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Oregon Bulletin

August 1, 2011

 

Oregon Health Authority,
Division of Medical Assistance Programs
Chapter 410

Rule Caption: 7/11 – Allows the Authority to conduct medical assistance eligibility determinations using OAR chapter 461 medical eligibility rules.

Adm. Order No.: DMAP 10-2011

Filed with Sec. of State: 6-29-2011

Certified to be Effective: 7-1-11

Notice Publication Date: 6-1-2011

Rules Adopted: 410-120-0006

Subject: The General Rules program administrative rules govern Division payments for services to clients. The Division adopted a new rule (OAR 410-120-0006) to allow the Oregon Health Authority to conduct medical assistance-eligibility determinations using the Department of Human Services’ OAR chapter 461 medical assistance eligibility rules. This rule also allows the appeal processes for Authority determinations to be conducted pursuant to OAR chapter 461, division 25.

Rules Coordinator: Darlene Nelson—(503) 945-6927

410-120-0006

Medical Eligibility Standards

As the state Medicaid and CHIP agency, the Oregon Health Authority (Authority) is responsible for establishing and implementing eligibility policies and procedure consistent with applicable law. As outlined in 943-001-0020, the Authority, and the Department of Human Services (Department) work together to adopt rules to assure that medical assistance eligibility procedures and determinations are consistent across both agencies.

(1) The Authority adopts and incorporates by reference the rules established in OAR Chapter 461, for all medical eligibility requirements for medical assistance when the Authority conducts eligibility determinations.

(2) Any reference to OAR Chapter 461 in Oregon Administrative Rules or contracts of the Authority are deemed to be references to the requirements of this rule, and shall be construed to apply to all eligibility policies, procedures and determinations by or through the Authority.

(3) For purposes of this rule, references in OAR chapter 461 to the Department or to the Authority shall be construed to be references to both agencies.

(4) Effective July 1, 2011 the Authority shall conduct medical eligibility determinations using the OAR chapter 461 rules which are in effect on the date the Authority makes the medical eligibility determination.

(5) A request for a hearing resulting from a determination under this rule, made by the Authority shall be handled pursuant to the hearing procedures set out in division 25 of OAR Chapter 461. References to “the Administrator” in division 25 of chapter 461 or “the Department” are hereby incorporated as references to the” Authority.”

[Publications: Publications referenced are available from the agency.]

Stat. Auth.: ORS 413.042

Stats. Implemented: ORS 413.042 & 414.065

Hist.: DMAP 10-2011, f. 6-29-11, cert. ef. 7-1-11

 

Rule Caption: 7/11 – NCCI edit appeals; Oregon Health Authority (OHA) definition; Pilot project for CAWEM women.

Adm. Order No.: DMAP 11-2011

Filed with Sec. of State: 6-29-2011

Certified to be Effective: 7-1-11

Notice Publication Date: 6-1-2011

Rules Amended: 410-120-0000, 410-120-0030, 410-120-1560

Subject: The General Rules program administrative rules govern Division payments for services to clients. The Division amended as follows:

      OAR 410-120-0000, Definitions: 2009 Legislative session created the Oregon Health Authority and moved various Divisions from the Department of Human Services. The Division revised this rule to reflect this change. The Division also added a definition for the National Correct Coding Initiative (NCCI) edits required by the Affordable Care Act.

      OAR 410-120-0030, Children’s Health Insurance Program: The Division amended this rule to add Columbia, Crook, Douglas, Jefferson, Morrow, Union and Wasco counties to participate in the prenatal care expansion providing prenatal care during pregnancy and labor and delivery services under CHIP for women who are not eligible for Medicare and who are at or below 185% of FPL, subject to the Centers for Medicare and Medicaid Services (CMS) approval.

      OAR 410-120-1560, Provider Appeals: The Affordable Care Act requires Medicaid agencies to use NCCI edits. The Division amended this rule to specify the inclusion of provider appeals for an NCCI edit.

      • All above rules reflect the Oregon Health Authority name change and updated statutory reference.

      • Other text may be revised to improve readability and to take care of necessary “housekeeping” corrections.

Rules Coordinator: Darlene Nelson—(503) 945-6927

410-120-0000

Acronyms and Definitions

Identification of acronyms and definitions within this rule specifically pertain to their use within the Oregon Health Authority (Authority), Division of Medical Assistance Programs (Division) administrative rules. This rule does not include an exhaustive list of Division acronyms and definitions. For more information, see Oregon Health Plan (OHP) program OAR 410-141-0000, Acronyms and Definitions, and any appropriate governing acronyms and definitions in the Department of Human Services (Department) chapter 407 administrative rules, or contact the Division.

(1) AAA – Area Agency on Aging.

(2) Abuse – Provider practices that are inconsistent with sound fiscal, business, or medical practices and result in an unnecessary cost to the Division, or in reimbursement for services that are not medically necessary or that fail to meet professionally recognized standards for health care. It also includes recipient practices that result in unnecessary cost to the Division.

(3) Acupuncturist – A person licensed to practice acupuncture by the relevant state licensing board.

(4) Acupuncture services – Services provided by a licensed acupuncturist within the scope of practice as defined under state law.

(5) Acute – A condition, diagnosis or illness with a sudden onset and that is of short duration.

(6) Acquisition cost – Unless specified otherwise in individual program administrative rules, the net invoice price of the item, supply or equipment, plus any shipping and/or postage for the item.

(7) Addiction and Mental Health Division (AMH) – A division within the Authority that administers mental health and addiction programs and services.

(8) Adequate record keeping – Documentation that supports the level of service billed. See 410-120-1360, Requirements for Financial, Clinical, and Other Records, and the individual provider rules.

(9) Administrative medical examinations and reports – Examinations, evaluations, and reports, including copies of medical records, requested on the DMAP 729 form through the local Department branch office or requested or approved by the Division to establish client eligibility for a medical assistance program or for casework planning.

(10) Adverse event – An undesirable and unintentional, though not unnecessarily unexpected, result of medical treatment.

(11) All-inclusive rate – The nursing facility rate established for a facility. This rate includes all services, supplies, drugs and equipment as described in OAR 411-070-0085, and in thealth departments, schools, education service districts, developmental disability service programs, area agencies on aging (AAAs), federally recognized American Indian tribes).

(13) Ambulance – A specially equipped and licensed vehicle for transporting sick or injured persons which meets the licensing standards of the Department or the licensing standards of the state in which the ambulance provider is located.

(14) Ambulatory Surgical Center (ASC) – A facility licensed as an ASC by the Department.

(15) American Indian/Alaska Native (AI/AN) – A member of a federally recognized Indian tribe, band or group, an Eskimo or Aleut or other Alaska native enrolled by the Secretary of the Interior pursuant to the Alaska Native Claims Settlement Act, 43 U.S.C. 1601, or a person who is considered by the Secretary of the Interior to be an Indian for any purpose.

(16) American Indian/Alaska Native (AI/AN) clinic – A clinic recognized under Indian Health Services (IHS) law or by the Memorandum of Agreement between IHS and the Centers for Medicare and Medicaid Services (CMS).

(17) Ancillary services – Services supportive of or necessary to the provision of a primary service (e.g., anesthesiology is an ancillary service necessary for a surgical procedure); Typically, such medical services are not identified in the definition of a condition/treatment pair, but are medically appropriate to support a service covered under the OHP benefit package; ancillary services and limitations are specified in the OHP (Managed Care) administrative rules related to the Oregon Health Services Commission’s Prioritized List of Health Services (410-141-0480 through 410-141-0520), the General Rules Benefit Packages (410-120-1210), Exclusions (410-120-1200) and applicable individual program rules.

(18) Anesthesia services – Administration of anesthetic agents to cause loss of sensation to the body or body part.

(19) Atypical provider – Entity able to enroll as a billing provider (BP) or performing provider for medical assistance programs related non-health care services but which does not meet the definition of health care provider for National Provider Identification (NPI) purposes.

(20) Audiologist – A person licensed to practice audiology by the State Board of Examiners for Speech Pathology and Audiology.

(21) Audiology – The application of principles, methods and procedures of measurement, testing, appraisal, prediction, consultation, counseling and instruction related to hearing and hearing impairment for the purpose of modifying communicative disorders involving speech, language, auditory function, including auditory training, speech reading and hearing aid evaluation, or other behavior related to hearing impairment.

(22) Automated Voice Response (AVR) – A computer system that provides information on clients’ current eligibility status from the Division by computerized phone or Web-based response.

(23) Benefit Package – The package of covered health care services for which the client is eligible.

(24) Billing agent or billing service – Third party or organization that contracts with a provider to perform designated services in order to facilitate an Electronic Data Interchange (EDI) transaction on behalf of the provider.

(25) Billing provider (BP) – A person, agent, business, corporation, clinic, group, institution, or other entity who submits claims to and/or receives payment from the Division on behalf of a performing provider and has been delegated the authority to obligate or act on behalf of the performing provider.

(26) Buying Up – The practice of obtaining client payment in addition to the Division or managed care plan payment to obtain a non-covered service or item. (See 410-120-1350 Buying Up)

(27) By Report (BR) – Services designated, as BR require operative or clinical and other pertinent information to be submitted with the billing as a basis for payment determination. This information must include an adequate description of the nature, and extent of need for the procedure. Information such as complexity of symptoms, final diagnosis, pertinent physical findings, diagnostic and therapeutic procedures, concurrent problems, and follow-up care will facilitate evaluation.

(28) Children, Adults and Families Division (CAF) – A division within the Department, responsible for administering self-sufficiency and child-protective programs.

(29) Children’s Health Insurance Program (CHIP) – A federal and state funded portion of the Oregon Health Plan (OHP) established by Title XXI of the Social Security Act and administered by the Division.

(30) Chiropractor – A person licensed to practice chiropractic by the relevant state licensing board.

(31) Chiropractic services – Services provided by a licensed chiropractor within the scope of practice, as defined under state law and Federal regulation.

(32) Citizen/Alien-Waived Emergency Medical (CAWEM) – Aliens granted lawful temporary resident status, or lawful permanent resident status under the Immigration and Nationality Act, are eligible only for emergency services and limited service for pregnant women. Emergency services for CAWEM are defined in OAR 410-120-1210 (3)(f).

(33) Claimant – a person who has requested a hearing.

(34) Client – A person who is currently receiving medical assistance (also known as a recipient).

(35) Clinical Social Worker – A person licensed to practice clinical social work pursuant to State law.

(36) Contiguous Area – The area up to 75 miles outside the border of the State of Oregon.

(37) Contiguous area provider – A provider practicing in a contiguous area.

(38) Co-payments – The portion of a claim or medical, dental or pharmaceutical expense that a client must pay out of their own pocket to a provider or a facility for each service. It is usually a fixed amount that is paid at the time service is rendered. (See 410-120-1230 Client Copayment)

(39) Cost effective – The lowest cost health care service or item that, in the judgment of Division staff or its contracted agencies, meets the medical needs of the client.

(40) Current Dental Terminology (CDT) – A listing of descriptive terms identifying dental procedure codes used by the American Dental Association.

(41) Current Procedural Terminology (CPT) – The physicians’ CPT is a listing of descriptive terms and identifying codes for reporting medical services and procedures performed by physicians and other health care providers.

(42) Date of receipt of a claim – The date on which the Division receives a claim, as indicated by the Internal Control Number (ICN) assigned to a claim. Date of receipt is shown as the Julian date in the 5th through 7th position of the ICN.

(43) Date of service – The date on which the client receives medical services or items, unless otherwise specified in the appropriate provider rules. For items that are mailed or shipped by the provider, the date of service is the date on which the order was received, the date on which the item was fabricated, or the date on which the item was mailed or shipped.

(44) Dental emergency services – Dental services provided for severe tooth pain, unusual swelling of the face or gums, or an avulsed tooth.

(45) Dental Services – Services provided within the scope of practice as defined under state law by or under the supervision of a dentist.

(46) Dentist – A person licensed to practice dentistry pursuant to state law of the state in which he/she practices dentistry, or a person licensed to practice dentistry pursuant to Federal law for the purpose of practicing dentistry as an employee of the Federal government.

(47) Denturist – A person licensed to practice denture technology pursuant to State law.

(48) Denturist services – Services provided, within the scope of practice as defined under State law, by or under the personal supervision of a denturist.

(49) Dental hygienist – A person licensed to practice hygiene under the direction of a licensed professional within the scope of practice pursuant to State law.

(50) Dental hygienist with Limited Access Certification (LAC) – A person licensed to practice dental hygiene with LAC pursuant to State law.

(51) Department – the Department of Human Services.

(52) Department of Human Services (Department) – The Department or DHS means the Department of Human Services established in ORS Chapter 409, including such divisions, programs and offices as may be established therein. Wherever the former Office of Medical Assistance Programs, OMAP or DMAP is used in contract or in administrative rule, it shall mean the Division of Medical Assistance Programs (Division). Wherever the former Office of Mental Health and Addiction Services or OMHAS is used in contract or in rule, it shall mean the Addictions and Mental Health Division (AMHD). Wherever the former Seniors and People with Disabilities or SPD is used in contract or in rule, it shall mean the Seniors and People with Disabilities Division (SPD). Wherever the former Children Adults and Families or CAF is used in contract or rule, it shall mean the Children, Adults and Families Division (CAF). Wherever the former Health Division is used in Contract or in rule, it shall mean the Public Health Division (PHD).

(53) Department representative – A person who represents the Department and presents the position of the Department in a hearing.

(54) Diagnosis code – As identified in the International Classification of Diseases, 9th revision, Clinical Modification (ICD-9-CM), the primary diagnosis code is shown in all billing claims, unless specifically excluded in individual provider rule(s). Where they exist, diagnosis codes shall be shown to the degree of specificity outlined in OAR 410-120-1280, Billing.

(55) Diagnosis Related Group (DRG) – A system of classification of diagnoses and procedures based on the ICD-9-CM.

(56) Division of Medical Assistance Programs (Division) – A division within the Authority; the Division is responsible for coordinating the medical assistance programs within the State of Oregon including the Oregon Health Plan (OHP) Medicaid demonstration, the State Children’s Health Insurance Program (SCHIP -Title XXI), and several other programs.

(57) Division member – An OHP client enrolled with a PHP.

(58) Durable Medical Equipment, Prosthetics, Orthotics and and Medical Supplies (DMEPOS) – Equipment that can stand repeated use and is primarily and customarily used to serve a medical purpose. Examples include wheelchairs, respirators, crutches and custom built orthopedic braces. Medical supplies are non-reusable items used in the treatment of illness or injury. Examples of medical supplies include diapers, syringes, gauze bandages and tubing.

(59) Early and Periodic Screening, Diagnosis and Treatment (EPSDT) Services (aka, Medicheck) – The Title XIX program of EPSDT services for eligible clients under age 21. It is a comprehensive child health program to assure the availability and accessibility of required medically appropriate health care services and to help Division clients and their parents or guardians effectively use them.

(60) Electronic Data Interchange (EDI) – The exchange of business documents from application to application in a federally mandated format or, if no federal standard has been promulgated, using bulk transmission processes and other formats as the Authority designates for EDI transactions. For purposes of rules 407-120-0100 through 407-120-0200, EDI does not include electronic transmission by web portal.

(61) EDI submitter – An individual or an entity authorized to establish an electronic media connection with the Authority to conduct and EDI transaction. An EDI submitter may be a trading partner or an agent of a trading partner.

(62) Electronic Verification System (EVS) eligibility information that has met the legal and technical specifications of the Division in order to offer eligibility information to enrolled providers of the Division.

(63) Emergency department – The part of a licensed hospital facility open 24 hours a day to provide care for anyone in need of emergency treatment.

(64) Emergency medical condition – a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that a prudent layperson, who possesses an average knowledge of health and medicine, could reasonably expect the absence of immediate medical attention to result in placing the health of the individual (or with respect to a pregnant woman, the health of the woman or her unborn child) in serious jeopardy, serious impairment to bodily functions or serious dysfunction of any bodily organ or part. An emergency medical condition is determined based on the presenting symptoms (not the final diagnosis) as perceived by a prudent layperson (rather than a health care professional) and includes cases in which the absence of immediate medical attention would not in fact have had the adverse results described in the previous sentence. (This definition does not apply to clients with CAWEM benefit package. CAWEM emergency services are governed by OAR 410-120-1210(3)(f)(B)).

(65) Emergency Medical transportation – Transportation necessary for a client with an emergency medical condition, as defined in this rule, and requires a skilled medical professional such as an Emergency Medical Technician (EMT) and immediate transport to a site, usually a hospital, where appropriate emergency medical service is available.

(66) Evidence-based medicine- is the conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients. The practice of evidence based medicine means integrating individual clinical expertise with the best available external clinical evidence from systematic research. By individual clinical expertise we mean the proficiency and judgment that individual clinicians acquire through clinical experience and clinical practice. Increased expertise is reflected in many ways, but especially in more effective and efficient diagnosis and in the more thoughtful identification and compassionate use of individual patients’ predicaments, rights, and preferences in making clinical decisions about their care. By best available external clinical evidence we mean clinically relevant research, often from the basic sciences of medicine, but especially from patient centered clinical research into the accuracy and precision of diagnostic tests (including the clinical examination), the power of prognostic markers, and the efficacy and safety of therapeutic, rehabilitative, and preventive regimens. External clinical evidence both invalidates previously accepted diagnostic tests and treatments and replaces them with new ones that are more powerful, more accurate, more efficacious, and safer. (Source: BMJ 1996; 312:71-72 (13 January))

(67) False claim – A claim that a provider knowingly submits or causes to be submitted that contains inaccurate, misleading or omitted information and such inaccurate, misleading or omitted information would result, or has resulted, in an overpayment.

