f. & cert. ef. 3-15-04 thru 8-15-04; OMAP 27-2004, f. 4-22-04 cert. ef. 5-1-04; OMAP 73-2005, f. 12-29-05, cert. ef. 1-1-06; OMAP 17-2006, f. 6-12-06, cert. ef. 7-1-06; DMAP 39-2008, f. 12-11-08, cert. ef. 1-1-09
410-125-0190
Outpatient Rate Calculations -- Type A, Type B, and Critical Access Oregon Hospitals
(1) The Office of Rural Health designates Type A, Type B, and Critical Access Oregon Hospitals.
(2) Reimbursement to Type A, Type B, and Critical Access Oregon Hospitals for covered outpatient services is as follows:
(a) Interim reimbursement for outpatient covered services is the hospital specific cost to charge percentage from the last finalized cost settlement, except laboratory, diagnostic and therapeutic radiology, nuclear medicine, CT scans, MRI services, other imaging services, and maternity case management services which are based on the Division of Medical Assistance Programs (Division) fee schedule;
(b) Retrospective cost-based reimbursement is made for all Fee-For-Service covered outpatient services during the annual cost settlement period;
(c) Cost-based reimbursement is derived from the most recent audited Medicare Cost Report and adjusted to reflect Medicaid mix of services.
(3) Notwithstanding subsection (2) of this rule, this subsection becomes effective for dates of service on and after January 1, 2006, but will not be operative as the basis for payments until the Division determines all necessary federal approvals have been obtained. Reimbursement to Type A, Type B, and Critical Access Oregon Hospitals for covered outpatient services is as follows:
(a) Interim reimbursement for outpatient covered services is the hospital specific cost to charge percentage from the last finalized cost settlement, except clinical laboratory, which are based on the Division's fee schedule;
(b) Retrospective cost-based reimbursement is made for all fee-for-service covered outpatient services during the annual cost settlement period;
(c) Cost-based reimbursement is derived from the most recent audited Medicare Cost Report and adjusted to reflect Medicaid mix of services.
Stat. Auth.: ORS 413.042

Stats. Implemented: ORS 414.065

Hist.: AFS 14-1980, f. 3-27-80, ef. 4-1-80; AFS 57-1980, f. 8-29-80, ef. 9-1-80; AFS 18-1982(Temp), f. & ef. 3-1-82; AFS 60-1982, f. & ef. 7-1-82; Renumbered from 461-015-0120(5); AFS 37-1983(Temp), f. & ef. 7-15-83; AFS 1-1984, f. & ef. 1-9-84; AFS 45-1984, f. & ef. 10-1-84; AFS 6-1985, f. 1-28-85, ef. 2-1-85; AFS 52-1985, f. 9-3-85, ef. 10-1-85; AFS 46-1986(Temp), f. 6-25-86, ef. 7-1-86; AFS 61-1986, f. 8-12-86, ef. 9-1-86; AFS 33-1987(Temp), f. & ef. 7-22-87; AFS 46-1987, f. & ef. 10-1-87; AFS 62-1987(Temp), f. 12-30-87, ef. 1-1-88; AFS 12-1988, f. 2-10-88, cert. ef. 6-1-88; AFS 26-1988, f. 3-31-88, cert. ef. 4-1-88; AFS 47-1988(Temp), f. 7-13-88, cert. ef. 7-1-88; AFS 63-1988, f. 10-3-88, cert. ef. 12-1-88; AFS 7-1989(Temp), f. 2-17-89, cert. ef. 3-1-89; AFS 15-1989(Temp), f. 3-31-89, cert. ef. 4-1-89; AFS 36-1989(Temp), f. & cert. ef. 6-30-89; AFS 37-1989(Temp), f. 6-30-89, cert. ef. 7-1-89; AFS 45-1989, f. & cert. ef. 8-21-89; AFS 49-1989(Temp), f. 8-24-89, cert. ef. 9-1-89; AFS 72-1989, f. & cert. ef. 12-1-89, Renumbered from 461-015-0124; HR 18-1990(Temp), f. 6-29-90, cert. ef 7-1-90; HR 21-1990, f. & cert. ef. 7-9-90, Renumbered from 461-015-0540 & 461-015-0550; HR 31-1990(Temp), f. & cert. ef. 9-11-90; HR 2-1991, f. & cert. ef. 1-4-91; HR 15-1991(Temp), f. & cert. ef. 4-8-91; HR 28-1991(Temp), f. & cert. ef. 7-1-91; HR 32-1991(Temp), f. & cert. ef. 7-29-91; HR 53-1991, f. & cert. ef. 11-18-91, Renumbered from 410-125-0780 & 410-125-0800; HR 22-1993(Temp), f. & cert. ef. 9-1-93; HR 36-1993, f. & cert. ef. 12-1-93; OMAP 35-2001, f. 9-24-01, cert. ef. 10-1-01; OMAP 73-2005, f. 12-29-05, cert. ef. 1-1-06; OMAP 17-2006, f. 6-12-06, cert. ef. 7-1-06
410-125-0195
Outpatient Services In-State DRG Hospitals
(1) The National Drug Code (NDC)
must be included on all claim formats for physician administered drug codes required
by the Deficit Reduction Act of 2005.
(2) For discharges prior to
January 1, 2012, In-State Diagnostic Related Grouper (DRG) hospital outpatient and
emergency services are reimbursed under a cost-based methodology.
(a) Interim reimbursement:
(A) The interim reimbursement
percentage is developed using the cost-to-charge ratio methodology, derived from
the Medicare cost report, and applied to billed charges;
(B) The interim payment is the
estimated percentage needed to achieve 100 percent of hospital cost in aggregate;
and
(C) This interim percentage
is applied to all outpatient charges except for clinical laboratory services. Interim
reimbursement for clinical laboratory services is calculated according to rates
published in the Division of Medical Assistance Programs’ (Division) fee schedule.
(b) Settlement reimbursement:
(A) For Medicaid- and Children’s
Health Insurance Program-eligible (Titles XIX and XXI of the Social Security Act)
clients, an adjustment to 100 percent of outpatient costs is made during the cost
settlement process;
(B) For General Assistance (GA)
clients, outpatient hospital services are reimbursed at 50 percent of billed charges
or 59 percent of costs, whichever is less.
(3) Effective for discharges
on or after January 1, 2012:
(a) In-State DRG hospital outpatient
and emergency services will be reimbursed in accordance with Code of Federal Regulations
42 Part 419 Prospective Payment System for Hospital Outpatient Department Services,
using the Ambulatory Payment Classification (APC) Group methodology, and
(b) Payments will be based on
rates determined by State Actuarial Services to be equivalent to 100 percent of
Medicare outpatient payments for each DRG hospital.
Stat. Auth.: ORS 413.042

Stats. Implemented: ORS 414.065

Hist.: AFS 14-1980, f. 3-27-80,
ef. 4-1-80; AFS 57-1980, f. 8-29-80, ef. 9-1-80; AFS 18-1982(Temp), f. & ef.
3-1-82; AFS 60-1982, f. & ef. 7-1-82; Renumbered from 461-015-0120(5); AFS 37-1983(Temp),
f. & ef. 7-15-83; AFS 1-1984, f. & ef. 1-9-84; AFS 45-1984, f. & ef.
10-1-84; AFS 6-1985, f. 1-28-85, ef. 2-1-85; AFS 52-1985, f. 9-3-85, ef. 10-1-85;
AFS 46-1986(Temp), f. 6-25-86, ef. 7-1-86; AFS 61-1986, f. 8-12-86, ef. 9-1-86;
AFS 33-1987(Temp), f. & ef. 7-22-87; AFS 46-1987, f. & ef. 10-1-87; AFS
62-1987(Temp), f. 12-30-87, ef. 1-1-88; AFS 12-1988, f. 2-10-88, cert. ef. 6-1-88;
AFS 26-1988, f. 3-31-88, cert. ef. 4-1-88; AFS 47-1988(Temp), f. 7-13-88, cert.
ef. 7-1-88; AFS 63-1988, f. 10-3-88, cert. ef. 12-1-88; AFS 7-1989(Temp), f. 2-17-89,
cert. ef. 3-1-89; AFS 15-1989(Temp), f. 3-31-89, cert. ef. 4-1-89; AFS 36-1989(Temp),
f. & cert. ef. 6-30-89; AFS 37-1989(Temp), f. 6-30-89, cert. ef. 7-1-89; AFS
45-1989, f. & cert. ef. 8-21-89; AFS 49-1989(Temp), f. 8-24-89, cert. ef. 9-1-89;
AFS 72-1989, f. & cert. ef. 12-1-89, Renumbered from 461-015-0124; HR 18-1990(Temp),
f. 6-29-90, cert. ef 7-1-90; HR 21-1990, f. & cert. ef. 7-9-90, Renumbered from
461-015-0540 & 461-015-0550; HR 31-1990(Temp), f. & cert. ef. 9-11-90; HR
2-1991, f. & cert. ef. 1-4-91; HR 15-1991(Temp), f. & cert. ef. 4-8-91;
HR 28-1991(Temp), f. & cert. ef. 7-1-91; HR 32-1991(Temp), f. & cert. ef.
7-29-91; HR 53-1991, f. & cert. ef. 11-18-91, Renumbered from 410-125-0780 &
410-125-0800; HR 22-1993(Temp), f. & cert. ef. 9-1-93; HR 36-1993, f. &
cert. ef. 12-1-93; OMAP 34-1999, f. & cert. ef. 10-1-99; OMAP 13-2003, f. 2-28-03,
cert. ef. 3-1-03; OMAP 16-2003(Temp), f. & cert. ef. 3-10-03 thru 8-1-03; OMAP
37-2003, f. & cert. ef. 5-1-03; OMAP 90-2003, f. 12-30-03 cert. ef. 1-1-04;
OMAP 78-2004(Temp), f. & cert. ef. 10-1-04 thru 3-15-05; Administrative correction,
3-18-05; OMAP 21-2005, f. 3-21-05, cert. ef. 4-1-05; OMAP 73-2005, f. 12-29-05,
cert. ef. 1-1-06; OMAP 17-2006, f. 6-12-06, cert. ef. 7-1-06; OMAP 43-2006, f. 12-15-06,
cert. ef. 1-1-07; DMAP 39-2008, f. 12-11-08, cert. ef.
1-1-09; DMAP 10-2009(Temp), f. 4-29-09, cert. ef. 5-1-09
thru 10-28-09; DMAP 31-2009, f. 9-22-09, cert. ef. 10-1-09; DMAP 48-2011(Temp),
f. 12-23-11, cert. ef. 1-1-12 thru 6-25-12; DMAP 32-2012, f. 6-29-12, cert. ef.
7-1-12
410-125-0200
Time Limitation for Submission of Claims
Division of Medical Assistance Programs (Division) will accept a claim up to 12 months after the date of service. The date of discharge is the date of service for an inpatient hospital claim.
Stat. Auth.: ORS 413.042