(68) Family planning services – Services for clients of child bearing age (including minors who can be considered to be sexually active) who desire such services and which are intended to prevent pregnancy or otherwise limit family size.

(69) Federally Qualified Health Center (FQHC) – A federal designation for a medical entity which receives grants under Section 329, 330, or 340 of the Public Health Service Act; or a facility designated as a FQHC by Centers for Medicare and Medicaid (CMS) upon recommendation of the U.S. Public Health Service.

(70) Fee-for-service provider – A medical provider who is not reimbursed under the terms of a Division contract with a Prepaid Health Plan (PHP), also referred to as a Managed Care Organization (MCO). A medical provider participating in a PHP may be considered a fee-for-service provider when treating clients who are not enrolled in a PHP.

(71) Fraud – An intentional deception or misrepresentation made by a person with the knowledge that the deception could result in some unauthorized benefit to himself or some other person. It includes any act that constitutes fraud under applicable federal or state law.

(72) Fully dual eligible – For the purposes of Medicare Part D coverage (42 CFR 423.772), Medicare clients who are also eligible for Medicaid, meeting the income and other eligibility criteria adopted by the Department for full medical assistance coverage.

(73) General Assistance (GA) – Medical assistance administered and funded 100% with State of Oregon funds through OHP.

(74) Healthcare Common Procedure Coding System (HCPCS) – A method for reporting health care professional services, procedures, and supplies. HCPCS consists of the Level l – American Medical Association’s Physician’s Current Procedural Terminology (CPT), Level II – National codes, and Level III – Local codes. The Division uses HCPCS codes; however, Division uses Current Dental Terminology (CDT) codes for the reporting of dental care services and procedures.

(75) Health Maintenance Organization (HMO) – A public or private health care organization which is a federally qualified HMO under Section 1310 of the U.S. Public Health Services Act. HMOs provide health care services on a capitated, contractual basis.

(76) Hearing aid dealer – A person licensed by the Board of Hearing Aid Dealers to sell, lease or rent hearing aids in conjunction with the evaluation or measurement of human hearing and the recommendation, selection, or adaptation of hearing aids.

(77) Home enteral nutrition – Services provided in the client’s place of residence to an individual who requires nutrition supplied by tube into the gastrointestinal tract, as described in the Home Enteral/Parenteral Nutrition and IV Services program provider rules.

(78) Home health agency – A public or private agency or organization which has been certified by Medicare as a Medicare home health agency and which is licensed by the Authority as a home health agency in Oregon, and meets the capitalization requirements as outlined in the Balanced Budget Act (BBA) of 1997.

(79) Home health services – Part-time or intermittent skilled nursing services, other therapeutic services (physical therapy, occupational therapy, speech therapy), and home health aide services made available on a visiting basis in a place of residence used as the client’s home.

(80) Home intravenous services – Services provided in the client’s place of residence to an individual who requires that medication (antibiotics, analgesics, chemotherapy, hydrational fluids, or other intravenous medications) be administered intravenously as described in the Home Enteral/Parenteral Nutrition and IV Services program administrative rules.

(81) Home parenteral nutrition – Services provided in the client’s residence to an individual who is unable to absorb nutrients via the gastrointestinal tract, or for other medical reasons, requires nutrition be supplied parenterally as described in the Home Enteral/Parenteral Nutrition and IV Services program administrative rules.

(82) Hospice – a public agency or private organization or subdivision of either that is primarily engaged in providing care to terminally ill individuals, is certified for Medicare, accredited by the Oregon Hospice Association, and is listed in the Hospice Program Registry.

(83) Hospital – A facility licensed by the Office of Public Health Systems as a general hospital which meets requirements for participation in the OHP under Title XVIII of the Social Security Act. The Division does not consider facilities certified by the CMS as long- term care hospitals, long term acute care hospitals or religious non-medical facilities as hospitals for reimbursement purposes. Out-of-state hospitals will be considered hospitals for reimbursement purposes if they are licensed as a short term acute care or general hospital by the appropriate licensing authority within that state, and if they are enrolled as a provider of hospital services with the Medicaid agency within that state.

(84) Hospital-based professional services – Professional services provided by licensed practitioners or staff based on a contractual or employee/employer relationship and reported as a cost on the Hospital Statement of Reasonable Cost report for Medicare and the Calculation of Reasonable Cost (Division 42) report for the Division.

(85) Hospital laboratory – A laboratory providing professional technical laboratory services as outlined under laboratory services, in a hospital setting, as either an inpatient or outpatient hospital service whose costs are reported on the hospital’s cost report to Medicare and to the Division.

(86) Indian Health Program – Any Indian health service facility, any Federally recognized Tribe or Tribal organization, or any FQHC with a 638 designation.

(87) Individual Adjustment Request Form (DMAP 1036) – Form used to resolve an incorrect payment on a previously paid claim, including underpayments or overpayments.

(88) Inpatient hospital services – Services that are furnished in a hospital for the care and treatment of an inpatient. (See Division Hospital Services program administrative rules in chapter 410, division 125 for inpatient covered services.)

(89) Institutional Level of Income Standards (ILIS) – Three times the amount SSI pays monthly to a person who has no other income and who is living alone in the community. This is the standard used for Medicaid eligible individuals to calculate eligibility for long-term nursing care in a nursing facility, Intermediate Care Facilities for the Mentally Retarded (ICF/MR) and individuals on ICF/MR waivers or eligibility for services under Seniors and People with Disabilities’ (SPD) Home and Community Based Waiver.

(90) Institutionalized – A patient admitted to a nursing facility or hospital for the purpose of receiving nursing and/or hospital care for a period of 30 days or more.

(91) International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) (including volumes 1, 2, and 3, as revised annually)— A book of diagnosis codes used for billing purposes when treating and requesting reimbursement for treatment of diseases.

(92) Laboratory – A facility licensed under ORS 438 and certified by CMS, Department of Health and Human Services (DHHS), as qualified to participate under Medicare, to provide laboratory services (as defined in this rule) within or apart from a hospital. An entity is considered to be a laboratory if the entity derives materials from the human body for the purpose of providing information for the diagnosis, prevention or treatment of any disease or impairment of, or the assessment of the health of, human beings. If an entity performs even one laboratory test, including waived tests for these purposes, it is considered to be a laboratory, under the Clinical Laboratory Improvement Act (CLIA).

(93) Laboratory services – Those professional and technical diagnostic analyses of blood, urine, and tissue ordered by a physician or other licensed practitioner of the healing arts within his/her scope of practice as defined under State law and provided to a patient by or under the direction of a physician or appropriate licensed practitioner in an office or similar facility, hospital, or independent laboratory.

(94) Licensed Direct Entry Midwife – A practitioner who has acquired the requisite qualifications to be registered and/or legally licensed to practice midwifery by the Public Health Division.

(95) Liability insurance – Insurance that provides payment based on legal liability for injuries or illness. It includes, but is not limited to, automobile liability Insurance, uninsured and underinsured motorist insurance, homeowner’s liability Insurance, malpractice insurance, product liability insurance, Worker’s Compensation, and general casualty insurance. It also includes payments under state wrongful death statutes that provide payment for medical damages.

(96) Managed Care Organization (MCO) – Contracted health delivery system providing capitated or prepaid health services, also known as a Prepaid Health Plan (PHP). An MCO is responsible for providing, arranging and making reimbursement arrangements for covered services as governed by state and federal law. An MCO may be a Chemical Dependency Organization (CDO), Fully Capitated Health Plan (FCHP), Dental Care Organization (DCO), Mental Health Organization (MHO), or Physician Care Organization (PCO).

(97) Maternity Case Management – A program available to pregnant clients. The purpose of Maternity Case Management is to extend prenatal services to include non-medical services, which address social, economic and nutritional factors. For more information refer to the Division’s Medical-Surgical Services Program administrative rules.

(98) Medicaid – A federal and state funded portion of the medical assistance programs established by Title XIX of the Social Security Act, as amended, administered in Oregon by the Authority.

(99) Medical assistance eligibility confirmation – Verification through the Electronic Verification System (EVS), AVR, Secure Web site or Electronic Data Interchange (EDI), or an authorized Department or Authority representative.

(100) Medical services – Care and treatment provided by a licensed medical provider directed at preventing, diagnosing, treating or correcting a medical problem.

(101) Medical transportation – Transportation to or from covered medical services.

(102) Medically appropriate – Services and medical supplies that are required for prevention, diagnosis or treatment of a health condition which encompasses physical or mental conditions, or injuries, and which are:

(a) Consistent with the symptoms of a health condition or treatment of a health condition;

(b) Appropriate with regard to standards of good health practice and generally recognized by the relevant scientific community, evidence-based medicine and professional standards of care as effective;

(c) Not solely for the convenience of an OHP client or a provider of the service or medical supplies; and

(d) The most cost effective of the alternative levels of medical services or medical supplies which can be safely provided to a Division client or Primary Care Manager (PCM) Member in the PHP’s or PCM’s judgment.

(103) Medicare – A federally administered program offering health insurance benefits for persons aged 65 or older and certain other aged or disabled persons. This program includes:

(a) Hospital Insurance (Part A) for Inpatient services in a hospital or skilled nursing facility, home health care, and hospice care; and

(b) Medical Insurance (Part B) for physicians’ services, outpatient hospital services, home health care, end-stage renal dialysis, and other medical services and supplies;

(c) Prescription drug coverage (Part D) – Covered Part D drugs include prescription drugs, biological products, insulin as described in specified paragraphs of section 1927(k) of the Social Security Act, and vaccines licensed under section 351 of the Public Health Service Act; also includes medical supplies associated with the injection of insulin; Part D covered drugs prohibit Medicaid Title XIX Federal Financial Participation (FFP). For limitations, see the Division’s Pharmaceutical Services program administrative rules in chapter 410, division 121.

(104) Medicheck for Children and Teens – Services also known as Early and Periodic Screening, Diagnosis and Treatment (EPSDT) services – The Title XIX program of EPSDT services for eligible clients under age 21. It is a comprehensive child health program to assure the availability and accessibility of required medically appropriate health care services and to help Division clients and their parents or guardians effectively use them.

(105) NCCI- National Correct Coding Initiative—- The Centers for Medicare and Medicaid Services (CMS) developed the National Correct Coding Initiative (NCCI) to promote national correct coding methodologies and to control improper coding leading to inappropriate payment.

(106) National Provider Identification (NPI) – Federally directed provider number mandated for use on HIPAA covered transactions; individuals, provider organizations and subparts of provider organizations that meet the definition of health care provider (45 CFR 160.103) and who conduct HIPAA covered transactions electronically are eligible to apply for an NPI; Medicare covered entities are required to apply for an NPI.

(107) Naturopath – A person licensed to practice naturopathy pursuant to State law.

(108) Naturopathic services – Services provided within the scope of practice as defined under State law.

(109) Non-covered services – Services or items for which the Division is not responsible for payment or reimbursement. Non-covered services are identified in:

(a) OAR 410-120-1200, Excluded Services and Limitations; and,

(b) 410-120-1210, Medical Assistance Benefit Packages and Delivery System;

(c) 410-141-0480, OHP Benefit Package of Covered Services;

(d) 410-141-0520, Prioritized List of Health Services; and

(e) Any other applicable Division administrative rules.

(110) Nurse Anesthetist, C.R.N.A. – A registered nurse licensed in the State of Oregon who is currently certified by the American Association of Nurse Anesthetists Council on Certification.

(111) Nurse Practitioner – A person licensed as a registered nurse and certified by the Board of Nursing to practice as a Nurse Practitioner pursuant to State law.

(112) Nurse Practitioner services – Services provided within the scope of practice of a Nurse Practitioner as defined under State law and by rules of the Board of Nursing.

(113) Nursing facility – A facility licensed and certified by the Department SPD and defined in OAR 411-070-0005.

(114) Nursing services – Health care services provided to a patient by a registered professional nurse or a licensed practical nurse under the direction of a licensed professional within the scope of practice as defined by State law.

(115) Nutritional counseling – Counseling which takes place as part of the treatment of a person with a specific condition, deficiency or disease such as diabetes, hypercholesterolemia, or phenylketonuria.

(116) Occupational Therapist – A person licensed by the State Board of Examiners for Occupational Therapy.

(117) Occupational Therapy – The functional evaluation and treatment of individuals whose ability to adapt or cope with the task of living is threatened or impaired by developmental deficiencies, physical injury or illness, aging process, or psychological disability; the treatment utilizes task-oriented activities to prevent or correct physical and emotional difficulties or minimize the disabling effect of these deficiencies on the life of the individual.

(118) Optometric services – Services provided, within the scope of practice of optometrists as defined under State law.

(119) Optometrist – A person licensed to practice optometry pursuant to State law.

(120) Oregon Health Authority (OHA)— The Authority or OHA means the Oregon Health Authority established in ORS Chapter 413, that administers the funds for Titles XIX and XXI of the Social Security Act. It is the single state agency for the administration of the medical assistance program under ORS chapter 414. For purposes of these rules the agencies under the authority of the OHA are the Public Health Division, the Addictions and Mental Health Division, and the Division of Medical Assistance Programs. These divisions are referred to as the Authority whereas the divisions under authority of the Department of Human Services are CAF and SPD and are referred to as the Department.

(121) Oregon Youth Authority (OYA) – The state department charged with the management and administration of youth correction facilities, state parole and probation services and other functions related to state programs for youth corrections.

(122) Out-of-State providers – Any provider located outside the borders of the State of Oregon:

(a) Contiguous area providers are those located no more than 75 miles from the border of the State of Oregon;

(b) Non-contiguous area providers are those located more than 75 miles from the borders of the State of Oregon.

(123) Outpatient hospital services – Services that are furnished in a hospital for the care and treatment of an outpatient. For information on outpatient-covered services, see the Division’s Hospital Services administrative rules found in chapter 410, division 125.

(124) Overdue claim – A valid claim that is not paid within 45 days of the date it was received.

(125) Overpayment – Payment(s) made by Division to a provider in excess of the correct Division payment amount for a service. Overpayments are subject to repayment to the Division.

(126) Overuse – Use of medical goods or services at levels determined by Division medical staff and/or medical consultants to be medically unnecessary or potentially harmful.

(127) Panel – The Hearing Officer Panel established by section 3, chapter 849, Oregon Laws 1999.

(128) Payment Authorization – Authorization granted by the responsible agency, office or organization for payment prior or subsequent to the delivery of services, as described in these General Rules and the appropriate program rules. See the individual program rules for services requiring authorization.

(129) Peer Review Organization (PRO) – An entity of health care practitioners of services contracted by the State to review services ordered or furnished by other practitioners in the same professional field.

(130) Pharmaceutical Services – Services provided by a Pharmacist, including medications dispensed in a pharmacy upon an order of a licensed practitioner prescribing within his/her scope of practice.

(131) Pharmacist – A person licensed to practice pharmacy pursuant to state law.

(132) Physical Capacity Evaluation – An objective, directly observed measurement of a person’s ability to perform a variety of physical tasks combined with subjective analysis of abilities of the person.

(133) Physical Therapist – A person licensed by the relevant State licensing authority to practice Physical Therapy.

(134) Physical Therapy – Treatment comprising exercise, massage, heat or cold, air, light, water, electricity or sound for the purpose of correcting or alleviating any physical or mental disability, or the performance of tests as an aid to the assessment, diagnosis or treatment of a human being. Physical Therapy shall not include radiology or electrosurgery.

(135) Physician – A person licensed to practice medicine pursuant to state law of the state in which he/she practices medicine, or a person licensed to practice medicine pursuant to federal law for the purpose of practicing medicine under a contract with the federal government.

(136) Physician Assistant – A person licensed as a physician assistant in accordance with ORS 677. Physician assistants provide medical services under the direction and supervision of an Oregon licensed physician according to a practice description approved by the Board of Medical Examiners.

(137) Physician Services – Services provided, within the scope of practice as defined under state law, by or under the personal supervision of a physician.

(138) Podiatric Services – Services provided within the scope of practice of podiatrists as defined under state law.

(139) Podiatrist – A person licensed to practice podiatric medicine pursuant to state law.

(140) Post-Payment Review – Review of billings and/or other medical information for accuracy, medical appropriateness, level of service or for other reasons subsequent to payment of the claim.

(141) Practitioner – A person licensed pursuant to state law to engage in the provision of health care services within the scope of the practitioner’s license and/or certification.

(142) Premium sponsorship – Premium donations made for the benefit of one or more specified Division clients (See 410-120-1390).

(143) Prepaid Health Plan (PHP) – A managed health, dental, chemical dependency, or mental health organization that contracts with the Division and/or AMH on a case managed, prepaid, capitated basis under OHP. PHP’s may be a Chemical Dependency Organization (CDO), Dental Care Organization (DCO), Fully Capitated Health Plan (FCHP), Mental Health Organization (MHO), or Physician Care Organization (PCO)

(144) Primary Care Physician – A physician who has responsibility for supervising, coordinating and providing initial and primary care to patients, initiating Referrals for consultations and specialist care, and maintaining the continuity of patient care.

(145) Primary Care Provider (PCP) – Any enrolled medical assistance provider who has responsibility for supervising, coordinating, and providing initial and primary care within their scope of practice for identified clients. PCPs initiate Referrals for care outside their scope of practice, consultations and specialist care, and assure the continuity of medically appropriate client care.

(146) Prior Authorization (PA) – Payment authorization for specified medical services or items given by Division staff, or its contracted agencies prior to provision of the service. A physician referral is not a PA.