Stats. Implemented: ORS 414.065

Hist.: AFS 49-1989(Temp), f. 8-24-89, cert. ef. 9-1-89; AFS 72-1989, f. & cert. ef. 12-1-89; HR 21-1990, f. & cert. ef. 7-9-90, Renumbered from 461-015-0250; HR 31-1990(Temp), f. & cert. ef. 9-11-90; HR 2-1991, f. & cert. ef. 1-4-91; HR 42-1991, f. & cert. ef. 10-1-91
410-125-0201
Independent ESRD Facilities
(1) Independent End Stage Renal Dialysis (ESRD) Facilities:
(a) ESRD Facilities are reimbursed for Continuous Ambulatory Peritoneal Dialysis.
(b) (CAPD), Continuous Cycling Peritoneal Dialysis (CCPD), and Hemodialysis:
(A) Composite at 80% of the Medicare allowed amount, except for Epoetin.
(B) Epoetin is reimbursed at 100% of the Medicare maximum allowed amount.
(2) Other dialysis related charges which are allowed by Medicare, are reimbursed at 80% of the Medicare maximum allowed amount. Allowable clinical laboratory charges are reimbursed according to the Division fee schedule. Billed charges may not exceed the Medicare maximum allowable amount.
(3) The Division follows Medicare's criteria for coverage of Epoetin, Intradialytic Parenteral Nutrition services, and the frequency schedule for laboratory tests for ESRD services. When laboratory tests are performed at a frequency greater than specified by Medicare, the additional tests must be billed separately, and are covered by the Division only if the tests are medically justified by accompanying documentation. A diagnosis of ESRD alone is not sufficient medical evidence to warrant coverage of the additional tests.
Stat. Auth.: ORS 413.042

Stats. Implemented: ORS 414.065

Hist.: AFS 14-1980, f. 3-27-80, ef. 4-1-80; AFS 57-1980, f. 8-29-80, ef. 9-1-80; AFS 18-1982(Temp), f. & ef. 3-1-82; AFS 60-1982, f. & ef. 7-1-82; Renumbered from 461-015-0120(5); AFS 37-1983(Temp), f. & ef. 7-15-83; AFS 1-1984, f. & ef. 1-9-84; AFS 45-1984, f. & ef. 10-1-84; AFS 6-1985, f. 1-28-85, ef. 2-1-85; AFS 52-1985, f. 9-3-85, ef. 10-1-85; AFS 46-1986(Temp), f. 6-25-86, ef. 7-1-86; AFS 61-1986, f. 8-12-86, ef. 9-1-86; AFS 33-1987(Temp), f. & ef. 7-22-87; AFS 46-1987, f. & ef. 10-1-87; AFS 62-1987(Temp), f. 12-30-87, ef. 1-1-88; AFS 12-1988, f. 2-10-88, cert. ef. 6-1-88; AFS 26-1988, f. 3-31-88, cert. ef. 4-1-88; AFS 47-1988(Temp), f. 7-13-88, cert. ef. 7-1-88; AFS 63-1988, f. 10-3-88, cert. ef. 12-1-88; AFS 7-1989(Temp), f. 2-17-89, cert. ef. 3-1-89; AFS 15-1989(Temp), f. 3-31-89, cert. ef. 4-1-89; AFS 36-1989(Temp), f. & cert. ef. 6-30-89; AFS 37-1989(Temp), f. 6-30-89, cert. ef. 7-1-89; AFS 45-1989, f. & cert. ef. 8-21-89; AFS 49-1989(Temp), f. 8-24-89, cert. ef. 9-1-89; AFS 72-1989, f. & cert. ef. 12-1-89, Renumbered from 461-015-0124; HR 9-1990(Temp), f. 3-30-90, cert. ef. 4-1-90; HR 21-1990, f. & cert. ef. 7-9-90, Renumbered from 461-015-0560; HR 31-1990(Temp), f. & cert. ef. 9-11-90; HR 2-1991, f. & cert. ef. 1-4-91; HR 28-1991(Temp), f. & cert. ef. 7-1-91; HR 53-1991, f. & cert. ef. 11-18-91, Renumbered from 410-125-0820; OMAP 34-1999, f. & cert. ef. 10-1-99; OMAP 73-2005, f. 12-29-05, cert. ef. 1-1-06
410-125-0210
Third Party Resources and Reimbursement
(1) The Division of Medical Assistance Programs (Division) establishes maximum allowable reimbursements for all services. When clients have other third party payers, the payment made by that payer is deducted from the Division maximum allowable payment.
(2) The Division will not make any additional reimbursement when a third party pays an amount equal to or greater than the Division reimbursement. The Division will not make any additional reimbursement when a third party pays 100 percent of the billed charges, except when Medicare Part A is the primary payer.
(3) When Medicare is Primary:
(a) The Division calculates the reimbursement for these claims in the same manner as described in the Inpatient and Outpatient Rates Calculations Sections above;
(b) Payment is the Division allowable payment, less the Medicare payment, up to the amount of the deductible and/or coinsurance due. For clients who are Qualified Medicare Beneficiaries the Division does not make any reimbursement for a service that is not covered by Medicare. For clients who are Qualified Medicare/Medicaid Beneficiaries the Division payment is the Division allowable, less the Part A payment up to the amount of the deductible due for services by either Medicare or Medicaid.
(4) When Medicare is Secondary:
(a) An individual admitted to a hospital may have Medicare Part B, but not Part A. The Division calculates the reimbursement for these claims in the same manner as described in the Inpatient Rates Calculations Section above. Payment is the Division allowable payment, less the Medicare Part B payment;
(b) An individual receiving services in the outpatient setting may have most services covered by Medicare Part B. The Division payment is the Division allowable payment, less the Part B payment, up to the amount of the coinsurance and deductible due. For services provided in the outpatient setting which are not covered by Medicare, (for example, Take Home Drugs), the Division payment is the Division allowable payment as calculated in the Outpatient Rates Calculation Section above;
(c) Most Medicare-Medicaid clients have Medicare Part A, Part B, and full Medicaid coverage. The Division refers to these clients as Qualified Medicare-Medicaid Beneficiaries (QMM). However, a few individuals have Medicare coverage and only limited additional coverage through Medicaid. The Division refers to these clients as Qualified Medicare Beneficiaries (QMB). For QMB clients, the Division does not make reimbursement for a service that is a not covered service for Medicare.
(d) Clients who are Qualified Medicare-Medicaid Beneficiaries will have coverage for services that are not covered by Medicare if those services are covered by the Division.
(5) For clients with Physician Care Organization (PCO) or Prepaid Health Plan (PHP) Coverage, the Division payment is limited to those services that are not the responsibility of the PCO or PHP. Payment is made at the Division rates.
(6) Other Insurance:
(a) The Division pays the maximum allowable payment as described in the Inpatient and Outpatient Rates Calculations, less any third party payments;
(b) The Division will not make additional reimbursements when a third party payor (other than Medicare) pays an amount equal to or greater than the Division reimbursement, or 100 percent of billed charges.
(7) Medically Needy with Spend-Down. Reimbursement is the Division maximum allowable payment for covered services less the amount of the spend-down due.
Stat. Auth.: ORS 413.042