(147) Prioritized List of Health Services – Also referred to as the Prioritized List, the Oregon Health Services Commission’s (HSC) listing of health services with “expanded definitions” of ancillary Services and preventive services and the HSC practice guidelines, as presented to the Oregon Legislative Assembly. The Prioritized List is generated and maintained by HSC. The Prioritized List governs medical assistance programs’ health services and benefit packages pursuant to these General Rules (OAR 410-120-0000 et seq.) and OAR 410-141-0480 through 410-141-0520.

(148) Private Duty Nursing Services – Nursing services provided within the scope of license by a registered nurse or a licensed practical nurse, under the general direction of the patient’s physician to an individual who is not in a health care facility.

(149) Provider – An individual, facility, institution, corporate entity, or other organization which supplies health care services or items, also termed a performing provider, or bills, obligates and receives reimbursement on behalf of a performing provider of services, also termed a billing provider (BP). The term provider refers to both performing providers and BP(s) unless otherwise specified.

(150) Provider Organization – a group practice, facility, or organization that is:

(a) An employer of a provider, if the provider is required as a condition of employment to turn over fees to the employer; or

(b) The facility in which the service is provided, if the provider has a contract under which the facility submits claims; or

(c) A foundation, plan, or similar organization operating an organized health care delivery system, if the provider has a contract under which the organization submits the claim; and

(d) Such group practice, facility, or organization is enrolled with the Authority, and payments are made to the group practice, facility or organization.

(e) If such entity solely submits billings on behalf of providers and payments are made to each provider, then the entity is an agent.

(See Subparts of Provider Organization)

(151) Public Health Clinic – A clinic operated by county government.

(152) Public Rates – The charge for services and items that providers, including Hospitals and nursing facilities, made to the general public for the same service on the same date as that provided to Division clients.

(153) Qualified Medicare Beneficiary (QMB) – A Medicare beneficiary, as defined by the Social Security Act and its amendments.

(154) Qualified Medicare and Medicaid Beneficiary (QMM) – A Medicare beneficiary who is also eligible for Division coverage.

(155) Quality Improvement Organization (QIO) – An entity that has a contract with CMS under Part B of Title XI to perform utilization and quality control review of the health care furnished, or to be furnished, to Medicare and Medicaid clients; formerly known as a Peer Review Organization.

(156) Radiological Services – Those professional and technical radiological and other imaging services for the purpose of diagnosis and treatment ordered by a physician or other licensed practitioner of the healing arts within the scope of practice as defined under state law and provided to a patient by or under the direction of a physician or appropriate licensed practitioner in an office or similar facility, Hospital, or independent radiological facility.

(157) Recipient – A person who is currently eligible for medical assistance (also known as a client).

(158) Recreational therapy – recreational or other activities that are diversional in nature (includes, but is not limited to, social or recreational activities or outlets).

(159) Recoupment – An accounts receivable system that collects money owed by the provider to the Division by withholding all or a portion of a provider’s future payments.

(160) Referral – The transfer of total or specified care of a client from one provider to another. As used by the Division, the term referral also includes a request for a consultation or evaluation or a request or approval of specific services. In the case of clients whose medical care is contracted through a Prepaid Health Plan (PHP), or managed by a Primary Care Physician, a referral is required before non-emergency care is covered by the PHP or the Division.

(161) Remittance Advice (RA) – The automated notice a provider receives explaining payments or other claim actions. It is the only notice sent to providers regarding claim actions.

(162) Request for Hearing – A clear expression, in writing, by an individual or representative that the person wishes to appeal a Department or Authority decision or action and wishes to have the decision considered by a higher authority.

(163) Retroactive Medical Eligibility – Eligibility for medical assistance granted to a client retroactive to a date prior to the client’s application for medical assistance.

(164) Sanction – An action against providers taken by the Division in cases of fraud, misuse or abuse of division requirements.

(165) School Based Health Service – A health service required by an Individualized Education Plan (IEP) during a child’s education program which addresses physical or mental disabilities as recommended by a physician or other licensed practitioner.

(166) Seniors and People with Disabilities Division (SPD) – An Office of the Department responsible for the administration of programs for seniors and people with disabilities.

(167) Service agreement – An agreement between the Division and a specified provider to provide identified services for a specified rate. Service agreements may be limited to services required for the special needs of an identified client. Service agreements do not preclude the requirement for a provider to enroll as a provider.

(168) Sliding Fee Schedule – A fee schedule with varying rates established by a provider of health care to make services available to indigent and low-income individuals. The sliding-fee schedule is based on ability to pay.

(169) Social Worker – A person licensed by the Board of Clinical Social Workers to practice clinical social work.

(170) Speech-Language Pathologist – A person licensed by the Oregon Board of Examiners for Speech Pathology.

(171) Speech-Language Pathology Services – The application of principles, methods, and procedure for the measuring, evaluating, predicting, counseling or instruction related to the development and disorders of speech, voice, or language for the purpose of preventing, habilitating, rehabilitating, or modifying such disorders in individuals or groups of individuals.

(172) Spend-Down – The amount the client must pay for medical expenses each month before becoming eligible for medical assistance under the Medically Needy Program. The spend-down is equal to the difference between the client’s total countable income and Medically Needy program income limits.

(173) State Facility – A Hospital or training center operated by the State of Oregon, which provides long-term medical or psychiatric care.

(174) Subparts (of a provider organization) – For NPI application, subparts of a health care provider organization would meet the definition of health care provider (45 CFR 160.103) if it were a separate legal entity and if it conducted HIPAA-covered transactions electronically, or has an entity do so on its behalf, could be components of an organization or separate physical locations of an organization.

(175 Subrogation – Right of the State to stand in place of the client in the collection of third party resources (TPR).

(164) Supplemental Security Income (SSI) – A program available to certain aged and disabled persons which is administered by the Social Security Administration through the Social Security office.

(177) Surgical Assistant – A person performing required assistance in surgery as permitted by rules of the State Board of Medical Examiners.

(178) Suspension – A sanction prohibiting a provider’s participation in the medical assistance programs by deactivation of the provider’s Division-assigned billing number for a specified period of time. No payments, Title XIX or State Funds, will be made for services provided during the suspension. The number will be reactivated automatically after the suspension period has elapsed.

(179) Targeted Case Management (TCM)- Activities that will assist the client in a target group in gaining access to needed medical, social, educational and other services. This includes locating, coordinating, and monitoring necessary and appropriate services. TCM services are often provided by Allied Agency providers.

(180) Termination – A sanction prohibiting a provider’s participation in the Division’s programs by canceling the provider’s Division-assigned billing number and agreement. No payments, Title XIX or State Funds, will be made for services provided after the date of termination. Termination is permanent unless:

(a) The exceptions cited in 42 CFR 1001.221 are met; or

(b) Otherwise stated by the Division at the time of termination.

(181) Third Party Resource (TPR) – A medical or financial resource which, under law, is available and applicable to pay for medical Services and items for a Division client.

(182) Transportation – See Medical Transportation.

(183) Type A Hospital – A hospital identified by the Office of Rural Health as a Type A hospital.

(184) Type B AAA Unit – A Type B Area Agency on Aging (AAA) funded by Oregon Project Independence (OPI), Title III – Older Americans Act, and Title XIX of the Social Security Act.

(185) Type B Hospital – A hospital identified by the Office of Rural Health as a Type B hospital.

(186) Usual Charge (UC) – The lesser of the following unless prohibited from billing by federal statute or regulation:

(a) The provider’s charge per unit of service for the majority of non-medical assistance users of the same service based on the preceding month’s charges;

(b) The provider’s lowest charge per unit of service on the same date that is advertised, quoted or posted. The lesser of these applies regardless of the payment source or means of payment;

(c) Where the provider has established a written sliding fee scale based upon income for individuals and families with income equal to or less than 200% of the federal poverty level, the fees paid by these individuals and families are not considered in determining the usual charge. Any amounts charged to third party resources (TPR) are to be considered.

(187) Utilization Review (UR) – The process of reviewing, evaluating, and assuring appropriate use of medical resources and services. The review encompasses quality, quantity, and appropriateness of medical care to achieve the most effective and economic use of health care services.

(188) Valid Claim – An invoice received by the Division or the appropriate Authority/Department office for payment of covered health care services rendered to an eligible client which:

(a) Can be processed without obtaining additional information from the provider of the goods or services or from a TPR; and

(b) Has been received within the time limitations prescribed in these General Rules (OAR 410 division 120).

(189) Vision Services – Provision of corrective eyewear, including ophthalmological or optometric examinations for determination of visual acuity and vision therapy and devices.

Stat. Auth.: ORS 409.050, 409.010, 409.110 & 414.065

Stats. Implemented: ORS 414.065

Hist.: AFS 5-1981, f. 1-23-81, ef. 3-1-81; AFS 33-1981, f. 6-23-81, ef. 7-1-81; AFS 47-1982, f. 4-30-82 & AFS 52-1982, f. 5-28-82, ef. 5-1-82, for providers located in the geographical areas covered by the branch offices of North Salem, South Salem, Dallas, Woodburn, McMinnville, Lebanon, Albany and Corvallis, ef. 6-30-82 for remaining AFS branch offices; AFS 57-1982, f. 6-28-82, ef. 7-1-82; AFS 81-1982, f. 8-30-82, ef. 9-1-82; AFS 4-1984, f. & ef. 2-1-84; AFS 12-1984, f. 3-16-84, ef. 4-1-84; AFS 13-1984(Temp), f. & ef. 4-2-84; AFS 37-1984, f. 8-30-84, ef. 9-1-84; AFS 24-1985, f. 4-24-85, ef. 6-1-85; AFS 13-1987, f. 3-31-87, ef. 4-1-87; AFS 7-1988, f. & cert. ef. 2-1-88; AFS 69-1988, f. & cert. ef. 12-5-88; HR 2-1990, f. 2-12-90, cert. ef. 3-1-90, Renumbered from 461-013-0005; HR 25-1991(Temp), f. & cert. ef. 7-1-91; HR 41-1991, f. & cert. ef. 10-1-91; HR 32-1993, f. & cert. ef. 11-1-93; HR 2-1994, f. & cert. ef. 2-1-94; HR 31-1994, f. & cert. ef. 11-1-94; HR 40-1994, f. 12-30-94, cert. ef. 1-1-95; HR 5-1997, f. 1-31-97, cert. ef. 2-1-97; HR 21-1997, f. & cert. ef. 10-1-97; OMAP 20-1998, f. & cert. ef. 7-1-98; OMAP 10-1999, f. & cert. ef. 4-1-99; OMAP 31-1999, f. & cert. ef. 10-1-99; OMAP 11-2000, f. & cert. ef. 6-23-00; OMAP 35-2000, f. 9-29-00, cert. ef. 10-1-00; OMAP 42-2002, f. & cert. ef. 10-1-02; OMAP 3-2003, f. 1-31-03, cert. ef. 2-1-03; OMAP 62-2003, f. 9-8-03, cert. ef.10-1-03; OMAP 67-2004, f. 9-14-04, cert. ef. 10-1-04; OMAP 10-2005, f. 3-9-05, cert. ef. 4-1-05; OMAP 39-2005, f. 9-2-05, cert. ef. 10-1-05; OMAP 65-2005, f. 11-30-05, cert. ef. 1-1-06; OMAP 15-2006, f. 6-12-06, cert. ef. 7-1-06; OMAP 45-2006, f. 12-15-06, cert. ef. 1-1-07; DMAP 24-2007 f. 12-11-07 cert. ef. 1-1-08; DMAP 34-2008, f. 11-26-08, cert. ef. 12-1-08; DMAP 13-2009 f. 6-12-09, cert. ef. 7-1-09; DMAP 11-2011, f. 6-29-11, cert. ef. 7-1-11

410-120-0030

Children’s Health Insurance Program

(1) The Children’s Health Insurance Program (CHIP) is a federal non-entitlement program for children under 19 years of age that provides health coverage for uninsured, low-income children who are ineligible for Medicaid and meet the CHIP eligibility requirements. The CHIP program is administered by the Oregon Health Authority (Authority) in accordance with the Oregon Health Plan waiver and the CHIP state plan. The General Rules Program (OAR 410-120-0000 et. seq.) and Oregon Health Plan Program rules (OAR 410-141-0000 et. seq.) applicable to the Medicaid program are also applicable to the Authority’s CHIP program.

(2) Eligibility criteria, including but not limited to income methodologies and citizenship requirements for medical assistance applicable to children under the age of 19 years, are established in OAR chapter 461 through the program acronym OHP-CHP.

(3) Benefit package of covered services: Children determined eligible for CHIP receive the same OHP Plus benefits as covered under Medicaid categorically needy program. (For benefits refer to OAR 410-120-1210).

(4) CHIP Prenatal coverage for women not eligible for Medicaid at or below 185% of the FPL:

(a) Notwithstanding subsections (2) and (3) of this rule, pregnant women, who are not eligible for Medicaid and who reside in the participating counties during pregnancy will receive expanded medical services (OHP Plus benefit package, as limited under subsection (d) of this subsection) to provide prenatal care for the unborn child and labor and delivery services through this expansion program. The benefit identifier for this category is BMH, PERC code CX:

(A) Effective 4/1/08 Multnomah and Deschutes;

(B) Effective 10/1/09 Benton, Clackamas, Hood River and Jackson;

(C) Effective 1/1/11 Lane.

(D) Effective 7/1/11 Columbia, Crook, Douglas, Jefferson, Morrow, Union and Wasco.

(b) This population is exempt from managed care enrollment. The preferred service delivery system will be Primary Care Management (PCM). Fee-for-service (FFS) enrollment will be available by exception for continuity of care or other Authority-approved reasons that could justify disenrollment from a PCM under OAR 410-141-0085;

(c) Pilot project services continue through labor and delivery. The day after pregnancy ends, eligibility for medical services is based on eligibility categories established in OAR chapter 461;

(d) The following services are not covered for the pilot project:

(i) Postpartum care beyond the global payment;

(ii) Sterilization;

(iii) Abortion;

(iv) Death with dignity services;

(v) Hospice.

Stat. Auth.: ORS 409.010, 409.040 & 409.050

Stats. Implemented: ORS 414.025 & 414.065

Hist.: DMAP 7-2008(Temp), f. 3-17-08 & cert. ef. 4-1-08 thru 9-15-08; DMAP 14-2008, f. 6-13-08, cert. ef. 7-1-08; DMAP 29-2009(Temp), f. 9-15-09, cert. ef. 10-1-09 thru 3-25-10; DMAP 37-2009, f. 12-15-09, cert. ef. 1-1-10; DMAP 18-2010, f. 6-23-10, cert. ef. 7-1-10; DMAP 23-2010, f. & cert. ef. 9-1-10; DMAP 39-2010, f. 12-28-10, cert. ef. 1-1-11; DMAP 11-2011, f. 6-29-11, cert. ef. 7-1-11

410-120-1560

Provider Appeals

(1) For purposes of Division of Medical Assistance Programs (Division) provider appeal rules in chapter 410, division 120 the following terms and definitions are used:

(a) “Provider” means a person or entity enrolled with the Division, or under contract with the Division that is subject to the Division rules, that has requested an appeal in relation to health care, items, drugs or services provided or requested to be provided to a client on a fee-for-service basis or under contract with the Division where that contract expressly incorporates these rules;

(b) “Provider Applicant” means a person or entity that has submitted an application to become an enrolled provider with the Division but the application has not been approved;

(c) “Prepaid Health Plan” has the meaning in OAR 410-141-0000, except to the extent that Mental Health Organizations (MHO) have separate procedures applicable to provider grievances and appeals;

(d) “Prepaid Health Plan provider” means a person or entity enrolled with the Division but that provided health care services, supplies or items to a client enrolled with a PHP, including both participating providers and non-participating providers as those terms are defined in OAR 410-141-0000, except that services provided to a client enrolled with an MHO shall be governed by the provider grievance and appeal procedures administered by the Office of Mental Health and Addiction Services;

(e) The “Provider Appeal Rules” refers to the rules in OAR 410-120-1560 to 410-120-1700, describing the availability of appeal procedures and the procedures applicable to each appeal procedure.

(f) “Non-participating provider” has the meaning in OAR 410-141-0000

(2) A Division of Medical Assistance Programs (Division) enrolled provider may appeal a Division decision in which the provider is directly adversely affected such as the following:

(a) A denial or limitation of payment allowed for services or items provided;

(b) A denial related to a NCCI edit;

(c) A denial of provider’s application for new or continued participation in the Medical Assistance Program; or

(d) Sanctions imposed, or intended to be imposed, by the Medical Assistance program on a provider or provider entity; and

(e) Division overpayment determinations made under OAR 410-120-1397.

(3) Client appeals of actions must be handled in accordance with OAR 140-120-1860 and 410-120-1865.

(4) A provider appeal is initiated by filing a timely request in writing for review with the Division.

(a) A provider appeal request is not required to follow a specific format as long as it provides a clear written expression from a provider or provider applicant expressing disagreement with a Division decision or from a Prepaid Health Plan (PHP) provider expressing disagreement with a decision by a PHP.

(b) The request should identify the decision made by the Division or a PHP that is being appealed and the reason the provider disagrees with that decision.

(c) A provider appeal request is timely if it is received by the Division within 180 calendar days of the date of the Division’s decision or the date of the PHP decision on the provider’s appeal to the PHP.

(5) Types and methods for provider appeals are listed below.

(a) A Division of Medical Assistance Programs (Division) denial of or limitation of payment allowed, Division claim decision including prior authorization decision, or Division overpayment determination for services or items provided to a client must be appealed as claim re-determinations under OAR 410-120-1570.

(b) A notice of sanctions imposed, or intended to be imposed, the effect of the notice of sanction is, or will be, to deny suspend or revoke a provider number necessary to participate in the medical assistance on a provider, or provider applicant is entitled to appeal under OAR 410-120-1600. A provider that is entitled to appeal a notice of sanction as a contested case may request administrative review instead of contested case hearing if the provider submits a written request for administrative review of the notice of sanction and agrees in writing to waive the right to a contested case hearing and the Division agrees to review the appeal of the notice of sanction as an administrative review.

(c) All provider appeals of Division decisions not described in paragraphs (4)(a) or (b) are handled as administrative reviews in accordance with OAR 410-120-1580, unless Division issues an order granting a contested case hearing.

(6) Decisions that adversely affect a provider may be made by different program areas within the Department/Authority.

(a) Decisions issued by the Office of Payment Accuracy and Recovery (OPAR) or the Department information security office shall be appealed in accordance with the process described in the notice,

(b) Other program areas within the Department/Authority that have responsibility for administering medical assistance funding, such as nursing home care or community mental health and developmental disabilities program services, may make decisions that adversely affect a provider. Those providers are subject to the provider grievance or appeal processes applicable to those payment or program areas.

(c) Some decisions that adversely affect a provider are issued on behalf of the Division by Department or Authority contractors such as the Division pharmacy benefits manager, by entities performing statutory functions related to the medical assistance programs such as the Drug Use Review Board, or by other entities in the conduct of program integrity activities applicable to the administration of the medical assistance programs. For these decisions made on behalf of the division in which the Division has legal authority to make the final decision in the matter, a provider may appeal such a decision to the Division as an administrative review and the Division may accept such review.

(d) This rule does not apply to contract administration issues that may arise solely between the Division and a PHP. Such issues shall be governed by the terms of the applicable contract.

(e) The Division provides limited provider appeals for Prepaid Health Plan providers (PHP providers) or non-participating providers concerning a decision by a Prepaid Health Plan (PHP). In general, the relationship between a PHP and PHP providers is a contract matter between them. Client appeals are handled under the client appeal rules, not provider appeal rules.

(i) The PHP provider seeking a provider appeal must have a current valid provider enrollment agreement with the Division and, unless the provider is a non-participating provider, must also have a contract with the Prepaid Health Plan as a PHP provider; and

(ii) The PHP provider or non-participating provider must have exhausted the applicable appeal procedure established by the PHP and the request for provider appeal must include a copy of the written decision(s) of the PHP that is being appealed from and a copy of any PHP policy being applied in the appeal; and

(iii) The PHP provider appeal or non-participating provider appeal from a PHP decision is limited to issues related to the scope of coverage and authorization of services under the Oregon Health Plan, including whether services are included as covered on the Prioritized List, guidelines, and in the OHP Benefit package. The Division provider appeal process does not include PHP payment or claims reimbursement amount issues, except in relation to non-participating provider matters governed by Division rule.

(iv) A timely provider appeal must be made within 30 calendar days from the date of the PHP’s decision and include evidence that the PHP was sent a copy of the provider appeal. In every provider appeal involving a PHP decision, the PHP will be treated as a participant in the appeal.

(7) In the event a request for provider appeal is not timely, the Division will determine whether the failure to file the request was caused by circumstances beyond the control of the provider, provider applicant or PHP provider. In determining whether to accept a late request for review, the Division requires the request to be supported by a written statement that explains why the request for review is late. The Division may conduct such further inquiry as the Division deems appropriate. In determining timeliness of filing a request for review, the amount of time that the Division determines accounts for circumstances beyond the control of the provider is not counted. The Division may refer an untimely request to the Office of Administrative Hearings for a hearing on the question of timeliness.

(8) The burden of presenting evidence to support a provider appeal is on the provider, provider applicant or PHP provider.

(a) Consistent with OAR 410-120-1360, payment on a claim will only be made for services that are adequately documented and billed in accordance with OAR 410-120-1280 and all applicable administrative rules related to covered services for the client’s benefit package and establishing the conditions under which services, supplies or items are covered, such as the Prioritized List, medical appropriateness and other applicable standards.

(b) Eligibility for enrollment and for continued enrollment is based on compliance with applicable rules, the information submitted or required to be submitted with the application for enrollment and the enrollment agreement, and the documentation required to be produced or maintained in accordance with OAR 410-120-1360.

(9) Provider appeal proceedings, if any, will be held in Salem, unless otherwise stipulated to by all parties and agreed to by the Division.

Stat. Auth.: ORS 409.050, 409.010, 409.110 & 414.065

Stats. Implemented: ORS 409.010

Hist.: AFS 13-1984(Temp), f. & ef. 4-2-84; AFS 37-1984, f. 8-30-44, ef. 9-1-84; AFS 51-1985, f. 8-16-85, ef. 9-1-85; AFS 47-1982, f. 4-30-82 & AFS 52-1982, f. 5-28-82, ef. 5-1-82 for providers located in the geographical areas covered by the branch offices of North Salem, South Salem, Dallas, Woodburn, McMinnville, Lebanon, Albany and Corvallis, ef. 6-30-82 for remaining AFS branch offices; HR 2-1990, f. 2-12-90, cert. ef. 3-1-90, Renumbered from 461-013-0191; HR 41-1991, f. & cert. ef. 10-1-91; HR 32-1993, f. & cert. ef. 11-1-93, Renumbered from 410-120-0780; HR 5-1997, f. 1-31-97, cert. ef. 2-1-97; OMAP 41-2000, f. & cert. ef. 12-1-00; OMAP 19-2003, f. 3-26-03, cert. ef. 4-1-03; OMAP 39-2005, f. 9-2-05, cert. ef. 10-1-05; OMAP 15-2006, f. 6-12-06, cert. ef. 7-1-06; DMAP 24-2007, f. 12-11-07 cert. ef. 1-1-08; DMAP 13-2009 f. 6-12-09, cert. ef. 7-1-09; DMAP 11-2011, f. 6-29-11, cert. ef. 7-1-11

 

Rule Caption: 7/11 – Expanding access to diabetic supplies by allowing both DMEPOS providers and pharmacies to dispense.

Adm. Order No.: DMAP 12-2011

Filed with Sec. of State: 6-29-2011

Certified to be Effective: 7-1-11

Notice Publication Date: 6-1-2011

Rules Amended: 410-122-0520

Subject: The Durable Medical Equipment, Prosthetics, Orthotics and Supplies Program administrative rules govern Division payments for services to certain clients. The Division amended this administrative rule governing diabetic supplies to:

      • Accommodate pharmacies as eligible dispensing agents of this supply type;

      • Clarify the requirements of prior authorization and supply limitations;

      • Add new claims submission criteria that are needed to implement this expansion to client access;

      • Reflect the Division’s governing agency change from Department of Human Resources to Oregon Health Authority and update statutory reference.

      • Improve readability and to take care of other necessary “housekeeping” corrections.

Rules Coordinator: Darlene Nelson—(503) 945-6927

410-122-0520

Glucose Monitors and Diabetic Supplies

(1) Indications and limitations of coverage and medical appropriateness:

(a) The Division of Medical Assistance Programs (Division) may cover home blood glucose monitors and related diabetic supplies for clients with diabetes who can self-monitor blood glucose (SMBG) or be monitored with assistance;

(b) Coverage of home blood glucose monitors is limited to clients meeting all of the following conditions:

(A) The client has diabetes which is being treated by a practitioner; and

(B) The glucose monitor and related accessories and supplies have been ordered by a practitioner who is treating the client’s diabetes; and

(C) The client or caregiver has successfully completed training or is scheduled to begin training in the use of the monitor, test strips, and lancing devices; and

(D) The client or caregiver is capable of using the test results to assure the client’s appropriate glycemic control; and

(E) The device is designed for home use;

(c) Home blood glucose monitors with special features (E2100 or E2101) may be covered for clients who meet the basic coverage criteria (1)(b)(A)-(E) of this rule; and:

(A) The treating practitioner certifies that the client has a severe visual impairment (i.e., best corrected visual acuity of 20/200 or worse) requiring use of this special monitoring system; or

(B) For code E2101, the treating practitioner certifies that the client has an impairment of manual dexterity severe enough to require the use of this special monitoring system.

(d) If a glucose monitor is covered, lancets blood glucose test reagent strips glucose control solutions insulin syringes and spring powered devices for lancets) may also be covered. Coverage limitations for these supplies are as follows:

(A) A4258 – only one spring powered device every six months;

(B) A4253 and A4259 – The provider of the test strips and lancets must maintain, in their records, the order from the treating practitioner. Before dispensing more test strips and lancets, the client must have nearly exhausted their supply. The amount of test strips and lancets covered are based on the needs of the client according to the following limitations:

(i) Up to 100 test strips and 100 lancets every three months for clients who are not currently being treated with insulin injections;

(ii) Up to 100 test strips and 100 lancets every month for clients who are currently being treated with insulin injections;

(iii) For clients under age 19 with Type I diabetes, up to 100 test strips and 100 lancets every month;

(iv) For clients with gestational diabetes:

(I) Insulin-treated: Up to 100 test strips and 100 lancets per month no longer than 60 days beyond the duration of the pregnancy;

(II) Non-insulin treated: Up to 100 test strips and 100 lancets per month no longer than 60 days beyond the duration of the pregnancy;

(v) Upon refills of quantities that exceed the utilization guidelines, the treating practitioner must have:

(I) Documented in the client’s medical record the specific reason for the additional supplies for that particular client; and

(II) Seen the client and have evaluated their diabetes control within six months prior to ordering quantities that exceed the utilization guidelines; and

(III) Documented in the client’s medical record, a specific narrative statement that adequately specifies the frequency at which the client is actually testing or a copy of the client’s log; or there must be documentation in the provider’s records, (e.g., a copy of the client’s log) that the client is actually testing at a frequency that corroborates the quantity of supplies that have been dispensed. If the client is regularly using quantities of supplies that exceed the utilization guidelines, new documentation must be present at least every six months;

(C) Home blood glucose monitors are subject to a limit of one monitor per two calendar years.

(e) Diabetic supply providers must not dispense a quantity of supplies exceeding a client’s expected utilization. Providers should stay attuned to atypical utilization patterns on behalf of their clients and verify with the ordering practitioner that the atypical utilization is, in fact, warranted. Regardless of utilization, a provider must not dispense more than a three month quantity of glucose testing supplies (i.e. up to 300 test strips, 300 lancets, and 500 insulin syringes) at a time. A PA must be obtained prior to dispensing amounts in excess of these utilization limits.;

(f) Providers may contact the treating practitioner to renew an order; however, the request for renewal may only be made with the client’s continued monthly use of testing supplies and only with the client’s or caregiver’s request to the provider for order renewal;

(g) An order refill does not have to be approved by the ordering practitioner; however, a client or their caregiver must specifically request refills of glucose monitor supplies before they are dispensed. The provider must not automatically dispense a quantity of supplies on a predetermined regular basis, even if the client has “authorized” this in advance;

(h) Purchase fee for a glucose monitor includes normal, low and high-calibrator solution/chips (A4256), a battery (A4233, A4234, A4235 or A4236) and a spring-powered lancet device (A4258);

(i) The following services are not covered:

(A) Peroxide (A4244), betadine or phisoHex (A4246, A4247); (B) Alternate site blood glucose monitors;

(C) Blood glucose monitors and related supplies prescribed on an “as needed” basis;

(D) Blood glucose test or reagent strips that use a visual reading and are not used in a glucose monitor;

(E) Continuous glucose monitoring devices;

(F) Disposable gloves;

(G) Home blood glucose disposable monitors;

(H) Jet injectors;

(I) Insulin delivery devices and related supplies;

(J) Reflectance colorimeter devices used for measuring blood glucose levels in clinical settings;

(K) Urine test or reagent strips or tablets.

(2) Guidelines:

(a) Insulin-treated means that the client is receiving insulin injections to treat their diabetes. Insulin does not exist in an oral form and therefore clients taking oral medication to treat their diabetes are not insulin-treated;

(b) A severe visual impairment is defined as a best corrected visual acuity of 20/200 or worse in both eyes;

(c) An order renewal is the act of obtaining an order for an additional period of time beyond that previously ordered by the treating practitioner;

(d) An order refill is the act of replenishing quantities of previously ordered items during the time period in which the current order is valid;

(e) A4256 describes control solutions containing high, normal, and low concentrations of glucose that can be applied to test strips to check the integrity of the test strips. This code does not describe the strip or chip which is included in a vial of test strips and which calibrates the glucose monitor to that particular vial of test strips;

(f) For glucose test strips (A4253), 1 unit of service = 50 strips. For lancets (A4259), 1 unit of service = 100 lancets;

(3) Documentation requirements:

(a) For codes requiring prior authorization (PA), submit documentation which supports coverage criteria as specified in this rule are met;

(b) The order for home blood glucose monitors and/or diabetic testing supplies must include all of the following:

(A) All item(s) to be dispensed;

(B) The specific frequency of testing;

(C) The treating practitioner’s signature;

(D) The date of the treating practitioner’s signature;

(E) A start date of the order - only required if the start date is different than the signature date;

(c) A new order must be obtained when there is a change in the testing frequency;

(d) For E2100 or E2101 in a client with impaired visual acuity, submit documentation which includes a narrative statement from the practitioner that indicates the client’s specific numerical visual acuity (e.g., 20/400) and that this result represents “best corrected” vision;

(e) For E2101 - clients with impaired manual dexterity, submit documentation which includes a narrative statement from the practitioner that indicates an explanation of the client’s medical condition necessitating the monitor with special features;

(f) When requesting quantities of supplies which exceed utilization guidelines as specified in (1)(d)(B)(i)-(iv) (e.g., more than 100 blood glucose test strips per month for insulin-dependent diabetes mellitus), submit documentation supporting the medical appropriateness for the higher utilization as specified in (1)(d)(B)(v)(I)-(III) to the appropriate authorization authority for PA;

(g) Documentation which supports condition of coverage requirements for codes billed in this rule must be kept on file by the DMEPOS provider and made available to the Division on request;

(h) The appropriate diagnosis code describing the condition that necessitates glucose testing must be included on each claim for the monitor, accessories and supplies;(k) Diabetic supply providers are not prohibited from creating data collection forms in order to gather medically appropriate information; however, the Division will not rely solely on those forms to prove the medical appropriateness of services provided;

(l) A client’s medical records must support the justification for supplies dispensed and billed to the Division.

(4) Billing and Payment Guidelines

(a) Diabetic supplies must be billed using a National Drug Code (NDC) and be submitted to the Division via the Web Portal or Point of Sale Systems via pharmacy claim format. Claims submitted on these systems without NDC’s will not be processed. This NDC requirement applies to:

(A) Home glucose monitors; and

(B) Blood glucose test reagent strips;

(C) Lancets;

(D) Insulin syringes;

(E) Spring powered lancet devices;

(F) Calibrating solutions and chips.

(b) For specialized glucose monitors and the respective testing supplies, such as those with special features for the visually impaired and those with manual dexterity problems, provider must obtain a prior authorization (PA). After PA the provider can submit a professional claim to the Division.

(c) For orders received from prescribing clinician for blood glucose test reagent strips that exceed utilization guidelines outlined in Section (1)(d)(B)(i-iv) will require PA from the Division. Diabetic supply providers may initially dispense up to utilization limits (i.e. 300 test strips, 300 lancets, and 500 insulin syringes) prior to obtaining PA for orders that exceed utilization guidelines. After PA is issued the remaining amount may be dispensed for a three month time period.

(3) Procedure Codes: Table 122-0520 – Diabetic Supplies

[ED. NOTE: Tables referenced are available from the agency.]

Stat. Auth.: ORS 409.010, 409.050, 409.110, 414.065

Stats. Implemented: ORS 414.065

Hist.: HR 13-1991, f. & cert. ef. 3-1-91; HR 9-1993, f. & cert. ef. 4-1-93; HR 10-1994, f. & cert. ef. 2-15-94; HR 41-1994, f. 12-30-94, cert. ef. 1-1-95; HR 17-1996, f. & cert. ef. 8-1-96; HR 7-1997, f. 2-28-97, cert. ef. 3-1-97; OMAP 11-1998, f. & cert. ef. 4-1-98; OMAP 13-1999, f. & cert. ef. 4-1-99; OMAP 37-2000, f. 9-29-00, cert. ef. 10-1-00; OMAP 32-2001, f. 9-24-01, cert. ef. 10-1-01; OMAP 8-2002, f. & cert. ef. 4-1-02; OMAP 47-2002, f. & cert. ef. 10-1-02; OMAP 44-2004, f. & cert. ef. 7-1-04; OMAP 35-2006, f. 9-15-06, cert. ef. 10-1-06; DMAP 12-2007, f. 6-29-07, cert. ef. 7-1-07; DMAP 17-2008, f. 6-13-08, cert. ef. 7-1-08; DMAP 15-2009 f. 6-12-09, cert. ef. 7-1-09; DMAP 12-2011, f. 6-29-11, cert. ef. 7-1-11

 

Rule Caption: 7/11 – Implement, administer and audit the Oregon Medicaid Electronic Health Record (EHR) Incentive Program.

Adm. Order No.: DMAP 13-2011

Filed with Sec. of State: 6-29-2011

Certified to be Effective: 7-1-11

Notice Publication Date: 6-1-2011

Rules Adopted: 410-165-0000, 410-165-0020, 410-165-0040, 410-165-0080, 410-165-0100, 410-165-0120, 410-165-0140

Subject: The Medicaid (EHR) Incentive Program administrative rules govern Division of Medical Assistance Programs payments to certain providers. The Division adopted the rules listed above because Section 4201 of the American Reinvestment and Recovery Act of 2009 established a voluntary program to disburse incentive payments to Medicaid providers who adopt, implement, or upgrade, or become meaningful users of certified electronic health record systems.