Stats. Implemented: ORS 414.065

Hist.: AFS 14-1980, f. 3-27-80, ef. 4-1-80; AFS 57-1980, f. 8-29-80, ef. 9-1-80; AFS 60-1982, f. & ef. 7-1-82; AFS 37-1983(Temp), f. & ef. 7-15-83; AFS 1-1984, f. & ef. 1-9-84; AFS 46-1987, f. & ef. 10-1-87; AFS 7-1989(Temp), f. 2-17-89, cert. ef. 3-1-89; AFS 36-1989(Temp), f. & cert. ef. 6-30-89; AFS 37-1989(Temp), f. 6-30-89, cert. ef. 7-1-89; AFS 45-1989, f. & cert. ef. 8-21-89; AFS 72-1989, f. & cert. ef. 12-1-89, Renumbered from 461-015-0056; HR 18-1990(Temp), f. 6-29-90, cert. ef. 7-1-90; HR 21-1990, f. & cert. ef. 7-9-90, Renumbered from 461-015-0640; HR 31-1990(Temp), f. & cert. ef. 9-11-90; HR 2-1991, f. & cert. ef. 1-4-91; HR 28-1991(Temp), f. & cert. ef. 7-1-91; HR 32-1991(Temp), f. & cert. ef. 7-29-91; HR 53-1991, f. & cert. ef. 11-18-91, Renumbered from 410-125-1000; OMAP 73-2005, f. 12-29-05, cert. ef. 1-1-06; DMAP 34-2008, f. 11-26-08, cert. ef. 12-1-08
410-125-0220
Services Billed on the Electronic 837I or on the Paper UB-04 and Other Claim Forms
(1) All inpatient and outpatient
services provided by the hospital or hospital employees, unless otherwise specified
below, are billed on the electronic 837I (837 Institutional) or on the paper CMS
1450 (UB-04) claim form.
(2) Professional staff and other
providers: Services provided by other providers or professional staff with whom
the hospital has a contract or agreement regarding provision of services and whom
the hospital reimburses a salary or a fee are billed on the electronic 837I or paper
CMS 1450 (UB-04) along with other inpatient or outpatient charges if such costs
are reported on the hospital's Medicare Cost Report as a hospital cost.
(3) Residents and medical students:
Professional services provided by residents or medical students serving in the hospital
as residents or students at the time services are provided are reimbursed by the
Division of Medical Assistance Programs (Division) through graduate medical education,
for the hospitals that qualify (See OAR 410-125-0141) for payments and may not be
billed on the electronic 837I or paper CMS 1450 (UB-04).
(4) Diagnostic and similar services
provided by another provider or facility outside the hospital: When diagnostic or
short-term services are provided to an inpatient by another provider or facility
because the admitting hospital does not have the equipment or facilities to provide
all services required and the patient is returned within 24 hours to the admitting
hospital, the admitting hospital should add the following charges to the inpatient
electronic 837I or paper CMS 1450 (UB-04) claim:
(a) Charges from the other provider
or hospital under the appropriate Revenue Code. The admitting hospital is responsible
for reimbursing the other provider or hospital. The Division will not reimburse
the other provider or hospital; and
(b) Charges for transportation
to the other facility or provider. These must be billed under Revenue Code 542.
No prior authorization of the transport is required. The hospital will arrange for
the transport and pay the transportation provider for the transport. The Division
will not reimburse the transportation provider. This is the only instance in which
transportation charges can be billed on the electronic 837I or paper CMS 1450 (UB-04).
(5) Orthotics, prosthetics,
durable medical equipment and implants:
(a) When a provider of orthotic
or prosthetic devices provides services or materials to an inpatient through an
agreement or arrangement with the hospital, the cost of those services will be billed
by the hospital on the electronic 837I or the paper CMS 1450 (UB-04), along with
all other inpatient services. The hospital is responsible for reimbursing the provider.
The Division will not reimburse the provider;
(b) Wheelchairs provided to
the client for the client's use after discharge from the hospital may be billed
separately by the durable medical equipment supplier or by the hospital if the hospital
is the supplier.
(6) Pharmaceutical and home
parenteral/enteral services: All hospital pharmaceutical charges must be billed
on the electronic 837I or paper UB-04, except home parenteral and enteral services
and medications provided to patients who are in nursing homes:
(a) Home parenteral and enteral
services, including home hyperalimentation, Home IV antibiotics, home IV analgesics,
home enteral therapy, home IV chemotherapy, home IV hydrational fluids, and other
home IV drugs, require prior authorization and must be billed on the Pharmacy Invoice
Form in accordance with the rules in the Home Enteral/Parenteral Program rules (chapter
410, division 148);
(b) Medications provided to
clients who are in nursing homes must be billed on the Pharmacy Invoice Form in
accordance with the rules in the Pharmaceutical Services Program rules (chapter
410, division 121).
(7) Dental services: Dental
services provided by hospitals are billed on the electronic 837I or paper CMS 1450
(UB-04). For hospital dentistry requirements refer to the Dental Service Program
rules (chapter 410, division 123).
(8) End-stage renal dialysis
facilities: Hospitals providing end-stage renal dialysis and free-standing end-stage
renal dialysis facilities will bill on the electronic 837I or paper CMS 1450 (UB-04)
as described in these rules and instructions and will be reimbursed at the hospital's
interim rate.
(9) Maternity case management:
(a) Hospital clinics may serve
as maternity case managers for pregnant clients. The Medical-Surgical Program rules
(chapter 410, division 130) contain information on the scope of services, definition
of program terms, procedure codes, and provider qualifications. These services are
billed by hospitals on the electronic 837I or paper CMS 1450 (UB-04); and
(b) Providers must bill using
Revenue Code 569.
(10) Home health care services.
Hospitals that operate home health care services must obtain a separate provider
number and bill for these services in accordance with the Division’s Home
Health Care Services Program rules (chapter 410, division 127).
(11) Hospital operated air and
ground ambulance services. A hospital which operates an air or ground ambulance
service may apply to the Division for a provider number as an air or ground ambulance
provider. If costs for staff and equipment are reported on the Medicare Cost Report,
these costs must be identifiable. The Division will remove these costs from the
Medicare Cost Report in calculating the hospital's cost-to-charge ratio for outpatient
services. These services are billed on the electronic 837P (837 Professional) claim
form or the paper CMS-1500 in accordance with the rules and restrictions contained
in the Medical Transportation Program rules (chapter 410, division 136).
(12) Supervising physicians
providing services in a teaching setting:
(a) Services provided on an
inpatient or outpatient basis by physicians who are on the faculty of teaching hospitals
may be billed on the electronic 837I or paper CMS 1450 (UB-04) with other inpatient
or outpatient charges only when:
(A) The physician is serving
as an employee of the hospital, or receives reimbursement from the hospital for
provision of services, during the period of time when services are provided; and
(B) The hospital does not report
these services as a direct medical education cost on the Medicare and the Division’s
cost report.
(b) The services of supervising
faculty physicians are not to be billed to the Division on either the electronic
837P, the paper CMS-1500 or the electronic 837I or paper CMS 1450 (UB-04)if the
hospital elects to report the cost of these professional services as a direct medical
education cost on the Medicare and the Division’s cost report; and
(c) The services of supervising
faculty physicians are billed on the electronic 837P or the paper CMS-1500 if the
physician is serving in a private capacity during the period of time when services
are provided, i.e., the physician is receiving no reimbursement from the hospital for the period of time during which
services are provided. Refer to the Medical-Surgical Services rules (chapter 410,
division 130) or additional information on billing on the electronic 837P or the
paper CMS-1500.
[Publications: Publications referenced
are available from the agency.]
Stat. Auth.: ORS 413.042

Stats. Implemented: ORS 414.065

Hist.: AFS 14-1980, f. 3-27-80,
ef. 4-1-80; AFS 30-1982, f. 4-26-82 & AFS 51-1982, f. 5-28-82, ef. 5-1-82 for
providers located in the geographical areas covered by the AFS branch offices located
in North Salem, South Salem, Dallas, Woodburn, McMinnville, Lebanon, Albany and
Corvallis, ef. 6-30-82 for remaining AFS branch offices; AFS 37-1983(Temp), f. &
ef. 7-15-83; AFS 1-1984, f. & ef. 1-9-84; AFS 45-1984, f. & ef. 10-1-84;
AFS 48-1984(Temp), f. 11-30-84, ef. 12-1-84; AFS 29-1985, f. 5-22-85, ef. 5-29-85;
AFS 44-1985, f. & ef. 7-1-85; AFS 52-1985, f. 9-3-85, ef. 10-1-85; AFS 38-1986,
f. 4-29-86, ef. 6-1-86; AFS 46-1987, f. & ef. 10-1-87; AFS 49-1989(Temp), f.
8-24-89, cert. ef. 9-1-89; AFS 72-1989, f. & cert. ef. 12-1-89, Renumbered from
461-015-0055, 461-015-0130, 461-015-0135; HR 21-1990, f. & cert. ef. 7-9-90,
Renumbered from 461-015-0260, 461-015-0290, 461-015-0300, 461-015-0310, 461-015-0320,
461-015-0420, 461-015-0430; HR 42-1991, f. & cert. ef. 10-1-91, Renumbered from
410-125-0280, 410-125-0300, 410-125-0320, 410-125-0340, 410-125-0540 & 410-125-0560;
HR 39-1992, f. 12-31-92, cert. ef. 1-1-93; HR 36-1993, f. & cert. ef. 12-1-93;
HR 5-1994, f. & cert. ef. 2-1-94; HR 4-1995, f. & cert. ef. 3-1-95; OMAP
28-2000, f. 9-29-00, cert. ef. 10-1-00; OMAP 70-2004, f. 9-15-04, cert. ef. 10-1-04;
OMAP 13-2005, f. 3-11-05, cert. ef. 4-1-05; OMAP 17-2006, f. 6-12-06, cert. ef.
7-1-06; DMAP 19-2008, f. 6-13-08, cert. ef. 7-1-08; DMAP 34-2008, f. 11-26-08, cert.
ef. 12-1-08; DMAP 37-2011, f. 12-13-11, cert. ef. 1-1-12
410-125-0221
Payment in Full
The payment made by Medicaid towards any inpatient or outpatient services, including cost outlier, disproportionate share, and capital payments, constitutes payment in full for the service.
Stat. Auth.: ORS 413.042