      These rules outline the Medicaid EHR Incentive Program criteria for participation of eligible professionals and eligible hospitals that adopt, implement, or upgrade, or successfully demonstrate meaningful use of certified electronic health record technology, and are qualified by the program.

      Implementation of these rules is pending approval from the Centers for Medicare and Medicaid Services.

      Note: OAR 410-165 0060 is re-filed to be effective July 22, 2011.

Rules Coordinator: Darlene Nelson—(503) 945-6927

410-165-0000

Basis and Purpose

(1) Oregon Administrative Rules (OAR) chapter 410, division 165, govern the Oregon Health Authority (Authority), Division of Medical Assistance Programs (Division), Medicaid Electronic Health Record (EHR) Incentive Program. The Medicaid EHR Incentive Program provides incentive payments to eligible providers participating in the Medicaid program who adopt, implement or upgrade, or successfully demonstrate meaningful use of certified EHR technology and who are qualified by the program.

(2) The Medicaid EHR Incentive Program is implemented pursuant to:

(a) The American Reinvestment and Recovery Act of 2009, Pub. L. No. 111-5, section 4201;

(b) The Centers for Medicare and Medicaid Services (CMS) federal regulation 42 CFR Part 495 (2010) pursuant to the Social Security Act sections 1903(a)(3)(F) and 1903(t);

(c) The Division’s General Rules Program, OAR chapter 410, division 120;

(d) The Authority’s General Rules Program, OAR chapter 943, division 120; and

(e) The Department of Human Services’ Administrative Services Division and Director’s Office Provider Rules, OAR chapter 407, division 120.

Stat. Auth.: ORS 413.042

Stats. Implemented: ORS 409.010, 413.042, 414.033

Hist.: DMAP 13-2011, f. 6-29-11, cert. ef. 7-1-11

410-165-0020

Definitions

For the purposes of the Medicaid Electronic Health Record (EHR) Incentive Program Oregon Administrative Rules (OAR), chapter 410, division 165, the following definitions apply:

(1) Acceptance documents – Written evidence supplied by a provider to demonstrate that the provider met Medicaid EHR Incentive Program eligibility criteria or participation requirements according to standards specified by the Oregon Health Authority’s (Authority) Division of Medicaid Assistance Programs.

(2) Acute care hospital – A healthcare facility, including but not limited to a critical access hospital, with a Centers for Medicare and Medicaid Services’ (CMS) certification number (CCN) that ends in 0001-0879 or 1300-1399; and where the average length of patient stay is 25 days or fewer.

(3) Adopt, implement or upgrade:

(a) Acquire, purchase, or secure access to certified EHR technology

(b) Install or commence utilization of certified EHR technology capable of meeting meaningful use requirements; or

(c) Expand the available functionality of certified EHR technology capable of meeting meaningful use requirements at the practice site, including staffing, maintenance, and training, or upgrade from existing EHR technology to certified EHR technology.

(4) Certified EHR technology – As defined in 42 CFR 495.4 (2010) and 45 CFR 170.102 (2010 and 2011) per the Office of the National Coordinator for Health Information Technology EHR certification criteria.

(5) Children’s hospital – A separately certified hospital, either freestanding or hospital-within hospital that has a CCN that ends in 3300–3399; and predominantly treats individuals under 21 years of age.

(6) Dentist – As defined in OAR 410-120-0000; and as defined in 42 CFR 440.100.

(7) Eligible hospital – An acute care hospital with at least 10% Medicaid patient volume or a children’s hospital.

(8) Eligible professional – A physician; a dentist; a nurse practitioner, including a nurse-midwife nurse practitioner; or a physician assistant practicing in a Federally Qualified Health Center (FQHC) led by a physician assistant or a Rural Health Clinic (RHC), that is so led by a physician assistant, and meets patient volume requirements described in OAR 410-165-0060.

(9) Eligible provider – Eligible hospital or eligible professional.

(10) Encounter:

(a) For an eligible hospital either may apply:

(A) Services rendered to an individual per inpatient discharge; or

(B) Services rendered in an emergency department on any one day;

(b) For an eligible professional, services rendered to an individual on any one day.

(11) Enrolled provider – A hospital or health care practitioner who is actively registered with the Authority pursuant to OAR 407-120-0320.

(12) Entity promoting the adoption of certified EHR technology – An entity, designated by the Authority, that promotes the adoption of certified EHR technology by enabling: oversight of the business, operational and legal issues involved in the adoption and implementation of certified EHR technology; or the exchange and use of electronic clinical and administrative data between participating providers, in a secure manner, including but not limited to maintaining the physical and organizational relationship integral to the adoption of certified EHR technology by eligible providers.

(13) Federal fiscal year (FFY) – October 1 to September 30.

(14) Federally Qualified Health Center (FQHC) – As defined in OAR 410-120-0000.

(15) Group – A clinic as defined in OAR 407-120-0100.

(16) Hosital-based – An eligibility criterion that excludes an eligible professional from participating in the Medicaid EHR Incentive Program when an eligible professional furnishes 90 percent or more of the eligible professional’s Medicaid covered services in a hospital emergency room (place of service code 23), or inpatient hospital (place of service code 21) in the calendar year (CY) preceding the payment year.

(17) Individuals receiving Medicaid – Individuals served by an eligible provider where the services rendered would qualify under the Medicaid encounter definition.

(18) Meaningful EHR user— An eligible provider that, for an EHR reporting period for a payment year, demonstrates (in accordance with 42 CFR 495.8) meaningful use of certified EHR technology by meeting the applicable objectives and associated measures in 42 CFR 495.6 and as prescribed by 42 CFR Part 495.

(19) Medicaid encounter:

(a) For an eligible hospital either may apply:

(A) Services rendered to an individual per inpatient discharge where Medicaid (or a Medicaid demonstration project approved under the Social Security Act section 1115) paid for part or all of the service; or Medicaid (or a Medicaid demonstration project approved under the Social Security Act section 1115) paid all or part of the individual’s premiums, copayments, or cost-sharing; or

(B) Services rendered in an emergency department on any one day where Medicaid (or a Medicaid demonstration project approved under the Social Security Act section 1115) paid for part or all of the service; or Medicaid (or a Medicaid demonstration project approved under the Social Security Act section 1115) paid all or part of the individual’s premiums, copayments, and cost-sharing;

(b) For an eligible professional either may apply:

(A) Services rendered to an individual on any one day where Medicaid (or a Medicaid demonstration project approved under the Social Security Act section 1115) paid for part or all of the service; or

(B) Medicaid (or a Medicaid demonstration project approved under the Social Security Act section 1115) paid all or part of the individual’s premiums, copayments, and cost-sharing.

(20) National Provider Identifier – As defined in 45 CFR Part 160 and OAR 410-120-0000.

(21) Needy individual – Individuals served by an eligible professional where the services rendered qualify under the needy individual encounter definition.

(22) Needy individual encounter – Services rendered to an individual on any one day where:

(a) Medicaid or Children’s Health Insurance Program (CHIP) (or a Medicaid or CHIP demonstration project approved under the Social Security Act section 1115) paid for part or all of the service;

(b) Medicaid or CHIP (or a Medicaid or CHIP demonstration project approved under the Social Security Act section 1115) paid all or part of the individual’s premiums, copayments, or cost-sharing;

(c) The services were furnished at no cost, and calculated consistent with 42 CFR 495.310(h); or

(d) The services were paid for at a reduced cost based on a sliding scale determined by the individual’s ability to pay.

(23) Nurse practitioner – As defined in OAR 410-120-0000; and as defined in 42 CFR 440.166.

(24) Panel – A managed care panel, medical or health home program panel, or similar provider structure with capitation or case assignment that assigns patients to providers.

(25) Payment year —

(a) The CY for an eligible professional; or

(b) The FFY for an eligible hospital.

(26) Pediatrician – A physician who predominately treats individuals under 21.

(27) Physician – As defined in OAR 410-120-0000; and as defined in 42 CFR 440.50.

(28) Physician assistant – As defined in OAR 410-120-0000; and as defined in 42 CFR 440.60.

(29) Practices predominately – An eligibility criterion to permit use of needy individual patient volume that applies when more than 50 percent of an eligible professional’s total patient encounters over a period of six months in the calendar year preceding the payment year occur at an FQHC or RHC.

(30) Preparer – A person authorized by a provider to act on behalf of the provider to complete an application for a Medicaid EHR incentive via an electronic media connection with the Authority.

(31) Provider Web Portal – The Department of Human Services’ web site that provides a secure gateway for authorized providers to apply for the Medicaid EHR Incentive Program.

(32) Qualify – The Medicaid EHR Incentive Program determines an eligible provider meets the eligibility criteria and participation requirements to receive a Medicaid EHR incentive payment for the payment year.

(33) Rural Health Clinic (RHC) – A clinic located in a rural and medically underserved community, designated as an RHC by CMS. Payment by Medicare and Medicaid to an RHC is on a cost-related basis for outpatient physician and certain non-physician services.

(34) So led – When an FQHC or RHC has a physician assistant who is:

(a) The primary provider in the clinic;

(b) A clinical or medical director at the clinical site of practice; or

(c) An owner of the RHC.

Stat. Auth.: ORS 413.042

Stats. Implemented: ORS 409.010, 413.042, 414.033

Hist.: DMAP 13-2011, f. 6-29-11, cert. ef. 7-1-11

410-165-0040

Application

(1) An eligible provider must apply to the Medicaid Electronic Health Record (EHR) Incentive Program each year that the eligible provider seeks an incentive payment. In order to apply, an eligible provider must:

(a) Register with the Centers for Medicare and Medicaid Services (CMS) for each payment year;

(b) Apply to the Oregon Medicaid EHR Incentive Program after registering with CMS for each payment year; and

(c) Attest, and ensure that the eligible provider’s preparer attests, that:

(A) The information submitted is true, accurate, and complete; and

(B) Any falsification or concealment of a material fact may be prosecuted under federal and state laws;

(d) Maintain, for a period of no less than seven years from the date of completed application, complete, accurate, and unaltered copies of all acceptance documents associated with all data transmissions and attestations. The information maintained must include, at a minimum documentation to support:

(A) The adoption, implementation, or upgrade of certified EHR technology including, but not limited to the purchase agreement or contract;

(B) Demonstration of meaningful use for the year corresponding to the payment year;

(C) Patient volume for the year corresponding to the payment year; and

(D) The eligible hospital’s payment calculation data including, but not limited to Medicare cost reports.

(2) An eligible provider may submit to Oregon the acceptance documents to support attestation at application.

(3) The Medicaid EHR Incentive Program reviews the completed application and the documentation provided to determine if the eligible provider qualifies for an incentive payment:

(a) The information provided may be subject to verification by the program;

(b) The Medicaid EHR Incentive Program determines if the eligible provider’s information complies with the eligibility criteria and participation requirements;

(c) The program notifies the eligible provider about the incentive payment determination;

(d) The Oregon Health Authority (Authority) may reduce the incentive payment to pay off debt if an eligible provider or incentive payment recipient owes a debt under a collection mandate to the state of Oregon. The incentive payment is considered paid to the eligible provider even when part or all of the incentive may offset the debt. The Authority may not reduce the incentive payment amount for any other purpose unless permitted or required by federal or state regulation; and

(e) The Authority distributes 1099 forms to the tax identification number designated to receive the Medicaid EHR incentive payment.

Stat. Auth.: ORS 413.042

Stats. Implemented: ORS 409.010, 413.042, 414.033

Hist.: DMAP 13-2011, f. 6-29-11, cert. ef. 7-1-11

410-165-0080

Meaningful Use

(1) An eligible provider must demonstrate being a meaningful Electronic Health Record (EHR) user as prescribed by 42 CFR 495.4 and 42 CFR 495.8.

(2) An eligible provider must satisfy meaningful use objectives and measures as prescribed by 42 CFR 495.6. The state of Oregon has an exception that requires an eligible provider to satisfy the objective “Capability to submit electronic data to immunization registries or immunization information systems and actual submission in accordance with applicable law and practice” as part of the core requirements for Stage 1:

(a) If an eligible hospital is deemed to be a meaningful EHR user by Medicare for a payment year, then the eligible hospital is automatically deemed to be a meaningful EHR user for the Medicaid EHR Incentive Program for the same payment year;

(b) An eligible hospital deemed to be a meaningful EHR user by Medicare for a payment year does not have to meet Oregon’s exception to qualify for the Medicaid EHR incentive payment for the same payment year.

Stat. Auth.: ORS 413.042

Stats. Implemented: ORS 409.010, 413.042 & 414.033

Hist.: DMAP 13-2011, f. 6-29-11, cert. ef. 7-1-11

410-165-0100

Participation and Incentive Payments

(1) An eligible provider applying for a Medicaid Electronic Health Record (EHR) incentive payment must meet the Medicaid EHR Incentive Program eligibility criteria and participation requirements for each year that the eligible provider applies to qualify for an incentive payment:

(a) An eligible provider must meet the eligibility criteria for each payment year of:

(A) Type of eligible provider;

(B) Patient volume minimum; and

(C) Certified EHR technology requirements for the first payment year and meaningful use requirements for the subsequent payment years;

(b) An eligible provider must meet the participation requirements for each payment year including:

(A) Be an enrolled Medicaid provider with the Oregon Health Authority’s (Authority) Division of Medical Assistance Programs (Division);

(B) Provide up to date provider information to the Division;

(C) Possess an active professional license and comply with all licensing statutes and regulations within the state where the eligible provider practices;

(D) Possess an active Provider Web Portal account;

(E) Be able to receive electronic funds transfer from the Authority; and

(F) Comply with all applicable Oregon Administrative Rules (OAR), including chapter 407, division 120, chapter 410, division 120, and chapter 943, division 120;

(c) An eligible professional may reassign the entire amount of the incentive payment to:

(A) The eligible professional’s employer with which the eligible professional has a contractual arrangement allowing the employer to bill and receive payments for the eligible professional’s covered professional services;

(B) An entity with which the eligible professional has a contractual arrangement allowing the entity to bill and receive payments for the eligible professional’s covered professional services; or

(C) An entity promoting the adoption of certified EHR technology.

(2) An eligible professional must follow the Medicaid EHR Incentive Program participation conditions including an eligible professional must:

(a) Receive an incentive payment from only one state for a payment year;

(b) Only receive an incentive payment from either Medicare or Medicaid for a payment year, but not both;

(c) Not receive more than the maximum incentive amount of $63,750 over a six-year period; or the maximum incentive of $42,500 over a six-year period if the eligible professional qualifies as a pediatrician who meets the 20 percent patient volume minimum and less than the 30 percent patient volume;

(d) Participate in the Medicaid EHR Incentive Program:

(A) Starting as early as calendar year (CY) 2011, but no later than CY 2016;

(B) Ending no later than CY 2021;

(C) For a maximum of six years; and

(D) On a consecutive or non-consecutive annual basis;

(e) Be allowed to switch between the Medicare and Medicaid EHR Incentive Program only one time after receiving at least one incentive payment, and only for a payment year before 2015.

(3) Payments are disbursed to an eligible professional on a rolling basis following verification of eligibility for the payment year:

(a) An eligible professional is paid an incentive amount for the corresponding payment year for each year of qualified participation in the Medicaid EHR Incentive Program;

(b) The payment structure is as follows for:

(A) An eligible professional qualifying with 30 percent minimum patient volume:

(i) The first payment year incentive amount is $21,250; and

(ii) The second, third, fourth, fifth, or sixth payment year incentive amount is $8,500; or

(B) An eligible pediatrician qualifying with 20 percent, but less than 30 percent minimum patient volume:

(i) The first payment year incentive amount is $14,167; and

(ii) The second, third, fourth, fifth, or sixth payment year incentive amount is $5,667.

(4) An eligible hospital must follow the Medicaid EHR Incentive Program participation conditions including that the eligible hospital:

(a) Receives a Medicaid EHR incentive payment from only one state for a payment year;

(b) May participate in both the Medicare and Medicaid EHR Incentive Programs if the eligible hospital meets all eligibility criteria for the payment year for both programs;

(c) Participates in the Medicaid EHR Incentive Program:

(A) Starting as early as federal fiscal year (FFY) 2011 but no later than FFY 2016;

(B) Ending no later than FFY 2021;

(C) For a maximum of three years;

(D) On a consecutive or non-consecutive annual basis for federal fiscal years prior to FFY 2016; and

(E) On a consecutive annual basis for federal fiscal years starting in FFY 2016;

(d) A multi-site hospital with one Centers for Medicare and Medicaid Services’ Certification Number is considered one hospital for purposes of calculating payment.

(5) Payments are disbursed to an eligible hospital on a rolling basis following verification of eligibility for the payment year. An eligible hospital is paid the aggregate incentive amount over three years of qualified participation in the Medicaid EHR Incentive Program:

(a) The payment structure as listed in Table 165-0100-1 is as follows:

(A) The first payment year incentive amount is equal to 50% of the aggregate amount;

(B) The second payment year incentive amount is equal to 40% of the aggregate amount; and

(C) The third payment year incentive amount is equal to 10% of the aggregate amount;

(b) The aggregate EHR hospital incentive amount is calculated as the product of the “overall EHR amount” times the “Medicaid Share” as listed in Table 165-00100-2. The aggregate amount is calculated once, for the first year participation, and then paid over three years according to the payment schedule:

(A) The overall EHR amount for an eligible hospital is based upon a theoretical four years of payment the hospital would receive, and is the sum of the following calculation performed for each of such four years. For each year, the overall EHR amount is the product of the initial amount, the Medicare share and the transition factor:

(i) The initial amount as listed in Table 165-0100-3 is equal to the sum of the base amount, which is set at $2,000,000 for each of the theoretical four years, plus the discharge-related amount, that is calculated for each of the theoretical four years:

(I) The discharge-related amount is $200 per discharge for the 1,150th through the 23,000th discharge, based upon the total discharges for the eligible hospital (regardless of source of payment) from the hospital fiscal year that ends during the FFY prior to the fiscal year that serves as the first payment year. No discharge-related amount is added for discharges prior to the 1,150th or any discharges after the 23,000th;

(II) For purposes of calculating the discharge-related amount for the last three of the theoretical four years of payment, discharges are assumed to increase each year by the provider’s average annual rate of growth; negative rates of growth must also be applied. Average annual rate of growth is calculated as the average of the annual rate of growth in total discharges for the most recent three years for which data are available per year.

(ii) The Medicare share that equals 1;

(iii) The transition factor, that equals:

(I) 1 for the first of the theoretical four years;

(II) 0.75 for the second of the theoretical four years;

(III) 0.5 for the third of the theoretical four years; and

(IV) 0.25 for the fourth of the theoretical four years;

(B) The Medicaid share for an eligible hospital is equal to a fraction:

(i) The numerator for the FFY and with respect to the eligible hospital is the sum of:

(I) The estimated number of inpatient-bed-days that are attributable to Medicaid individuals; and

(II) The estimated number of inpatient-bed-days that are attributable to individuals who are enrolled in a managed care organization, a pre-paid inpatient health plan, or a pre-paid ambulatory health plan administered under 42 CFR Part 438;

(ii) The denominator is the product of:

(I) The estimated total number of inpatient-bed-days with respect to the eligible hospital during such period; and

(II) The estimated total amount of the eligible hospital’s charges during such period, not including any charges that are attributable to charity care, divided by the estimated total amount of the hospital’s charges during such period;

(iii) In computing inpatient-bed-days for the Medicaid share, an eligible hospital may not include the following:

(I) Estimated inpatient-bed-days attributable to individuals that may be made under Medicare Part A; or

(II) Inpatient-bed-days attributable to individuals who are enrolled with a Medicare Advantage organization under Medicare Part C;

(iv) If an eligible hospital’s charity care data necessary to calculate the portion of the formula for the Medicaid share are not available, the eligible hospital’s data on uncompensated care may be used to determine an appropriate proxy for charity care, but must include a downward adjustment to eliminate bad debt from uncompensated care data if bad debt is not otherwise differentiated from uncompensated care. Auditable data sources must be used; and

(v) If an eligible hospital’s data necessary to determine the inpatient bed-days attributable to Medicaid managed care patients are not available, that amount is deemed to equal 0. In the absence of an eligible hospital’s data necessary to compute the percentage of inpatient bed days that are not charity care as described under (B)(ii)(II) in this section, that amount is deemed to be 1.

(6) Table 165-0100-1

(7) Table 165-0100-2

(8) Table 165-0100-3

[ED. NOTE: Tables referenced are available from the agency.]

Stat. Auth.: ORS 413.042

Stats. Implemented: ORS 409.010, 413.042, 414.033

Hist.: DMAP 13-2011, f. 6-29-11, cert. ef. 7-1-11

410-165-0120

Appeals

(1)The appeals process for the Medicaid Electronic Health Record (EHR) Incentive Program is pursuant to 42 CFR 495.370 and the Oregon Health Authority’s (Authority) Provider Appeals Rules in the Oregon Administrative Rules (OAR) chapter 410, division 120.

(2) For purposes of OAR chapter 410, division 165, a provider who applies for a Medicaid EHR incentive payment may appeal a decision by the Medicaid EHR Incentive Program as outlined in the Authority’s Division of Medical Assistance Programs’ Provider Appeal Rules (OAR chapter 410, division 120). The provider’s appeal must note the specific reason for the appeal, which must be due to:

(a) An incentive payment;

(b) An incentive payment amount;

(c) A provider eligibility determination;

(d) The demonstration of adopting, implementing or upgrading; or

(e) Meaningful use eligibility.

Stat. Auth.: ORS 413.042

Stats. Implemented: ORS 409.010, 413.042, 414.033

Hist.: DMAP 13-2011, f. 6-29-11, cert. ef. 7-1-11

410-165-0140

Oversight and Audits

(1) A provider who qualifies for a Medicaid Electronic Health Record (EHR) incentive payment under the Medicaid (EHR) Incentive Program is subject to audit or other post-payment review procedures as authorized in Oregon Administrative Rule (OAR) 407-120-1505.

(2) The Oregon Health Authority and the Department of Human Services have the authority to recover overpayments from the person or entity who received an incentive payment from the Medicaid EHR Incentive Program.

(3) The person or entity who received a Medicaid EHR incentive overpayment must repay the amount specified within 30 calendar days from the mailing date of written notification of the overpayment as prescribed by OAR 407-120-1505

Stat. Auth.: ORS 413.042

Stats. Implemented: ORS 409.010, 413.042, 414.033

Hist.: DMAP 13-2011, f. 6-29-11, cert. ef. 7-1-11

 

Rule Caption: 7/11 – Semi-Annual PDL updates, expansion of 90-day fill list of maintenance medications, changes to allow for the billing of certain diabetic supplies by pharmacies, and updates for vaccination billing, PA criteria update.

Adm. Order No.: DMAP 14-2011

Filed with Sec. of State: 6-29-2011

Certified to be Effective: 7-1-11

Notice Publication Date: 6-1-2011

Rules Amended: 410-121-0147, 410-121-0155, 410-121-0157, 410-121-0160, 410-121-0185, 410-121-0200

Subject:410-121-0147: Clarification of coverage for certain drug products, nutritional supplements, vitamins, vaccines, and active pharmaceutical ingredients

      410-121-0155: New language relating to program changes to allow pharmacies to be reimbursed for the provision of certain diabetic supplies

      410-121-0157: Inclusion of requirements under the Affordable Care Act for drug manufacturers that participate in the CMS Medicaid Drug Rebate Program that require the Division to collect drug rebates for drugs dispensed by Medicaid Managed Care Organizations

      410-121-0160: Inclusion of terms and conditions for enrolled pharmacies to participate in an annual claims volume survey for dispensing fee determination

      410-121-0185: Changes to billing requirements for pharmacy based immunizations.

      410-121-0200: Billing requirements for reimbursement of certain diabetic supplies

      • All above rules reflect the Division’s agency authority from the Department of Human Services to the Oregon Health Authority and updated statutory reference.

      • Other text may be revised to improve readability and to take care of necessary “housekeeping” corrections.

      Note: Not all “Rule Filing Caption” issues listed above are included in this permanent filing. Permanent filing is delayed for “PA Criteria Guide updates” (OAR 410-121-0040 and “Expansion of 90-day fill list of maintenance medications.” OAR 410-121-0030, (Preferred Drug List updates) is filed on a separate Permanent Certificate to be effective 7/17/11.

Rules Coordinator: Darlene Nelson—(503) 945-6927

410-121-0147

Exclusions and Limitations

(1) The following items are not covered for payment by the Division of Medical Assistance Programs (Division):

(a) Drug products for diagnoses below the funded line on the Health Services Commission Prioritized List or an excluded service under Oregon Health Plan (OHP) coverage;

(b) Home pregnancy kits;

(c) Fluoride for individuals over 18 years of age;

(d) Expired drug products;

(e) Drug products from non-rebatable manufacturers, with the exception of selected oral nutritionals, vitamins, and vaccines;

(f) Active Pharmaceutical Ingredients (APIs) and Excipients as described by Centers for Medicare and Medicaid (CMS);

(g) Drug products that are not assigned a National Drug Code (NDC) number;

(h) Drug products that are not approved by the Food and Drug Administration (FDA);

(i) Drug products dispensed for Citizen/Alien-Waived Emergency Medical client benefit type;

(j) Drug Efficacy Study Implementation (DESI) drugs (see OAR 410-121-0420);

(k) Medicare Part D covered drugs or classes of drugs for fully dual eligible clients.

(2) Effective on or after April 1, 2008, Section 1903(i) of the Social Security Act requires that written (nonelectronic) prescriptions for covered outpatient drugs for Medicaid clients be executed on a tamper-resistant pad in order to be eligible for federal matching funds. To meet this requirement, the Division shall only reimburse for covered Medicaid outpatient drugs only when the written (nonelectronic) prescription is executed on a tamper-resistant pad, or the prescription is electronically submitted to the pharmacy.

(3) Drugs requiring a skilled medical professional for safe administration will be billed by the medical professional’s office; unless otherwise specified by the Division.

Stat. Auth.: ORS 409.010 & 414.065

Stats. Implemented: ORS 414.065

Hist.: HR 22-1993(Temp),f. & cert. ef. 9-1-93; HR 34-1993(Temp), f. & cert. ef. 12-1-93; HR 11-1994, f. 2-25-94, cert. ef. 2-27-94; HR 25-1994, f. & cert. ef. 7-1-94; HR 2-1995, f. & cert. ef. 2-1-95; HR 22-1997, f. & cert. ef. 10-1-97; OMAP 1-1999, f. & cert. ef. 2-1-99; OMAP 31-2001, f. 9-24-01, cert. ef. 10-1-01; OMAP 18-2004, f. 3-15-04 cert. ef. 4-1-04; OMAP 65-2005, f. 11-30-05, cert. ef. 1-1-06; OMAP 16-2006, f. 6-12-06, cert. ef. 7-1-06; DMAP 9-2008, f. 3-31-08, cert. ef. 4-1-08; DMAP 17-2010, f. 6-15-10, cert. ef. 7-1-10; DMAP 14-2011, f. 6-29-11, cert. ef. 7-1-11

410-121-0155

Reimbursement

(1) The Division shall pay the lesser of the provider’s usual charge to the general public for a drug or the estimated acquisition cost (EAC) plus a dispensing fee. The EAC is defined by the Division as the lesser of:

(a) The Average Actual Acquisition Cost (AAAC) of the drug;

(b) In cases where no AAAC is available, the Division shall reimburse at Wholesale Acquisition Cost (WAC);

(c) The Federally Mandated Upper Limit (FUL) for certain multiple source drugs as established and published by CMS;

(d) 340B covered entities and federally qualified health centers or their contracted agents that fill Medicaid patient prescriptions with drugs purchased at the prices authorized under Section 340B of the Public Health Service Act must bill Medicaid for the actual acquisition cost.

(2) The Division shall revise its EAC file weekly. Pharmacies must make available to the Division, or its contractor, any information necessary to determine the pharmacy’s actual acquisition cost of drug products dispensed to the Division’s clients.

(3) The AAAC shall serve as the basis for reimbursement. Individual pharmacies are required to participate in an AAC survey conducted by the Division, or its contractor, not more than one time per every 18 to 24-month period. Pharmacies that do not respond to AAC survey requests may be subject to disenrollment as providers for the Oregon Health Plan.

(4) If a provider is unable to purchase a particular drug product at the AAAC the provider shall report this to the Division or its contractor for further review through a dispute resolution process. Providers may submit inquiries via telephone, facsimile, via electronic mail, or the contractor’s secure web site: http://or.mslc.com/RequestRateReview.aspx:

(a) The Division or its contractor shall respond to all inquiries or complaints within 24 hours and resolve the issue within 5 business days;

(b) The pricing dispute resolution process shall include the Division or its contractor verifying the accuracy of pricing to ensure consistency with marketplace pricing and drug availability;

(c) Price adjustments shall be made during the next weekly pricing update.

(5) Payment for covered fee-for-service drug products shall be the lesser of the billed amount or the EAC of the generic form, minus applicable copayments, plus a professional dispensing fee.

(6) Payment for trade name forms of multiple source products:

(a) Shall be the EAC of the trade name form, minus applicable copayments, plus a professional dispensing fee;

(b) The Division shall pay only if the prescribing practitioner has received a prior authorization for the trade name drug, or;

(c) The brand drug is listed on the Division’s Preferred Drug List.

(7) No professional dispensing fee is allowed for dispensing pill splitters/cutters or diabetic supplies and glucose monitors which are exempt from co-payments under OHP General Rules.

(8) Payment for pill splitters/cutters with a National Drug Code (NDC) number shall be reimbursed at the lesser of the billed amount or the EAC, and:

(a) A practitioner prescription is required, and;

(b) The Division shall only pay for one pill splitter/cutter per client in a twelve-month period.

(9) A prescription is required for glucose monitors and related diabetic supplies.

(10) Payment for glucose monitors and related diabetic supplies billed with an NDC shall be reimbursed at a percentage of Medicare’s rate for the HCPCS procedure code. The Division’s reimbursement rates are listed in the DMAP fee schedule located at: http://www.oregon.gov/DHS/
healthplan/data_pubs/feeschedule/downloads.shtml

Stat. Auth.: ORS 184.750, 184.770, 409.050 & 414.065

Stats. Implemented: ORS 414.065

Hist.: PWC 818(Temp), f. 10-22-76, ef. 11-1-76; PWC 831, f. 2-18-77, ef. 3-1-77; PWC 846(Temp), f. & ef. 7-1-77; PWC 858, f. 10-14-77, ef. 11-1-77; PWC 869, f. 12-30-77, ef. 1-1-78; AFS 15-1979(Temp), f. 6-29-79, ef. 7-1-79; AFS 41-1979, f. & ef. 11-1-79; AFS 15-1981, f. 3-5-81, ef. 4-1-81; AFS 35-1981(Temp), f. 6-26-81, ef. 7-1-81; AFS 53-1981(Temp), f. & ef. 8-14-81; AFS 70-1981, f. 9-30-81, ef. 10-1-81; AFS 44-1982, f. 4-30-82 & AFS 52-1982, f. 5-28-82, ef. 5-1-82 for providers located in the geographical areas covered by the branch offices of North Salem, South Salem, Dallas, Woodburn, McMinnville, Lebanon, Albany and Corvallis, ef. 6-30-82 for remaining AFS branch offices. AFS 74-1982 (Temp), f. 7-22-81, ef. 8-1-82; AFS 99-1982, f. 10-25-82, ef. 11-1-82; AFS 113-1982(Temp), f. 12-28-82, ef. 1-1-83; AFS 13-1983, f. & ef. 3-21-83; AFS 51-1983(Temp), f. 9-30-83, ef. 10-1-83; AFS 56-1983, f. 11-17-83, ef. 12-1-83; AFS 18-1984, f. 4-23-84, ef. 5-1-84; AFS 53-1985, f. 9-20-85, ef. 10-1-85; AFS 42-1986(Temp), f. 6-10-86, ef. 7-1-86; AFS 52-1986, f. & ef. 7-2-86; AFS 12-1987, f. 3-3-87, ef. 4-1-87; AFS 56-1989, f. 9-28-89, cert. ef. 10-1-89, Renumbered from 461-016-0100; HR 29-1990, f. 8-31-90, cert. ef. 9-1-90, Renumbered from 461-016-0250; HR 20-1991, f. & cert. ef. 4-16-91; HR 20-1994, f. 4-29-94, cert. ef. 5-1-94; OMAP 29-2000, f. 9-29-00, cert. ef. 10-1-00; OMAP 31-2001, f. 9-24-01, cert. ef. 10-1-01; OMAP 61-2001(Temp), f. 12-13-01, cert. ef. 12-15-01 thru 3-15-02; OMAP 1-2002, cert. ef. 2-15-02; OMAP 32-2002, f. & cert. ef. 8-1-02; OMAP 40-2003, f. 5-27-03, cert. ef. 6-1-03; OMAP 57-2003, f. 9-5-03, cert. ef. 10-1-03; OMAP 18-2004, f. 3-15-04 cert. ef. 4-1-04; OMAP 19-2005, f. 3-21-05, cert. ef. 4-1-05; OMAP 16-2006, f. 6-12-06, cert. ef. 7-1-06; DMAP 26-2007, f. 12-11-07, cert. ef. 1-1-08; DMAP 5-2009(Temp), f. 3-26-09, cert. ef. 4-1-09 thru 9-25-09; DMAP 14-2009 f. 6-12-09, cert. ef. 7-1-09; DMAP 40-2010, f. 12-28-10, cert. ef. 1-1-11; DMAP 14-2011, f. 6-29-11, cert. ef. 7-1-11

410-121-0157

Participation in the Medicaid Drug Rebate Program

(1) The Oregon Medicaid Pharmaceutical Services Program is a participant in the Centers for Medicare and Medicaid Services (CMS) Medicaid Drug Rebate Program, created by the Omnibus Budget Reconciliation Act (OBRA) of 1990. The Patient Protection and Affordable Care Act (PPACA) enacted on March 23,2010 and the Health Care and Education Reconciliation Act of 2010, (HCERA) enacted on March 30, 2010, together called the Affordable Care Act, requires the Division to collect drug rebates for covered outpatient drugs dispensed to enrollees of Medicaid managed care organizations, (MCOs). The Medicaid Drug Rebate Program requires a drug manufacturer to enter into and have in effect a national rebate agreement with the Secretary of the Department of Health and Human Services for States to receive federal funding for outpatient drugs dispensed to Medicaid patients. The drug rebate program is administered by CMS’s Center for Medicaid and State Operations (CMSO). Pharmaceutical companies participating in this program have signed agreements with CMS to provide rebates to the Division of Medical Assistance Programs (Division) on all their drug products. The Division will reimburse providers only for outpatient drug products manufactured or labeled by companies participating in this program.