Stats. Implemented: ORS 414.065

Hist.: AFS 14-1980, f. 3-27-80, ef. 4-1-80; AFS 57-1980, f. 8-29-80, ef. 9-1-80; AFS 18-1982(Temp), f. & ef. 3-1-82; AFS 60-1982, f. & ef. 7-1-82; Renumbered from 461-015-0120(5); AFS 37-1983(Temp), f. & ef. 7-15-83; AFS 1-1984, f. & ef. 1-9-84; AFS 45-1984, f. & ef. 10-1-84; AFS 6-1985, f. 1-28-85, ef. 2-1-85; AFS 52-1985, f. 9-3-85, ef. 10-1-85; AFS 46-1986(Temp), f. 6-25-86, ef. 7-1-86; AFS 61-1986, f. 8-12-86, ef. 9-1-86; AFS 33-1987(Temp), f. & ef. 7-22-87; AFS 46-1987, f. & ef. 10-1-87; AFS 62-1987(Temp), f. 12-30-87, ef. 1-1-88; AFS 12-1988, f. 2-10-88, cert. ef. 6-1-88; AFS 26-1988, f. 3-31-88, cert. ef. 4-1-88; AFS 47-1988(Temp), f. 7-13-88, cert. ef. 7-1-88; AFS 63-1988, f. 10-3-88, cert. ef. 12-1-88; AFS 7-1989(Temp), f. 2-17-89, cert. ef. 3-1-89; AFS 15-1989 (Temp), f. 3-31-89, cert. ef. 4-1-89; AFS 36-1989(Temp), f. & cert. ef. 6-30-89; AFS 37-1989(Temp), f. 6-30-89, cert. ef. 7-1-89; AFS 45-1989, f. & cert. ef. 8-21-89; AFS 49-1989 (Temp), f. 8-24-89, cert. ef. 9-1-89; AFS 72-1989, f. & cert. ef. 12-1-89, Renumbered from 461-015-0006, 461-015-0020 & 461-015-0124; HR 18-1990(Temp), f. 6-29-90, cert. ef. 7-1-90; HR 21-1990, f. & cert. ef. 7-9-90, Renumbered from 461-015-0570; HR 31-1990(Temp), f. & cert. ef. 9-11-90; HR 36-1990 (Temp), f. 10-29-90, cert. ef. 11-1-90; HR 3-1991, f. & cert. ef. 1-4-91; HR 28-1991(Temp), f. & cert. ef. 7-1-91; HR 32-1991(Temp), f. & cert. ef. 7-29-91; HR 53-1991, f. & cert. ef. 11-18-91, Renumbered from 410-125-0840; OMAP 17-2006, f. 6-12-06, cert. ef. 7-1-06
410-125-0360
Definitions and Billing Requirements
(1) Total days on an inpatient claim must equal the number of accommodation days. Do not count the day of discharge when calculating the number of accommodation days.
(2) Inpatient services are reimbursed based on the admission date and discharge diagnosis.
(3) Inpatient services are services to patients who typically are admitted to the hospital before midnight and listed on the following day's census, with the following exceptions:
(a) A patient admitted and transferred to another acute care hospital on the same day is considered an inpatient;
(b) A patient who expires on the day of admission is an inpatient; and
(c) Births.
(4) Outpatient services:
(a) Outpatient services are services to patients who are treated and released the same day;
(b) Outpatient services also include services provided prior to midnight and continuing into the next day if the patient was admitted for ambulatory surgery, admitted to a birthing center, a treatment or observation room, or a short term stay bed;
(c) Outpatient observation services are services provided by a hospital, including the use of a bed and periodic monitoring by hospital nursing or other staff for the purpose of evaluation of a patient's medical condition. A maximum of 48 hours of outpatient observation shall be reimbursed. An outpatient observation stay that exceeds 48 hours must be billed as inpatient; and
(d) Outpatient observation services do not include the following:
(A) Services provided for the convenience of the patient, patient's family or physician but which are not medically necessary;
(B) Standard recovery period; and
(C) Routine preparation services and recovery for diagnostic services provided in a hospital outpatient department.
(5) Outpatient and inpatient services provided on the same day: If a patient receives services in the emergency room or in any outpatient setting and is admitted to an acute care bed in the same hospital on the same day, combine the emergency room and other outpatient charges related to that admission with the inpatient charges. Bill on a single UB-04 for both inpatient and outpatient services provided under these circumstances:
(a) If on the day of discharge, the client uses outpatient services at the same hospital, these must be billed on the UB-04 along with other inpatient charges, regardless of the type of service provided or the diagnosis of the client. Prescription medications provided to a patient being discharged from the hospital may be billed separately as outpatient Take Home Drugs if the patient receives more than a three-day supply.
(b) Inpatient and outpatient services provided to a client on the same day by two different hospitals shall be reimbursed separately. Each hospital shall bill for the services provided by that hospital.
(6) Outpatient procedures which result in an inpatient admission: If, during the course of an outpatient procedure, an emergency develops requiring an inpatient stay, place a "1" in the Type of Admission field. The principal diagnosis should be the condition or complication that caused the admission. Bill charges for the outpatient and inpatient services together.
[ED. NOTE: Forms referenced are available from the agency.]
Stat. Auth.: ORS 413.042

Stats. Implemented: ORS 414.065

Hist.: AFS 14-1980, f. 3-27-80, ef. 4-1-80; AFS 30-1982, f. 4-26-82 & AFS 51-1982, f. 5-28-82, ef. 5-1-82 for providers located in the geographical areas covered by the AFS branch offices located in North Salem, South Salem, Dallas, Woodburn, McMinnville, Lebanon, Albany and Corvallis, ef. 6-30-82 for remaining AFS branch offices; AFS 37-1983 (Temp), f. & ef. 7-15-83; AFS 1-1984, f. & ef. 1-9-84; AFS 45-1984, f. & ef. 10-1-84; AFS 48-1984(Temp), f. 11-30-84, ef. 12-1-84; AFS 29-1985, f. 5-22-85, ef. 5-29-85; AFS 52-1985, f. 9-3-85, ef. 10-1-85; AFS 38-1986, f. 4-29-86, ef. 6-1-86; AFS 46-1987, f. & ef. 10-1-87; AFS 49-1989(Temp), f. 8-24-89, cert. ef. 9-1-89; AFS 72-1989, f. & cert. ef. 12-1-89, Renumbered from 461-015-0055; HR 21-1990, f. & cert. ef. 7-9-90, Renumbered from 461-015-0330, 461-015-0340 & 461-015-0380; HR 31-1990(Temp), f. & cert. ef. 9-11-90; HR 2-1991, f. & cert. ef. 1-4-91; HR 42-1991, f. & cert. ef. 10-1-91, Renumbered from 410-125-0380 & 410-125-0460; HR 22-1993 (Temp), f. & cert. ef. 9-1-93; HR 36-1993, f. & cert. ef. 12-1-93; HR 4-1995, f. & cert. ef. 3-1-95; OMAP 34-1999, f. & cert. ef. 10-1-99; OMAP 70-2004, f. 9-15-04, cert. ef. 10-1-04; DMAP 19-2008, f. 6-13-08, cert. ef. 7-1-08; DMAP 34-2008, f. 11-26-08, cert. ef. 12-1-08; DMAP 32-2010, f. 12-15-10, cert. ef. 1-1-11
410-125-0400
Discharge
(1) A discharge from a hospital is the formal release of a patient to home, to another facility, such as an intermediate care facility or nursing home, to a home health care agency, or to another provider of health care services.
(2) For services beginning January 1, 1993, and later, the transfer of a patient from acute care to a distinct part physical rehabilitation unit (i.e., a unit exempt from the Medicare Prospective Payment System) within the same hospital will be considered a discharge. The admission to the rehabilitation unit is billed separately. All other transfers occurring within a hospital, including transfers to Medicare PPS-exempt psychiatric units, will not be considered discharges and all charges for services must be submitted on a single UB-04 billing for the admission.
(3) Transfer from a hospital occurs when an individual is formally released to another acute care hospital, to a skilled nursing facility, or an intermediate care facility. When a physician sends a patient directly to another hospital for further inpatient care, the discharge should be billed as a transfer, regardless of the mode of transportation.
(4) When the Division receives claims from two hospitals for the same patient, and the date of discharge from one hospital is the same as the date of admission to the other, the Division will assume that a transfer has occurred. The Division will change the discharge status code on the first claim to 02 (Transferred to Another Acute Care Facility), automatically generating an adjustment if the claim has already been adjudicated, unless discharge status on the claim is already 02 (Transfer) or 07 (Discharge AMA). If it is believed that the Division made an error in assigning Discharge Status code 02 to a claim, the hospital may submit an Adjustment Request along with supporting documentation from the medical record.
(5) A transfer between units within a hospital is not a transfer for billing purposes, except in the case of transfers to distinct part physical rehabilitation units. Note that transfers in the other direction, from rehabilitative care to acute care, are not considered discharges from the rehabilitation unit unless the stay in the acute setting exceeds seven days. Stays of seven days or less in the acute care setting should not be billed separately.
(6) Some transfers, including transfers to distinct part rehabilitation units, require prior authorization.
Stat. Auth.: ORS 413.042

Stats. Implemented: ORS 414.065

Hist.: AFS 49-1989(Temp), f. 8-24-89, cert. ef. 9-1-89; AFS 72-1989, f. & cert. ef. 12-1-89; HR 42-1991, f. & cert. ef. 10-1-91; HR 39-1992, f. 12-31-92, cert. ef. 1-1-93; HR 36-1993, f. & cert. ef. 12-1-93; DMAP 19-2008, f. 6-13-08, cert. ef. 7-1-08; DMAP 34-2008, f. 11-26-08, cert. ef. 12-1-08
410-125-0401
Definitions: Emergent, Urgent, and Elective Admissions
(1) EMERGENT ADMISSION -- an admission which occurs after the sudden onset of 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:
(a) Placing their health or the health of an unborn child in serious jeopardy;
(b) Serious impairment of bodily functions; or
(c) Serious dysfunction of any bodily organ or part. "Immediate medical attention" is defined as medical attention which could not be delayed by 24 hours.
(2) URGENT ADMISSION -- an admission which occurs for evaluation or treatment of a medical disorder that could become an emergency if not diagnosed or treated in a timely manner; that delay is likely to result in prolonged temporary impairment; and that unwarranted prolongation of treatment increases the risk of treatment by the need for more complex or hazardous treatment or the risk of development of chronic illness or inordinate physical or psychological suffering by the patient. An urgent admission is defined as one which could not have been delayed for a period of 72 hours.
(3) ELECTIVE ADMISSION -- an admission which is or could have been scheduled in advance and for which a delay of 72 hours or more in the delivery of medical treatment or diagnosis would not have substantially affected the health of the patient. See Prior Authorization section of the Hospital Services guide for requirements.
[Publications: Publications referenced are available from the agency.]
Stat. Auth.: ORS 413.042