(2) Documents in rule by reference: Names and Labeler Code numbers for participants in the Medicaid Drug Rebate Program are the responsibility of and maintained by CMS. The Division receives this information from CMS in the form of numbered and dated Releases. The Division includes in rule by reference, the CMS Releases online at: available on the Oregon Health Authority’s website: www.dhs.state.or.us/policy/healthplan/
guides/pharmacy/main.html. CMS Releases Drug Product Data and Drug Company Contact information that are available at: www.cms.hhs.gov/
MedicaidDrugRebateProgram/02_StateReleases.asp

(3) Retroactive effective dates: The CMS Medicaid Drug Rebate Program experiences frequent changes in participation and often this information is submitted to the Division after the effective date(s) of some changes. Therefore, certain participant additions and deletions may be effective retroactively. See specific instructions in the CMS Releases for appropriate effective date(s) of changes.

(4) The Division contracts with a Pharmacy Benefit Manager (PBM) to manage the Medicaid Rebate Dispute Resolution program. Pharmacy providers must verify the accuracy of their Medicaid pharmacy claims with the PBM within 30 days of request in instances where drug manufacturers dispute their claim information. Verification can be photocopies of drug invoices showing that the billed products were in stock during the time of the date of service.

(5) The actual National Drug Code (NDC) dispensed and the actual metric decimal quantity dispensed, must be billed.

Stat. Auth.: ORS 409.050 & 414.065

Stats. Implemented: ORS 414.065

Hist.: HR 16-1991(Temp), f. 4-12-91, cert. ef. 4-15-91; HR 22-1991, f. & cert. ef. 5-16-91; HR 23-1991(Temp), f. 6-14-91, cert. ef. 6-17-91; HR 31-1991, f. & cert. ef. 7-16-91; HR 36-1991(Temp), f. 9-16-91, cert. ef. 10-1-91; HR 45-1992, f. & cert. ef. 10-16-91; HR 50-1991(Temp), f. & cert. ef. 10-29-91; HR 1-1992, f. & cert. ef. 1-2-92; HR 13-1992, f. & cert. ef. 6-1-92; HR 21-1992, f. 7-31-92, cert. ef. 8-1-92; HR 31-1992, f. & cert. ef. 10-1-92; HR 34-1992, f. & cert. ef. 12-1-92; HR 4-1993, f. 3-10-93, cert. ef. 3-11-93; HR 7-1993 (Temp), f. & cert. ef. 4-1-93; HR 14-1993, f. & cert. ef. 7-2-93; HR 24-1993, f. & cert. ef. 10-1-93; HR 17-1994, f. & cert. ef. 4-1-94; HR 25-1994, f. & cert. ef. 7-1-94; HR 2-1995, f. & cert. ef. 2-1-95; HR 6-1995, f. 3-31-95, cert. ef. 4-1-95; HR 14-1995, f. 6-29-95, cert. ef. 7-1-95; HR 23-1995, f. 12-29-95, cert. ef. 1-1-96; HR 22-1997, f. & cert. ef. 10-1-97; HR 27-1997, f. & cert. ef. 12-1-97; OMAP 2-1998, f. 1-30-98, cert. ef. 2-1-98; OMAP 29-2000, f. 9-29-00, cert. ef. 10-1-00; OMAP 43-2000(Temp), f. 12-29-00, cert. ef. 1-1-01 thru 5-1-01; OMAP 3-2001, f. & cert. ef. 3-16-01; OMAP 24-2001(Temp) f. 5-9-01, cert. ef. 5-10-01 thru 11-1-01; OMAP 25-2001(Temp) f. 6-28-01, cert. ef. 7-1-01 thru 12-1-01; OMAP 27-2001(Temp) f. 7-30-01, cert. ef. 8-1-01 thru 1-26-02; OMAP 48-2001(Temp) f. 9-28-01, cert. ef. 10-1-01 thru 3-1-02; OMAP 56-2001(Temp), f. & cert. ef. 11-1-01 thru 4-15-02; OMAP 57-2001(Temp), f. 11-28-01, cert. ef. 12-1-01 thru 4-15-02; OMAP 66-2001(Temp), f. 12-28-01, cert. ef. 1-1-02 thru 5-15-02; OMAP 4-2002(Temp), f. & cert. ef. 3-5-02 thru 8-1-02; OMAP 16-2002(Temp) f. & cert. ef. 4-12-02 thru 9-1-02; OMAP 20-2002(Temp), f. & cert. ef. 5-15-02 thru 10-1-02; OMAP 34-2002(Temp), f. & cert. ef. 8-14-02 thru 1-15-03; OMAP 67-2002(Temp), f. & cert. ef. 11-1-02 thru 3-15-03; OMAP 6-2003(Temp), f. & cert. ef. 2-14-03 thru 7-1-03; OMAP 38-2003, f. & cert. ef. 5-9-03; OMAP 39-2003(Temp), f. & cert. ef. 5-15-03; OMAP 48-2003, f. & cert. ef. 7-7-03; OMAP 74-2003, f. & cert. ef. 10-1-03; OMAP 5-2004(Temp), f. & cert. ef. 2-4-04 thru 6-15-04; OMAP 24-2004, f. & cert. ef. 3-30-04; OMAP 31-2004(Temp), f. & cert. ef. 5-14-04 thru 10-15-04; OMAP 42-2004, f. 6-24-04 cert. ef. 7-1-04; OMAP 53-2004(Temp), f. & cert. ef. 9-10-04 thru 2-15-05; OMAP 82-2004, f. 10-29-04 cert. ef. 11-1-04; OMAP 1-2005(Temp), f. & cert. ef. 1-14-05 thru 6-1-05; OMAP 6-2005, f. 3-1-05, cert. ef. 3-31-05; OMAP 7-2005(Temp), f. 3-1-05, cert. ef. 4-1-05 thru 8-1-05; OMAP 30-2005, f. & cert. ef. 6-6-05; OMAP 55-2005, f. 10-25-05, cert. ef. 11-1-05; OMAP 5-2006, f. 3-22-06, cert. ef. 4-1-06; OMAP 7-2006(Temp), f. 3-29-06, cert. ef. 4-1-06 thru 9-15-06; OMAP 12-2006, f. 5-26-06, cert. ef. 6-1-06; OMAP 49-2006, f. 12-28-06, cert. ef. 1-1-07; DMAP 16-2008, f. 6-13-08, cert. ef. 7-1-08; DMAP 34-2008, f. 11-26-08, cert. ef. 12-1-08; DMAP 14-2011, f. 6-29-11, cert. ef. 7-1-11

410-121-0160

Dispensing Fees

(1) Professional dispensing fees allowable for services shall be based on an individual pharmacy’s annual claims volume as follows:

(a) Less than 49,999 claims a year = $14.01;

(b) Between 50,000 and 69,999 claims per year = $10.14;

(c) 70,000 or more claims per year = $9.68;

(2) All Division enrolled pharmacies shall be required to complete an annual survey that collects claim volumes from enrolled pharmacies and other information from the previous 12 month period to determine the appropriate dispensing fee reimbursement:

(a) Claims volume shall be stated by total OHP covered prescriptions and claims from all payer types;

(b) Survey activities shall be conducted by either the Division or its contractor and must be completed and returned by pharmacies within 14 days of receipt;

(c) Completed surveys must be signed with a letter of attestation by:

(A) The store owner or majority owner for independent pharmacies;

(B) The Pharmacy manager and the store manager or a corporate officer for chain pharmacies;

(d) Pharmacies that fail to respond to the survey or do not include the letter of attestation shall default to the lowest dispensing tier.

(3) Once a tier is established for a calendar year, the pharmacy’s dispensing fee shall remain in that tier until the next annual claims volume survey is conducted.

(4) Pharmacies newly enrolled with the Division shall be defaulted to the lowest dispensing tier until the next claims volume survey is conducted.

[Publications: Publications referenced are available from the agency.]

Stat. Auth.: ORS 184.750, 184.770, 409.050 & 414.065

Stats. Implemented: ORS 414.065

Hist.: AFS 51-1983(Temp), f. 9-30-83, ef. 10-1-83; AFS 56-1983, f. 11-17-83, ef. 12-1-83; AFS 41-1984(Temp), f. 9-24-84, ef. 10-1-84; AFS 1-1985, f. & ef. 1-3-85; AFS 54-1985(Temp), f. 9-23-85, ef. 10-1-85; AFS 66-1985, f. 11-5-85, ef. 12-1-85; AFS 13-1986(Temp), f. 2-5-86, ef. 3-1-86; AFS 36-1986, f. 4-15-86, ef. 6-1-86; AFS 52-1986, f. & ef. 7-2-86; AFS 12-1987, f. 3-3-87, ef. 4-1-87; AFS 28-1987(Temp), f. & ef. 7-14-87; AFS 50-1987, f. 10-20-87, ef. 11-1-87; AFS 41-1988(Temp), f. 6-13-88, cert. ef. 7-1-88; AFS 64-1988, f. 10-3-88, cert. ef. 12-1-88; AFS 56-1989, f. 9-28-89, cert. ef. 10-1-89, Renumbered from 461-016-0101; AFS 63-1989(Temp), f. & cert. ef. 10-17-89; AFS 79-1989, f. & cert. ef. 12-21-89; HR 20-1990, f. & cert. ef. 7-9-90, Renumbered from 461-016-0260; HR 29-1990, f. 8-31-90, cert. ef. 9-1-90; HR 21-1993(Temp), f. & cert. ef. 9-1-93; HR 12-1994, f. 2-25-94, cert. ef. 2-27-94; OMAP 5-1998(Temp), f. & cert. ef. 2-11-98 thru 7-15-98; OMAP 22-1998, f. & cert. ef. 7-15-98; OMAP 1-1999, f. & cert. ef. 2-1-99; OMAP 50-2001(Temp) f. 9-28-01, cert. ef. 10-1-01 thru 3-1-02; OMAP 60-2001, f. & cert. ef. 12-11-01; OMAP 32-2003(Temp), f. & cert. ef. 4-15-03 thru 9-15-03; OMAP 57-2003, f. 9-5-03, cert. ef. 10-1-03; OMAP 7-2004, f. 2-13-04 cert. ef. 3-15-04; OMAP 19-2004(Temp), f. & cert. ef. 3-15-04 thru 4-14-04; OMAP 21-2004, f. 3-15-04, cert. ef. 4-15-04; OMAP 19-2005, f. 3-21-05, cert. ef. 4-1-05; OMAP 16-2006, f. 6-12-06, cert. ef. 7-1-06; DMAP 26-2007, f. 12-11-07, cert. ef. 1-1-08; DMAP 40-2010, f. 12-28-10, cert. ef. 1-1-11; DMAP 14-2011, f. 6-29-11, cert. ef. 7-1-11

410-121-0185

Pharmacy Based Immunization Delivery

(1) When administering immunizations for adults (ages 19+) the pharmacy can bill either:

(a) Through Point-of-Sale (POS) using the appropriate National Drug Code (NDC) for the serum and the administration fee shall automatically be applied equivalent to Current Procedural Terminology (CPT) codes 90470-90474 ; or

(b) Bill on a CMS-1500 claim form using the appropriate immunization CPT code for the serum.

(2) If using a CMS-1500, you must also include:

(a) An ICD-9 diagnosis in field 21, and;

(b) The diagnosis code must be shown to the highest degree of specificity, and;

(c) Use the appropriate CPT code for the serum, code ranges 90476-90749; and

(d) Use the appropriate CPT code for the administration, code ranges 90470-90474.

(3) Pursuant to ORS 689.205 and the Board of Pharmacy administrative rules 855-019-0270 through 855-019-0290; pharmacists may prescribe and administer vaccines to children who are from the age of 11 through 18 years of age only if the pharmacy is enrolled in the Vaccines for Children (VFC) Program. The Division will not reimburse providers the cost of privately purchased vaccination.

(4) If the pharmacy is enrolled in the VFC Program, then only the administration fee shall be reimbursed by the Division and must be billed on a CMS-1500 claim form. For detailed information on billing for the VFC Program, refer to Medical Surgical Services OAR 410-130-0255.

Stat. Auth.: ORS 409.025, 409.040, 409.110, 413.042, & 414.065

Stats. Implemented: ORS 414.065

Hist.: OMAP 31-2001, f. 9-24-01, cert. ef. 10-1-01; OMAP 7-2002, f. & cert. ef. 4-1-02; OMAP 18-2004, f. 3-15-04 cert. ef. 4-1-04; OMAP 9-2005, f. 3-9-05, cert. ef. 4-1-05; DMAP 36-2008, f. 12-11-08, cert. ef. 1-1-09; DMAP 17-2010, f. 6-15-10, cert. ef. 7-1-10; DMAP 14-2011, f. 6-29-11, cert. ef. 7-1-11

410-121-0200

Billing Forms

Guidelines for using the Prescription Drug Invoice 5.1 Universal Claim Form:

(1) When a paper claim form is needed, this form is used to bill for all pharmacy services, home blood glucose monitors, and related diabetic supplies. These services must be billed with a National Drug Code (NDC);

(2) The provider may bill on the form when a valid Medical Care Identification has been presented (Refer to OAR 410-120-1140 Verification of Eligibility);

(3) All completed 5.1 Universal Claim Forms must be mailed to the Division of Medical Assistance Programs (Division);

(4) All other durable medical equipment and certain Enteral/ Parenteral nutrition and IV services must be billed on the CMS-1500, using the billing instructions found in the Division’s Durable Medical Equipment and Medical Supplies administrative rules (Division 122) and Supplemental Information, and the Division’s Home Enteral/Parenteral Nutrition and IV Services Administrative rules (Division 148) and Supplemental Information. These services are billed with HCPCS procedure codes.

[ED NOTE: Publications referenced are available from the agency.]

Stat. Auth.: ORS 409.050 & 414.065

Stats. Implemented: ORS 414.065

Hist.: HR 29-1990, f. 8-31-90, cert. ef. 9-1-90; HR 20-1994, f. 4-29-94, cert. ef. 5-1-94; OMAP 20-2003, f. 3-26-03, cert. ef. 4-1-03; OMAP 40-2003, f. 5-27-03, cert. ef. 6-1-03; OMAP 18-2004, f. 3-15-04 cert. ef. 4-1-04; DMAP 34-2008, f. 11-26-08, cert. ef. 12-1-08; DMAP 14-2011, f. 6-29-11, cert. ef. 7-1-11

 

Rule Caption: July 1, 2011 – Alignment with current licensing board rules.

Adm. Order No.: DMAP 15-2011

Filed with Sec. of State: 6-29-2011

Certified to be Effective: 7-1-11

Notice Publication Date: 6-1-2011

Rules Amended: 410-133-0040, 410-133-0080, 410-133-0120

Subject: The School-based Health Services Program administrative rules govern Division payments for services to certain clients. The Division amended as follows:

      • To revise and correct references to OARs sited in the rules listed above to align with the State’s licensing boards.

      • All above rules will reflect the Oregon Health Authority name change and updated statutory reference.

      • Other text may be revised to improve readability and to take care of necessary “housekeeping” corrections.

Rules Coordinator: Darlene Nelson—(503) 945-6927

410-133-0040

Definitions

(1) Adapted vehicle – Vehicle specifically designed or modified to transport passengers with disabilities.

(2) Adequate recordkeeping – In addition to General Rules OAR 410-120-0000, Definitions and 410-120-1360, Requirements for financial, clinical, and other records, documentation in the student’s educational record and on the Individualized Education Plan (IEP) or Individualized Family Service Plan( IFSP) showing the necessary and appropriate health services provided to the student detailed in the School-Based Health Services (SBHS) administrative rules (410-133-0000 and 410-133-0320).

(3) Agent – means a third party or organization that contracts with a provider, allied agency, or Prepaid Health Plan (PHP) to perform designated services in order to facilitate a transaction or conduct other business functions on its behalf. Agents include billing agents, claims clearinghouses, vendors, billing services, service bureaus, and accounts receivable management firms. Agents may also be clinics, group practices, and facilities that submit billings on behalf of providers but the payment is made to a provider, including the following: an employer of a provider, if a provider is required as a condition of employment to turn over his fees to the employer; the facility in which the service is provided, if a provider has a contract under which the facility submits the claim; or a foundation, plan, or similar organization operating an organized health care delivery system, if a provider has a contract under which the organization submits the claim. Agents may also include electronic data transmission submitters.

(4) Allied Agency – Local and regional governmental agencies and regional authorities that contract with the Department of Human Services (Department) or the Oregon Health Authority (Authority) to provide the delivery of services to covered individuals. (e.g., local mental health authority, community mental health program, Oregon Youth Authority, Department of Corrections, local health departments, public schools, Education Service Districts (ESDs), developmental disability service programs, Area Agencies on Aging (AAAs), federally recognized American Indian tribes).

(5) Assessment – A process of obtaining information to determine if a student qualifies for or continues to qualify for the Division of Medical Assistance Programs (Division) covered school-based health services.

(6) Assistive technology service – Services provided by medically qualified staff within the scope of practice under State law with training and expertise in the use of assistive technology (see 410-133-0080 Coverage and 410-133-0200 Not Covered Services in these rules).

(7) Audiologist – A person licensed to practice audiology by the State Board of Examiners for Speech Pathology and Audiology or holds a Certificate of Clinical Competency (CCC) from the American Speech and Hearing Association (ASHA) and meet the requirements in 42 CFR 440.110.

(8) Audiology – Assessment of children with hearing loss; determination of the range, nature and degree of hearing loss, including the referral for medical or other professional attention for restoration or rehabilitation due to hearing disorders; provision of rehabilitative activities, such as language restoration or rehabilitation, auditory training, hearing evaluation and speech conversation, and determination of the child’s need for individual amplification; obtaining and interpreting information; and coordinating care and integrating services relative to the student receiving services.

(9) “Authority” means the Oregon Health Authority (Please see General Rules 410-120-0000 Acronyms and Definitions)

(10) Automated Voice Response (AVR) – A computer system that provides information on clients’ current eligibility status from the Division of Medical Assistance Programs by computerized phone or web-based response.