Stats. Implemented: ORS 414.065

Hist.: HR 42-1991, f. & cert. ef. 10-1-91; HR 39-1992, f. 12-31-92, cert. ef. 1-1-93; OMAP 34-1999, f. & cert. ef. 10-1-99; OMAP 12-2001, f. 3-30-01, cert. ef. 4-1-01
410-125-0410
Readmission
(1) A patient whose readmission
for surgery or follow-up care is planned at the time of discharge must be placed
on leave of absence status, and both admissions must be combined into a single billing.
The Division of Medical Assistance Programs (Division) will make one payment for
the combined service. Examples of planned readmissions include, but are not limited
to, situations where surgery could not be scheduled immediately, a specific surgical
team was not available, bilateral surgery was planned, or when further treatment
is indicated following diagnostic tests but cannot begin immediately.
(2) A patient whose discharge and readmission to the hospital
is within thirty (30) days for the same or related diagnosis must be combined into
a single billing. Division shall make one payment for the amount appropriate for
the combined service.
(3) This rule does not apply to:
(a) Readmissions for an unrelated
diagnosis;
(b) Readmissions occurring more
than 30 days after the date of discharge;
(c) Readmissions for a diagnosis
that may require episodic (a series) acute care hospitalizations to stabilize the
medical condition such as, but not limited to: diabetes, asthma, or chronic obstructive
pulmonary disease. See billing instructions in the Hospital Supplemental guide
on the Division’s website for additional information.
Stat. Auth.: ORS 413.042

Stats. Implemented: ORS 414.065

Hist.: HR 36-1993, f. &
cert. ef. 12-1-93; ; OMAP 11-2004, f. 3-11-04, cert. ef. 4-1-04; OMAP 13-2005, f.
3-11-05, cert. ef. 4-1-05; DMAP 32-2010, f. 12-15-10, cert. ef. 1-1-11; DMAP 32-2012,
f. 6-29-12, cert. ef. 7-1-12
410-125-0450
Provider Preventable Conditions
(1) Health Care-Acquired Conditions
(HCAC):
(a) Formally known as Medicare’s
list of “hospital acquired conditions” (HAC) that apply to inpatient
hospital settings with dates of admission on or after January 1, 2011 except those
hospitals exempt from the reporting requirements.
(b) For inpatient hospital
admissions on or after July 1, 2012, all in-state, contiguous and non-contiguous
hospitals must report health care-acquired conditions.
(A) A HCAC is a condition
that is reasonably preventable and was not present or identified at the hospital
admission.
(B) A “present on admission”
(POA) indicator is a status code the hospital uses on an inpatient claim that indicates
if a condition was present at the time the order for inpatient admission occurs.
A POA indicator can also identify a condition that developed during an outpatient
encounter. This includes, but is not limited to the emergency department, observation,
and outpatient surgery.
(C) The Division of Medical
Assistance Program (Division) shall use the most recent list of conditions identified
as non-payable by Medicare. The Division may revise through addition or deletion
the selected conditions at any time during the fiscal year.
(D) Diagnosis-related groups
(DRG) and percentage paid hospitals must submit a POA indicator for the principal
diagnosis and every secondary diagnosis code. A valid POA indicator must be included
all inpatient hospital claims. Claims without a valid POA indicator shall be denied.
(E) Critical Access Hospitals
(CAH) must implement the POA reporting requirements by September 1, 2013.
(F) For a complete list of
HCACs and billing instructions please see the hospital supplemental guide.
(2) Other Provider-Preventable
Conditions (OPPC):
(a) Applies to any health
care setting, including but not limited to inpatient and outpatient hospital settings.
(b) Effective July 1, 2012
the Agency shall no longer cover the following conditions identified by the National
Coverage Determinations (NCD):
(A) Wrong surgical or other
invasive procedure performed on a patient;
(B) Surgical or other invasive
procedure performed on the wrong body part;
(C) Surgical or other invasive
procedure performed on the wrong patient.
(c) To protect the access
to care the Division requires:
(A) No reduction in payment
for a Provider Preventable Conditions (PPC) will be imposed on a provider when an
identified PPC for a client existed prior to the initiation of treatment for that
client by that provider.
(B) Reductions in provider
payment may be limited to the extent that the identified PPC would otherwise result
in an increase in payment; and the Division reasonably isolate for nonpayment the
portion of the payment directly related to treatment for, and related to the PPC.
(3) For clients with both
Medicare and Medicaid (duals) the agency may not act as secondary payer for Medicare
non-payment of HCAC.
Stat. Auth.: ORS 413.042
Stats. Implemented: ORS 414.065
Hist.: DMAP 32-2010, f. 12-15-10,
cert. ef. 1-1-11; DMAP 49-2011(Temp), f. 12-23-11, cert. ef. 1-1-12 thru 6-25-12;
DMAP 32-2012, f. 6-29-12, cert. ef. 7-1-12; DMAP 47-2013, f. 8-29-13, cert. ef.
9-3-13
410-125-0550
X-Ray or EKG Procedures Furnished in Emergency Room
The Division pays for only one interpretation of an x-ray or EKG procedure furnished to an emergency room patient, and that is for the interpretation and report that directly contributed to the diagnosis and treatment of the patient. A second interpretation of an x-ray or EKG is considered to be for quality control purposes only, and is not reimbursable. Payment will be made for a second interpretation only under unusual circumstances, such as questionable finding for which the physician performing the initial interpretation believes another physician's expertise is needed.
Stat. Auth.: ORS 413.042

Stats. Implemented : ORS 414.065

Hist.: OMAP 28-2000, 9-29-00, cert. ef. 10-1-00
410-125-0600
Non-Contiguous Out-of-State Hospital Services
(1) Non-contiguous out-of-state hospitals are those hospitals located more than 75 miles from the Oregon border.
(2) The hospital must be enrolled as a provider with Oregon Medical Assistance Programs to receive payment. Contact the Division for information on enrollment.
(3) Billings are sent to the Division.
(4) When the service provided is emergent or urgent, no prior authorization is required. The claim should be sent to the Division along with documentation supporting the emergent or urgent requirement for treatment.
(5) In a non-emergency situation, prior authorization is required for all services. Contact the Division.
(6) Claims must be billed on the electronic 837I or on a paper CMS 1450 (UB-04), unless other arrangements are made for billing through the Division.
Stat. Auth.: ORS 413.042

Stats. Implemented: ORS 414.065

Hist.: AFS 49-1989(Temp), f. 8-24-89, cert. ef. 9-1-89; AFS 72-1989, f. & cert. ef. 12-1-89; HR 21-1990, f. & cert. ef. 7-9-90, Renumbered from 461-015-0450; HR 31-1990(Temp), f. & cert. ef. 9-11-90; HR 2-1991, f. & cert. ef. 1-4-91; HR 42-1991, f. & cert. ef. 10-1-91; HR 36-1993, f. & cert. ef. 12-1-93; OMAP 17-2006, f. 6-12-06, cert. ef. 7-1-06; DMAP 19-2008, f. 6-13-08, cert. ef. 7-1-08; DMAP 34-2008, f. 11-26-08, cert. ef. 12-1-08
410-125-0620
Special Reports and Exams and Medical Records
Refer to the Division Administrative Exams and Reports Billing rules (chapter 410 division 150) for information and instructions on billing for administrative exams and reports.
Stat. Auth.: ORS 413.042

Stats. Implemented: ORS 414.065

Hist.: AFS 14-1980, f. 3-27-80, ef. 4-1-80; AFS 60-1982, f. & ef. 7-1-82; AFS 46-1987, f. & ef. 10-1-87; AFS 49-1989(Temp), f. 8-24-89, cert. ef. 9-1-89; AFS 72-1989, f. & cert. ef. 12-1-89, Renumbered from 461-015-0040; HR 21-1990, f. & cert. ef. 7-9-90, Renumbered from 461-015-0460; HR 42-1991, f. & cert. ef. 10-1-91; HR 39-1992, f. 12-31-92, cert. ef. 1-1-93; HR 36-1993, f. & cert. ef. 12-1-93; HR 3-1997, f. 1-31-97, cert. ef. 2-1-97; OMAP 34-1999, f. & cert. ef. 10-1-99; OMAP 28-2000, f. 9-29-00, cert. ef. 10-1-00; OMAP 70-2004, f. 9-15-04, cert. ef. 10-1-04
410-125-0640
Third Party Payers -- Other Resources, Client Responsibility and Liability
(1) Medicare: Do not send claims to the Division of Medical Assistance Programs (Division) until they have been billed to and adjudicated by Medicare:
(a) Exception: Take home drugs and other services, which are not covered by Medicare, may be billed directly to the Division without billing Medicare first;
(b) See: billing instructions in the Hospital Services Supplemental Information on the Division website for additional information on billing Medicare claims.
(2) Other Insurance. With the exception of services described in the General Rules, bill all other insurance first before billing the Division. Report the payments made by the other insurers.
(3) Motor vehicle accident fund:
(a) Enter 01 (Auto Accident) in the Occurrence Code Block and give the date of the accident;
(b) For all other clients, bill all other resources before billing the Division. Do not bill the Motor Vehicle Accident Fund.
(4) Employment Related Injuries: Enter 04 (Employment Related Accident) in the Occurrence Code Block and give the date of the injury.
(5) Liability:
(a) Liability refers to insurance that provides payment based on legal liability for injuries or illness or damages to property. It includes, but is not limited to, automobile liability insurance, uninsured and underinsured motorist insurance, homeowners' liability insurance, malpractice insurance, product liability insurance and general casualty insurance. It also includes payments under state "wrongful death" statutes that provide payment for medical damages;
(b) The provider may bill the insurer for liability prior to billing the Division. The provider may not bill both the Division and the insurer;
(c) The provider may bill the Division after receiving a payment denial from the insurer; however, the Division billing must be within 12 months of date of service. Payment accepted from the Division is payment in full;
(d) The provider may bill the Division without billing the liability insurer. However, payment accepted from the Division is payment in full. The payment made by the Division may not later be returned in order to pursue payment from the liability insurer. When the provider bills the Division, the provider agrees not to place any lien against the client's liability settlement;
(e) The provider has 12 months from the date of service to bill the Division. No payment will be made by the Division under any circumstances once the one year limit has passed if no billing has been received within that time.
(6) Adoption Agreements. Adopting parents and/or an adoption agency may be considered a prior resource. In some instances, the Division makes reimbursement to hospitals and other providers for services provided to a mother whose baby is to be adopted. The Division may also make reimbursement for services provided to the infant. Some adoption agreements, however, stipulate that the adoptive parents will make payment for part or all of the medical costs for the mother and/or the child. In these instances, the adoptive parent(s) and/or agency are a third party resource and should be billed before billing the Division for this service.
(7) Veteran's Administration Benefits:
(a) Some clients have limited benefits through the Veterans' Administration. Hospitals must bill the Veterans' Administration for VA covered services before billing the Division;
(b) The Veterans' Administration requires notification within 72 hours of an emergency admission to a non-VA hospital.
(8) Trust Funds. Some individuals will have trust funds that will pay for medical expenses. Occasionally a special trust fund will be set up to pay for extraordinary medical expenses, such as a transplant. These, and other trusts which pay medical expenses, are considered a prior resource. Bill the trust fund prior to billing the Division for services that are covered by the trust fund.
(9) Billing the Client. A provider may bill the client or any financially responsible relative or representative of that individual only as allowed in OAR 410-120-1280.
(10) The hospital may not bill the client under the following circumstances:
(a) For services which are covered by the Division;
(b) For services for which the Division has made payment;
(c) For services billed to the Division for which no payment is made because third party reimbursement exceeds the Division maximum allowed amount;
(d) For any deductible, coinsurance or co-pay amount;
(e) For services for which the Division has denied payment to the hospital as a result of one of the following:
(A) The hospital failed to supply the correct information to the Division to allow processing of the claim in a timely manner as described in these rules and the General Rules;
(B) The hospital failed to obtain prior authorization as described in these rules;
(C) The service provided by the hospital was determined by or the Division not to be medically appropriate; or
(D) The service provided by the hospital was determined by the QIO not to be medically appropriate, necessary, or reasonable.
Stat. Auth.: ORS 413.042

Stats. Implemented: ORS 414.065

Hist.: AFS 14-1980, f. 3-27-80, ef. 4-1-80; AFS 60-1982, f. & ef. 7-1-82; AFS 37-1983(Temp), f. & ef. 7-15-83; AFS 1-1984, f. & ef. 1-9-84; AFS 46-1987, f. & ef. 10-1-87; AFS 49-1989(Temp), f. 8-24-89, cert. ef. 9-1-89; AFS 72-1989, f. & cert. ef. 12-1-89, Renumbered from 461-015-0080 & 461-015-0126; HR 21-1990, f. & cert. ef. 7-9-90, Renumbered from 461-015-0470 & 461-015-0480; HR 31-1990(Temp), f. & cert. ef. 9-11-90; HR 2-1991, f. & cert. ef. 1-4-91; HR 42-1991, f. & cert. ef. 10-1-91, Renumbered from 410-125-0660; HR 22-1992, f. 7-31-92, cert. ef. 8-1-92; HR 39-1992, f. 12-31-92, cert. ef. 1-1-93; HR 36-1993, f. & cert. ef. 12-1-93; HR 5-1994, f. & cert. ef. 2-1-94; OMAP 28-2000, f. 9-29-00, cert. ef. 10-1-00; OMAP 70-2004, f. 9-15-04, cert. ef. 10-1-04; DMAP 34-2008, f. 11-26-08, cert. ef. 12-1-08
410-125-0641
Medicare
(1) A Medicare/Medicaid claim can automatically be sent to the Division after adjudicated by Medicare. This saves the effort of a second submission, as well as ensuring a more accurate and speedier payment by the Division. Medicare will automatically transmit the correct Medicare payment, coinsurance, and deductible information to the Division.
(2) Hard copy billings sent to Medicare can also be automatically sent to the Division. Refer to the Hospital Services Supplemental Information for specific billing instructions.
Stat. Auth.: ORS 413.042

Stats. Implemented: ORS 414.065

Hist.: HR 42-1991, f. & cert. ef. 10-1-91; HR 36-1993, f. & cert. ef. 12-1-93; OMAP 34-1999, f. & cert. ef. 10-1-99; OMAP 70-2004, f. 9-15-04, cert. ef. 10-1-04
410-125-0720
Adjustment Requests
(1) Most overpayment and under-payments are resolved through the adjustment process. Only paid claims can be adjusted. If no payment was made, the claim must be submitted using a CMS 1450 (UB-04) for processing. All overpayments must be reported. Overpayments will be taken from future payments.
(2) Much of the information required on the Adjustment Request Form is printed on the paper Remittance Advice or the electronic 835. Documentation may be submitted to support the request. Attach a copy of the claim and paper Remittance Advice or the electronic 835 to the Adjustment Request (DMAP 1036). Adjustment requests must be submitted in writing to the Division.
(3) Complete adjustment instructions can be found in Hospital Services Supplemental Information.
[Publications: Publications referenced are available from the agency.]
Stat Auth.: ORS 413.042

Stats. Implemented: ORS 414.065

Hist.: AFS 49-1989(Temp), f. 8-24-89, cert. ef. 9-1-89; AFS 72-1989, f. & cert. ef. 12-1-89; HR 21 1990, f. & cert. ef. 7-9-90, Renumbered from 461-015-0510; HR 31-1990(Temp), f. & cert. ef. 9-11-90; HR 2-1991, f. & cert. ef 1-4-91; HR 42-1991, f. & cert. ef. 10-1-91; OMAP 70-2004, f. 9-15-04, cert. ef. 10-1-04; OMAP 17-2006, f. 6-12-06, cert. ef. 7-1-06; DMAP 19-2008, f. 6-13-08, cert. ef. 7-1-08; DMAP 34-2008, f. 11-26-08, cert. ef. 12-1-08
410-125-1020
Filing of Cost Statement
(1) The hospital must file an annual Calculation of Reasonable Cost (DMAP 42), covering the latest fiscal period of operation of the hospital with Division of Medical Assistance Programs (Division):
(a) A Calculation of Reasonable Cost statement is filed for less than an annual period only when necessitated by the hospital's termination of their agreement with the Division, a change in ownership, or a change in the hospital's fiscal period;
(b) The hospital must use the same fiscal period for the Division 42 as that used for its Medicare report. If it doesn't have an agreement with Medicare, the hospital must use the same fiscal period it uses for filing its federal tax return;
(c) The report must be filed for both inpatient and outpatient services, even if the service is paid under a prospective payment system or fee schedule (e.g., Diagnosis-Related Groups (DRG) payments, outpatient clinical laboratory, etc.);
(d) In the absence of an agreement with Medicare, the hospital must use the same fiscal period as that used for filing their Federal tax return.
(2) Twelve months after the hospital's fiscal year end, the Division will send the hospital a computer printout listing all transactions between the hospital and the Division during that auditing period. The Calculation of Reasonable Cost statement (DMAP 42) is due within 90 days of receipt by the hospital of the computer printout. Failure to file within 90 days may result in a 20 percent reduction in the payment rate:
(a) Hospitals without an agreement with Medicare may be subject to a field audit;
(b) Hospitals without an agreement with Medicare are required to submit a financial statement giving details of all assets, liabilities, income, and expenses, audited by a Certified Public Accountant.
(3) Improperly completed or incomplete Calculation of Reasonable Cost statements will be returned to the hospital for proper completion. The statement is not considered to be filed until it is received in a correct and complete form.
(4) If a hospital knowingly, or has reason to know, files a cost statement containing false information, such action constitutes cause for termination of its agreement with the Division. Hospitals filing false reports may also be referred to prosecution under applicable statutes.
(5) Each Calculation of Reasonable Cost statement submitted to the Division must be signed by the individual who normally signs the hospital's Medicare reports, federal income tax return, and other reports. If the hospital has someone, other than an employee prepare the cost statement, that individual will also sign the statement and indicate his or her status with the hospital.
(6) Notwithstanding subsection (1) of this rule, this subsection becomes effective for dates of service on and after January 1, 2006, but will not be operative as the basis for payments until the Division determines all necessary federal approvals have been obtained. The hospital must file with the Division, an annual Calculation of Reasonable Cost (DMAP 42), covering the latest fiscal period of operation of the hospital:
(a) A Calculation of Reasonable Cost statement is filed for less than an annual period only when necessitated by the hospital's termination of their agreement with the Division, a change in ownership, or a change in the hospital's fiscal period;
(b) The hospital must use the same fiscal period for the DMAP 42 as that used for its Medicare report. If it doesn't have an agreement with Medicare, the hospital must use the same fiscal period it uses for filing its federal tax return;
(c) The report must be filed for both inpatient and outpatient services, even if the service is paid under a prospective payment system or fee schedule (e.g., DRG payments, outpatient clinical laboratory, etc.);
(d) In the absence of an agreement with Medicare, the hospital must use the same fiscal period as that used for filing their Federal tax return.
(7) Inpatient rehabilitation facilities are exempt from filing an annual calculation of reasonable Cost (DMAP 42) and not cost settled.
Stat. Auth.: ORS 413.042

Stats. Implemented: ORS 414.065

Hist.: AFS 14-1980, f. 3-27-80, ef. 4-1-80; AFS 57-1980, f. 8-29-80, ef. 9-1-80; AFS 18-1982(Temp), f. & ef. 3-1-82; AFS 60-1982, f. & ef. 7-1-82; Former (2) thru (5) Renumbered to 461-015-0121 thru 461-015-0124; AFS 37-1983(Temp), f. & ef. 7-15-83; AFS 1-1984, f. & ef. 1-9-84; AFS 52-1985, f. 9-3-85, ef. 10-1-85; AFS 46-1987, f. & ef. 10-1-87; AFS 39-1989(Temp), f. 6-30-89, cert. ef. 7-1-89; AFS 49-1989(Temp), f. 8-24-89, cert. ef. 9-1-89; AFS 72-1989, f. & cert. ef. 12-1-89, Renumbered from 461-015-0105, 461-015-0120 & 461-015-0122; HR 21-1990, f. & cert. ef. 7-9-90, Renumbered from 461-015-0650; HR 42-1991, f. & cert. ef. 10-1-91; OMAP 34-1999, f. & cert. ef. 10-1-99; OMAP 73-2005, f. 12-29-05, cert. ef. 1-1-06; DMAP 39-2008, f. 12-11-08, cert. ef. 1-1-09; DMAP 32-2010, f. 12-15-10, cert. ef. 1-1-11
410-125-1040
Accounting and Record Keeping
(1) All records for a given fiscal period must be kept for three years after the Medicare audit for that period has been finalized.
(2) Each hospital is required to make its financial records available for auditing within the state of Oregon at a location specified by the provider.
(3) All hospital records are subject to inspection and review by the Division personnel and Department of Health and Human Services personnel during the period the records are required to be held.
(4) All expenses must be documented in detail as a part of the record. All capital expenditures requiring approval under the Certificate of Need process, and not having such approval, will be disallowed.
(5) Hospitals without a Medicare agreement must use the Hospital Administrative Services (HAS) system of reporting.
(6) Record keeping and reporting must be based on date of service, not date of payment. Billings for patients determined by the Division to be eligible for Title XIX or Program 5 must be included as accruals, even those billings not yet paid.
Stat. Auth.: ORS 413.042

Stats. Implemented: ORS 414.065

Hist.: AFS 14-1980, f. 3-27-80, ef. 4-1-80; AFS 57-1980, f. 8-29-80, ef. 9-1-80; AFS 18-1982(Temp), f. & ef. 3-1-82; AFS 60-1982, f. & ef. 7-1-82; Renumbered from 461-015-0120(2); AFS 49-1989(Temp), f. 8-24-89, cert. ef. 9-1-89; AFS 72-1989, f. & cert. ef. 12-1-89, Renumbered from 461-015-0121; HR 21-1990, f. & cert ef. 7-9-90, Renumbered from 461-015-0660; HR 42-1991, f. & cert. ef. 10-1-91
410-125-1060
Fiscal Audits
(1) Year-end fiscal audits will include retrospective examination and verification of claims and the determination of allowable charges and costs of hospital services provided to Division clients.
(2) The principal source document for the fiscal audit of Title XIX/Title XXI and General Assistance patient billings and payments for a given fiscal period is the Division data processing printout. This printout includes all transactions for the audit period. Using gross totals from this printout and applying other information from the Division records, information received from the hospital, and other sources, the Division will compile detailed schedules of adjustments and revise the gross totals. A revised Calculation of Reasonable Cost Statement (DMAP 42) will be prepared using revised totals and information from the Medicare report.
(3) Cost Settlements: the Division will send the hospital a letter stating the amount of underpayment or overpayment calculated by the Division for the fiscal year examined. The letter will also state the hospital's inpatient/outpatient interim reimbursement rate for the period from the effective date of the change until the next fiscal year's audit is completed. Payment of the cost-settlement amount is due and payable within 30 days from the date of the letter.
(4) The Division , at its discretion, may grant a (30) thirty-day extension for the purpose of reviewing the cost settlement upon a written request by the hospital. If a (30) thirty-day extension is granted, payment of the cost settlement amount is due within sixty (60) days from the date of the letter. If the provider chooses to appeal the decision or rate, a written request for an administrative review, or contested case must be received by the Division within (30) thirty-days of the date of the letter notifying the hospital of the settlement amount and interim rate, or within sixty (60) days if the Division has granted a thirty (30) day extension, not withstanding the time limits in OAR 410-120-1580(3) or 410-120-1660(1). Upon receipt of the request, the Division will attempt to resolve any differences informally with the provider before scheduling the administrative review or hearing.
(5) Under extraordinary circumstances, the Division, at its discretion, may negotiate a repayment schedule with a hospital. The hospital may be required to submit additional information to support the hospital's request for a repayment schedule. The hospital will be required to pay interest associated with extended payments granted by the Division.
(6) The revised Calculation of Reasonable Cost, copies of adjustment schedules, and a copy of the printout are available to the hospital upon request. For Type A rural hospitals the Calculation of Reasonable Cost Statement will reflect the difference between payment at 100% of costs and payment for dates-of-services on or after January 1, 2006 under the fee schedule for clinical laboratory services provided by the hospital. An adjustment to the Cost Settlement will be made to reimburse a Type A hospital at 100% of costs for laboratory and radiology services provided to Medical Assistance Program clients during the period the hospital was designated a Type A hospital. Settlements to Type B and Critical Access hospitals will be made within the legislative appropriation.
(7) The adjusted Professional Component Cost-to-Charge ratio(s) will be applied to all corresponding revenue code charges as listed on the Hospital Claim Detail Reports for cost settlements finalized on or after October 1, 1999.
(8) Hospital Based Rural Health Clinics shall be subject to the rules in the Hospital Services for the Oregon Health Plan Guide for Type A and B Hospitals. Hospital Based Rural Health Clinics cost settlements for dates of service from January 1, 2001 shall be finalized to cost.
(9) No interim settlements will be made. No settlements will be made until after receipt and review of the audited Medicare cost report.
Stat. Auth.: ORS 413.042

Stats. Implemented: ORS 414.065

Hist.: AFS 14-1980, f. 3-27-80, ef. 4-1-80; AFS 57-1980, f. 8-29-80, ef. 9-1-80; AFS 18-1982(Temp), f. & ef. 3-1-82; AFS 60-1982, f. & ef. 7-1-82; Renumbered from 461-015-0120(3); AFS 52-1985, f. 9-3-85, ef. 10-1-85; AFS 46-1987, f. & ef. 10-1-87; AFS 49-1989(Temp), f. 8-24-89, cert. ef. 9-1-89; AFS 72-1989, f. & cert. ef. 12-1-89, Renumbered from 461-015-0122; HR 21-1990, f. & cert. ef. 7-9-90, Renumbered from 461-015-0670; HR 33-1990(Temp), f. & cert. ef. 10-1-90; HR 43-1990, f. & cert. ef. 11-30-90; HR 15-1991(Temp), f. & cert. ef. 4-8-91; HR 42-1991, f. & cert. ef. 10-1-91; HR 36-1993, f. & cert. ef. 12-1-93; HR 24-1995, f. 12-29-95, cert. ef. 1-1-96; HR 3-1997, f. 1-31-97, cert. ef. 2-1-97; OMAP 34-1999, f. & cert. ef. 10-1-99; OMAP 28-2000, f. 9-29-00, cert. ef. 10-1-00; OMAP 35-2001, f. 9-24-01, cert. ef. 10-1-01; OMAP 73-2005, f. 12-29-05, cert. ef. 1-1-06
410-125-1070
Type A and Type B Hospitals
(1) Type A and Type B hospitals must submit the following information to the Division of Medical Assistance Programs (Division):
(a) The aggregate percent increase in patient charges and the effective date of the increase within 30 days following the end of their fiscal year for increases in the preceding year. Aggregate percent increase in patient charges is defined as the percent increase in patient revenues due to charge increases; and
(b) The amount of payment received by the hospital, from each Division contracted managed care plan and third-party payers, for inpatient and outpatient hospital services provided to managed care members, within the hospital's fiscal year.
(2) When a hospital is contracted with a Prepaid Health Plan (PHP), within thirty (30) days of the Division request the hospital will supply the Division the following information:
(a) The name of the contracting PHP; and
(b) The dates for which the contract will be effective; and
(c) The contracted services and reimbursement rates.
(3) The hospital and PHP must coordinate payment information to verify and return the PHP payment data file sent by the Division within ninety (90) days from date the data file is received by the hospital.
(4) Failure to supply the requested information within timelines stated may result in a discretionary sanction or fine (see OAR 410-120-1440). No sanction or fine will be imposed if the Division determines, at its sole discretion, that the hospital was unable to coordinate payment information with the PHP through no fault of the hospital’s own.
Stat. Auth.: ORS 413.042

Stats. Implemented: ORS 414.065

Hist.: OMAP 12-2001, f. 3-30-01, cert. ef. 4-1-01; OMAP 31-2005, f. 6-20-05, cert. ef. 7-1-05; DMAP 34-2008, f. 11-26-08, cert. ef. 12-1-08
410-125-1080
Documentation
(1) Federal regulations require Medicaid
providers to maintain records that fully support the extent of services for which
payment has been requested, and that such records be furnished to the Division upon
request (42 CFR 431.107).
(2) When requested by the
Division or its medical review contractor, hospitals must submit sufficient medical
documentation to verify the emergency nature, medical necessity, quality and appropriateness
of treatment, and appropriateness of the length of stay for inpatient and outpatient
hospital services. The Division may request sufficient information to evaluate the
accuracy and appropriateness of ICD-10-CM Coding for the claim. In addition, the
Division may request an itemized billing for all services provided. The Division
will specify in its request what documentation is required.
Stat. Auth.: ORS 413.042
Stats. Implemented: ORS 414.065
Hist.: AFS 14-1980, f. 3-27-80,
ef. 4-1-80; AFS 60-1982, f. & ef. 7-1-82; AFS 46-1987, f. & ef. 10-1-87;
AFS 49-1989(Temp), f. 8-24-89, cert. ef. 9-1-89; AFS 72-1989, f. & cert. ef.
12-1-89, Renumbered from 461-015-0040; HR 21-1990, f. & cert. ef. 7-9-90, Renumbered
from 461-015-0680; DMAP 51-2015, f. 9-22-15, cert. ef. 10-1-15
410-125-2000
Access to Records
(1) Providers must furnish requested medical and financial documentation within 30 calendar days from the date of request. Failure to comply within 30 calendar days shall result in recovery of payment(s) made by the Division for services being reviewed.
(2) The Division conducts post payment review of admissions and claim records. The Division may request records from a hospital or may request access to records while at the hospital.
(3) The hospital has 30 days to provide the Division with copies of records. In some cases, there may be a more urgent need to review records.
(4) The Medical Payment Recovery Unit (MPRU) conducts recovery activities for the Division involving third party liability resources. MPRU may request records from the hospital. This unit has the same right to medical and financial information as the Division.
Stat. Auth.: ORS 413.042

Stats. Implemented: ORS 414.065

Hist.: AFS 14-1980, f. 3-27-80, ef. 4-1-80; AFS 60-1982, f. & ef. 7-1-82; AFS 46-1987, f. & ef. 10-1-87; AFS 49-1989(Temp), f. 8-24-89, cert. ef. 9-1-89; AFS 72-1989, f. & cert. ef. 12-1-89, Renumbered from 461-015-0040; HR 21-1990, f. & cert. ef. 7-9-90, Renumbered from 461-015-0690; HR 42-1991, f. & cert. ef. 10-1-91; OMAP 11-2004, f. 3-11-04, cert. ef. 4-1-04; OMAP 70-2004, f. 9-15-04, cert. ef. 10-1-04; DMAP 32-2010, f. 12-15-10, cert. ef. 1-1-11
410-125-2020
Post Payment Review
(1) All services provided by a hospital
in the inpatient or outpatient setting are subject to post-payment review by the
Division. Both emergency and non-emergency services may be reviewed. Claims for
services may be reviewed to determine:
(a) The medical necessity
of the admission or outpatient services provided;
(b) The appropriateness of
the length of stay;
(c) The appropriateness of
the plan of care;
(d) The accuracy of the ICD-10
coding and DRG assignment;
(e) The appropriateness of
the setting selected for service delivery;
(f) The quality of care of
the services provided;
(g) The nature of any service
coded as emergent;
(h) The accuracy of the billing;
(i) The care furnished is
appropriately documented.
(2) If the Division determines
that a hospital service was not within Division coverage parameters, the hospital
and attending physician shall be notified in writing and will have twenty days to
provide additional written documentation to support the medical necessity of the
admission and/or procedure(s).
(3) If the recommendation
for denial is upheld by the Division, the hospital and/or practitioner may request
a reconsideration of the denial within 30 days of the receipt of the denial.
(4) If the reconsidered decision
is to uphold the denial, payment to all providers of service shall be recovered.
(5) The hospital and/or practitioner
may appeal any final decision through the Division administrative appeals process.
(6) No payment shall be made
by the Division for inpatient services if the Division or Medicare has determined
the service is not medically necessary and/or appropriate.
Stat. Auth.: ORS 413.042
Stats. Implemented: ORS 414.065
Hist.: AFS 14-1980, f. 3-27-80,
ef. 4-1-80; AFS 1-1984, f. & ef. 1-9-84; AFS 38-1986, f. 4-29-86, ef. 6-1-86;
AFS 46-1987, f. & ef. 10-1-87; AFS 49-1989(Temp), f. 8-24-89, cert. ef. 9-1-89;
AFS 72-1989, f. & cert. ef. 12-1-89, Renumbered from 461-015-0090; HR 21-1990,
f. & cert. ef. 7-9-90, Renumbered from 461-015-0700; HR 42-1991, f. & cert.
ef. 10-1-91; OMAP 34-1999, f. & cert. ef. 10-1-99; OMAP 28-2000, f. 9-29-00,
cert. ef. 10-1-00; OMAP 70-2004, f. 9-15-04, cert. ef. 10-1-04; DMAP 32-2010, f.
12-15-10, cert. ef. 1-1-11; DMAP 51-2015, f. 9-22-15, cert. ef. 10-1-15
410-125-2030
Recovery of Payments
(1) Payments made by the Division of Medical Assistance Programs (Division) shall be recovered for:
(a) Services identified by the provider as emergent or urgent, but determined on retrospective review not to have been emergent or urgent. Payment shall also be recovered from the admitting and/or performing physician;
(b) Services determined by the Division that the readmission to the same hospital was the result of a premature discharge;
(c) Services were billed but not provided;
(d) Services provided at an inappropriate level of care, which includes the setting selected for service delivery;
(e) The Division non-covered services;
(f) Services, which were covered by a third party payer or other resources; or
(g) Services denied by a third party payer as not medically necessary.
(2) Payment to a physician and other providers of service for inpatient non-urgent or non-emergent services requiring prior authorization is subject to recovery by the Division if recovery is made from the hospital.
(3) If review by the Division results in a denial, the hospital may appeal any final decision through the Division Administrative Appeals process. See Administrative Hearings (chapter 410, division 120).
(4) As part of the Utilization Review Program, the Division shall develop and maintain a data system profiling the patterns of practice of institutions and practitioners. As a result of these profiles, the Division may initiate focused reviews. Any practitioner or hospital subject to a focused review shall be notified in advance of the review.
(5) All providers having a pattern of inappropriate utilization or inappropriate quality of care according to the current standards of the medical community and/or abuse of the Division rules or procedures shall be subject to corrective action. Actions taken shall be those determined appropriate by the Division, or sanctions established under the Oregon Revised Statues (ORS) or Oregon administrative rule and/or referral to a State or Federal authority, licensing body or regulatory agency for appropriate action.
Stat. Auth.: ORS 413.042

Stats. Implemented: ORS 414.065

Hist.: HR 42-1991, f. & cert. ef. 10-1-91; OMAP 34-1999, f. & cert. ef. 10-1-99; OMAP 28-2000, f. 9-29-00, cert. ef. 10-1-00; OMAP 70-2004, f. 9-15-04, cert. ef. 10-1-04; DMAP 32-2010, f. 12-15-10, cert. ef. 1-1-11
410-125-2040
Provider Appeals — Administrative Review
(1) A provider may request an administrative review regarding the decision(s) by the Division that affect the services they provide or have provided. See General Rules (chapter 410 division 120).
(2) A requests for an Administrative Review must be submitted in writing to the Medicaid Administrator, 500 Summer Street NE, E49, Salem, OR 97301-1079.
(3) The request must be received within 30 days of the date of notification of the payment decision or notification of change in reimbursement.
Stat. Auth.: ORS 413.042

Stats. Implemented: ORS 414.065

Hist.: AFS 49-1989(Temp), f. 8-24-89, cert. ef. 9-1-89; AFS 72-1989, f. & cert. ef. 12-1-89; HR 21-1990, f. & cert. ef. 7-9-90, Renumbered from 461-015-0710; HR 42-1991, f. & cert. ef. 10-1-91; OMAP 70-2004, f. 9-15-04, cert. ef. 10-1-04
410-125-2060
Provider Appeals — Hearing Request
If the hospital disagrees with the Division calculation of reasonable costs for outpatient services or inpatient services, the outpatient interim rate, DRG based prospective payment for inpatient services, the calculation of the hospital's unit value, or any other hospital reimbursement methodologies or payments, a written request for an appeal may be made to the Division in accordance with the General rules (chapter 410 division 120). A hearing request must be received not later than 30 days following the date of the notice of action. At the time of appeal, the hospital must submit any data the hospital wants DMAP to consider in support of the appeal. The appeal will be conducted as described in General rules.
Stat. Auth.: ORS 413.042

Stats. Implemented: ORS 414.065

Hist.: AFS 14-1980, f. 3-27-80, ef. 4-1-80; AFS 57-1980, f. 8-29-80, ef. 9-1-80; AFS 18-1982(Temp), f. & ef. 3-1-82; AFS 60-1982, f. & ef. 7-1-82; Renumbered from 461-015-0120(4); AFS 37-1983(Temp), f. & ef. 7-15-83; AFS 1-1984, f. & ef. 1-9-84; AFS 52-1985, f. 9-3-85, ef. 10-1-85; AFS 49-1989 (Temp), f. 8-24-89, cert. ef. 9-1-89; AFS 72-1989, f. & cert. ef. 12-1-89, Renumbered from 461-015-0123; HR 21-1990, f. & cert. ef. 7-9-90, Renumbered from 461-015-0720; HR 42-1991, f. & cert. ef. 10-1-91; OMAP 70-2004, f. 9-15-04, cert. ef. 10-1-04
410-125-2080
Administrative Errors
(1) If a hospital has been given incorrect information by Division of Medical Assistance Programs, Children, Adults, and Families Programs, or Aging and People with Disabilities/staff, and services were provided on the basis of this information, and payment has been denied as a result, the hospital may submit a request for payment as an Administrative Error.
(2) Include the following:
(a) An explanation of the problem;
(b) Any documents supporting the request for payment;
(c) A copy of any paper Remittance Advice or electronic 835 printouts received on this claim;
(d) A copy of the original claim.
(3) Send the request: Division of Medical Assistance Programs, Provider Inquiry, Administrative Errors, 500 Summer Street NE, E-44, Salem, OR 97301-1077.
Stat. Auth.: ORS 413.042

Stats. Implemented: ORS 414.065

Hist.: AFS 49-1989(Temp), f. 8-24-89, cert. ef. 9-1-89; AFS 72-1989, f. & cert. ef. 12-1-89; HR 21-1990, f. & cert. ef. 7-9-90, Renumbered from 461-015-0730; HR 42-1991, f. & cert. ef. 10-1-91; OMAP 70-2004, f. 9-15-04, cert. ef. 10-1-04; OMAP 17-2006, f. 6-12-06, cert. ef. 7-1-06

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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.
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