(11) Benefit Package – The “package” of covered health care services for which the Medicaid-eligible student is eligible. (See General Rules OAR 410-120-1210 Medical Assistance Benefit Packages and Delivery System)

(12) Billing agent or billing service – Third party or organization that contracts with a provider to perform designated services in order to facilitate an Electronic Data Interchange (EDI) transaction on behalf of the provider. Also see definition for Electronic Data Interchange (EDI) Submitter

(13) Billing Provider (BP) – A person, agent, business, corporation, clinic, group, institution, or other entity who submits claims to and/or receives payment from the Division of Medical Assistance Programs (Division) on behalf of a performing provider and has been delegated the authority to obligate or act on behalf of the performing provider. (See the Department-wide Support Services (DWSS) administrative rules in, chapter 407, division 120 Provider Rules, and the Division’s General Rules OAR 410-120-1260 and SBHS OAR 410-133-0140.)

(14) Billing time limit – Refers to the rules concerning the period of time allowed to bill services to the Division of Medical Assistance Programs (Division) see General Rules OAR 410-120-1300, Timely Submission of Claims. In general, those rules require initial submission within 12 months of the date of service or 18 months for resubmission.

(15) Centers for Medicare and Medicaid Services (CMS) – The federal regulatory agency for Medicaid programs.

(16) CMS-1500 – The standard federal billing form used to bill medical services.

(17) Certification – See “licensure.”

(18) Children’s Health Insurance Program (CHIP) – A federal and state funded portion of the Oregon Health Plan (OHP) established by Title XXI of the Social Security Act and administered in Oregon by the Oregon Health Authority (Authority) Division of Medical Assistance Programs (Division).

(19) Clinical Social Work Associate (CSWA) – A person working toward Licensed Clinical Social Worker (LCSW) licensure in compliance with Division 20, Procedure for Certification and Licensing, OAR 877-20-0000 through OAR 877-20-0060.

(20) Coordinated care – Services directly related to covered school-based health services (SBHS) specified in the individualized education program (IEP) or individualized family service plan (IFSP), performed by medically qualified staff, and allowed under OAR 410-133-0080, Coverage, to manage integration of those health services in an education setting. Coordinated care includes the following activities:

(a) Conference – The portion of a conference in a scheduled meeting, between medically qualified staff and interested parties, to develop, review, or revise components of school-based health services provided to a Medicaid-eligible student for the purpose to establish, re-establish or terminate a Medicaid covered health service on a Medicaid-eligible student’s Individualized Education Program (IEP) or Individualized Family Service Plan (IFSP); or to develop, review, or revise components of a health service currently provided to a Medicaid-eligible student to determine whether or not those covered health services continue to meet the student’s needs as specified on the student’s IEP or IFSP.

(b) Consultation – performed by medically qualified staff within the scope of practice providing technical assistance to or conferring with, special education providers, physicians, and families to assist them in providing a covered health service for Medicaid-eligible students related to a specific health service and health service goals and objectives in the individualized education program (IEP) or individualized family service plan (IFSP).

(c) Physician coordinated care – Meeting or communication with a physician in reference to oversight of care and treatment provided for a health service specified on a Medicaid-eligible student’s individualized education program (IEP) or individualized family service plan (IFSP).

(21) Cost Determination – The process of establishing an annual discipline fee (cost rate), based on the prior-year actual audited costs, used by an EA for the purpose of billing for covered school-based health services (see 410-133-0245 Cost Determination and Payment in these rules).

 (22) Covered entity – means a health plan, health care clearing house, health care provider, or allied agency that transmits any health information in electronic form in connection with a transaction, including direct data entry (DDE), and who must comply with the National Provider Identifier (NPI) requirements of 45 CFR 162.402 through 162.414. When a school provides covered SBHS services in the normal course of business and bills Medicaid for reimbursed covered transactions electronically in connection with that health care such as electronic claims, it is then a covered entity and must comply with the HIPAA Administrative Simplification Rules for Transactions and Code sets and Identifiers with respect to its transactions.

(23) Current Procedural Terminology (CPT) – The American Medical Association’s CPT is a listing of descriptive terms and identifying codes for reporting medical services and procedures performed by physicians and other health care providers. See the Division of Medical Assistance Programs’ General Rules Program (OAR 410-120-0000 Definitions).

(24) Data transmission – means the transfer or exchange of data between the Department and a web portal or electronic data interchange (EDI) submitter by means of an information system which is compatible for that purpose and includes without limitation, web portal, EDI, electronic remittance advice (ERA), or electronic media claims (EMC) transmissions.

(25) Delegated Health Care Aide – A non-licensed person trained and supervised by a licensed registered nurse (RN) or nurse practitioner (NP) to perform selected tasks of nursing care specific to the Medicaid-eligible student identified in the nursing plan of care pursuant to the Individualized Education Program/Individualized Family Service Plan (IEP/IFSP).

(26) Delegation of nursing task – A selected nursing task that is performed by an unlicensed person, trained and monitored by a licensed RN. Delegation and supervision of selected nursing tasks must comply with Oregon Administrative Rules (OARs), Board of Nursing, chapter 851, division(s) 45 and 47. A school medical (SM) provider must maintain documentation of the actual delegation, training, supervision and provision of the nursing service billed to Medicaid.

(27) “Department” means the Department of Human Services established in OAR chapter 407, including any divisions, programs and offices as may be established therein.

(28) Diagnosis code – As identified in the International Classification of Diseases 9th Revision, Clinical Modification (ICD-9-CM), the primary Diagnosis Code is shown in all billing claims, unless specifically excluded in individual Division provider rule(s). Where they exist, diagnosis codes shall be shown to the degree of specificity outlined in OAR 410-120-1280, Billing.

(29) Direct services – Face-to-face delivery of health services between the medically qualified staff who is the service provider and a Medicaid-eligible student.

(30) Division of Medical Assistance Programs (Division) – A Division within the Oregon Health Authority (Authority); the Division is responsible for coordinating the medical assistance programs within the State of Oregon including the Oregon Health Plan (OHP) Medicaid demonstration, the State Children’s Health Insurance Program (SCHIP- Title XXI), and several other programs.

(31) Early Intervention/Early Childhood Special Education (EI/ECSE) – EI is a program designed to address the unique needs of a child age 0-3 years and ECSE is a program for preschool children with a disability ages 3-5 years or eligible for Kindergarten.

(32) Educational Agency (EA) – For purposes of these rules, any public school, school district, Education Service District (ESD), state institution, or youth care center providing educational services to students, birth to age 21 through grade 12, that receives federal or state funds either directly or by contract or subcontract with the Oregon Department of Education (ODE).

(33) Education records – Those records, files, documents and other materials which contain information directly related to a student and maintained by an Education Agency (EA) or by a person acting for such EA as set forth in OAR 581-021-0220. (A school-based health services (SBHS) provider is required to keep and maintain supporting documentation for Medicaid reimbursed school-based health services for a period of seven (7) years; this documentation is part of the student’s education record but may be filed and kept separately by school health professionals.) See 410-133-0320 Documentation and Recordkeeping Requirements in these rules.

(34) Education Service District (ESD) – An education agency established to offer a resource pool of cost-effective, education-related, physical or mental health-related, state-mandated services to multiple local school districts within a geographic area described in ORS 334.010

(35) Electronic Data Interchange (EDI) – The exchange of business documents from application to application in a federally mandated format or, if no federal standard has been promulgated, using bulk transmission processes and other formats as the Department designates for EDI transactions. For purposes of these rules (OAR 407-120-0100 through 407-120-0200), EDI does not include electronic transmission by web portal.

(36) EDI submitter – An Individual or an entity authorized to establish an electronic media connection with the Department to conduct an EDI transaction. An EDI submitter may be a trading partner or an agent of a trading partner. Also see definition for billing agent in these rules.

(37) Electronic Verification System (EVS) – Eligibility information that have met the legal and technical specifications of the Division of Medical Assistance Programs (Division) in order to offer eligibility information to enrolled Division providers.

(38) Eligibility for special education services – A determination by a designated education agency (EA), through a team, that a child meets the eligibility criteria for early intervention (EI), early childhood special education (ECSE) or special education as defined in ORS 343 and OAR chapter 581, division 15.

(39) Evaluation – Evaluations are procedures performed by medically qualified staff to determine whether a Medicaid-eligible student is disabled and the nature and extent of the health services the student needs under the Individuals with Disabilities Education Act (IDEA) and in accordance with Oregon Department of Education OAR chapter 581 division 15. The Authority can only reimburse evaluations that establish, re-establish or terminate a school-based health services (SBHS) covered health service on a Medicaid-eligible student’s Individualized Education Program (IEP) or Individualized Family Service Plan (IFSP) under the Individuals with Disabilities Education Act (IDEA).

(40) Federal Medical Assistance Percentage (FMAP) – The percentage of federal matching dollars for qualified state medical assistance program expenditures.

(41) Healthcare Common Procedure Coding System (HCPCS) – A method for reporting health care professional services, procedures, and supplies. HCPCS consists of the Level I -American Medical Association’s Physician’s Current Procedural Terminology (CPT), Level II – National codes, and Level III – Local codes. DMAP uses HCPCS codes. See General Rules (OAR 410-120-1280 Billing).

(42) Health assessment plan (nursing) – Systematic collection of data for the purpose of assessing a Medicaid-eligible student’s health or illness status and actual or potential health care needs in the educational setting. Includes taking a nursing history, and an appraisal of the student’s health status through interview, information from the family and information from the student’s past health or medical record. A SBHS provider is required to keep and maintain the health assessment plan and supporting documentation for Medicaid reimbursed health services described in a Medicaid-eligible student’s individualized education program (IEP) or individualized family service plan (IFSP) for a period of seven (7) years, as part of the student’s education record, which may be filed and kept separately by school health professionals. (See 410-133-0320 Documentation and Recordkeeping Requirements.)

(43) Health care practitioner – A person licensed pursuant to state law to engage in the provision of health care services within the scope of the health care practitioner’s license and/or certification standards established by their health licensing agency. Medical provider and health care practitioner are interchangeable terms. See Definition for medical provider in these rules.

(44) Health services – Medical evaluation services provided by a physician for diagnostic and evaluation purposes for a Medicaid-eligible student that is found eligible under the Individuals with Disabilities Education Act (IDEA) and leads to an established Individualized Education Program (IEP) or Individualized Family service Plan (IFSP), physical or mental health evaluations, and assessment or treatment performed by medically qualified staff to achieve the goals set forth in a Medicaid-eligible student’s IEP or IFSP. A covered health service is one that is covered by the medical assistance program and is provided to enable the Medicaid-eligible student to benefit from a special education program (age 3-21) or to achieve developmental milestones in an early intervention program (age 0-3). “Health services” are synonymous with “medical services” in these rules. To determine whether a health service specified on an Individualized Education Program (IEP) or Individualized Family Service Plan (IFSP) is a covered School-Based Health Service (SBHS) (See 410-133-0080 Coverage and 410-133-0200 Not Covered Services).

(45) Health Services Commission (HSC) – An eleven member commission that is charged with reporting to the Governor the ranking of health benefits from most to least important, and representing the comparable benefits of each service to the entire population to be serviced.

(46) ID number – A number issued by the Authority used to identify Medicaid-eligible students. This number may also be referred to as recipient identification number; prime number; client medical ID Number or medical assistance program ID number.

(47) Individuals with Disabilities Education Act (IDEA) – The federal law ensuring the rights of children with disabilities to a “free and appropriate education” (FAPE).

(48) Individualized Education Plan (IEP) – A written statement of an educational program for a child with a disability which is developed, reviewed, or revised in a meeting in accordance with Oregon Department of Education OAR chapter 581, division 15. When an IEP is used as a prescription for Medicaid reimbursement for covered School-Based Health Services (SBHS), it must include: type of health service, amount, duration and frequency for the service provided. In order to bill Medicaid for covered health services they must be delivered by or under the supervision of medically qualified staff and must be recommended by a physician or appropriate health care practitioner acting within the scope of practice. See definition medically qualified staff.

(49) Individualized Family Service Plan (IFSP) – A written plan of early childhood special education (ECSE) services, early intervention (EI) services, and other services developed in accordance with criteria established by the Oregon Department of Education (ODE) for each child (age’s birth to 5 years) eligible for IFSP services. The plan is developed to meet the needs of a child with disabilities in accordance with requirements and definitions in OAR chapter 581, division 15. When an IFSP is used as a prescription for Medicaid reimbursement for SBHS covered services, it must include: type of health service, amount, duration and frequency for the service provided. In order to bill Medicaid for covered health services they must be delivered by or under the supervision of medically qualified staff and must be recommended by a physician or appropriate health care practitioner acting within their scope of practice. See definition medically qualified staff.

(50) Individualized Education Plan/Individualized Family Service Plan (IEP/IFSP) Team – A group of teachers, specialists, and parents responsible for determining eligibility, developing, reviewing, and revising an IEP or IFSP in compliance with the Oregon Department of Education (ODE) OAR chapter 581, division 15.

(51) Licensed Clinical Social Worker (LCSW) – A person licensed to practice clinical social work pursuant to State law.

(52) Licensed Physical Therapist Assistant (LPTA) – A person licensed to assist in the administration of physical therapy, solely under the supervision and direction of a physical therapist.

(53) Licensed Practical Nurse (LPN) – A person licensed to practice under the direction of a licensed professional within the scope of practice as defined by State law.

(54) Licensure – Documentation from state agencies demonstrating that licensed or certified individuals are qualified to perform specific duties and a scope of services within a legal standard recognized by the licensing agency. In the context of health services, licensure refers to the standards applicable to health service providers by health licensing authorities. For health services provided in the state of Oregon, licensure refers to the standards established by the appropriate State of Oregon licensing agency.

(55) Medicaid-eligible student – The child or student who has been determined to be eligible for Medicaid health services by the Authority. For purposes of this rule, Medicaid-eligible student is synonymous with “recipient” or “Oregon Health Plan (OHP) client”. For convenience, the term student used in these rules applies to both students covered by an Individualized Education Program (IEP) and children covered by an Individualized Family Service Plan (IFSP). Also for purposes of this rule, students or children whose eligibility is based on the Children’s Health Insurance Program (CHIP) shall be referred to as Medicaid-eligible students.

(56) Medical Assistance Program – A program for payment of health services provided to eligible Oregonians. Oregon’s medical assistance program includes Medicaid services including the Oregon Health Plan (OHP) Medicaid Demonstration, and the Children’s Health Insurance Program (CHIP). The Medical Assistance Program is administered by the Division of Medical Assistance Programs (Division), of the Oregon Health Authority .

(57) Medical Management Information System (MMIS) – A data collection system for processing paper and electronic claims for payment of health services provided to Medicaid-eligible recipients.

(58) Medical provider – An individual licensed by the State to provide health services within their governing body’s definitions and respective scope of practice. Medical provider and health care practitioner are interchangeable terms.

(59) Medical services – The care and treatment provided by a licensed health care practitioner to prevent, diagnose, treat, correct or address a medical problem; whether physical, mental or emotional. For the purposes of these rules, this term shall be synonymous with health services or health-related services listed on an Individualized Education Program (IEP) or Individualized Family Service Plan (IFSP), as defined in OAR chapter 581, division 15. Not all health-related services listed on an IEP or IFSP are covered as SBHS. See 410-133-0080 Coverage and 410-133-0200 Not Covered Services.

(60) Medical transportation – Specialized transportation in a vehicle adapted to meet the needs of passengers with disabilities transported to and from a SBHS covered service.

(61) Medically qualified staff:

(a) Staff employed by and/or through contract with an EA; and

(b) Licensed by the State to provide health services in compliance with State law defining and governing the scope of practice, described further in OAR 410-133-0120.

(62) Medication management – A task performed only by medically qualified staff, pursuant to a student’s Individualized Education Program/Individualized Family Service Plan (IEP/IFSP), which involves administering medications, observing for side effects, and monitoring signs and symptoms for medication administration.

(63) National Provider Identification (NPI) – Federally directed Provider number mandated for use on Health Insurance Portability Accountability Act (HIPAA) covered transactions; individuals, provider organizations, and subparts of provider organizations that meet the definition of health care provider (45 CFR 160.103) and who conduct HIPAA covered transactions electronically are eligible to apply for an NPI; Medicare covered entities are required to apply for an NPI.

(64) “Necessary and appropriate” health services – Those health services described in a Medicaid-eligible student’s IEP or IFSP which are:

(a) Consistent with the symptoms of a health condition or treatment of a health condition;

(b) Appropriate with regard to standards of good health practice and generally recognized by the relevant scientific community and professional standards of care as effective;

(c) Not solely for the convenience of the Medicaid-eligible student or provider of the service; and

(d) The most cost-effective of the alternative levels of health services, which can safely be provided to a Medicaid-eligible student.

(65) Nursing Diagnosis and Management Plan – A written plan that describes a Medicaid-eligible student’s actual and anticipated health conditions that are amenable to resolution by nursing intervention.

(66) Nursing Plan of Care – Written guidelines that are made a part of, and attached to the Individualized Education Program (IEP) or individualized Family Service Plan (IFSP) that identify specific health conditions of the Medicaid-eligible student, and the nursing regimen that is “necessary and appropriate” for the student. Development and maintenance of this plan includes establishing student and nursing goals, and identifying nursing interventions (including location, frequency, duration and delegation of care) to meet the medical care objective identified in their IEP or IFSP, see Oregon State Board of Nursing Practice Act, Division 47. The SBHS provider is responsible for developing the nursing plan of care and is required to keep and maintain a copy of the nursing plan of care as supporting documentation for Medicaid reimbursed health services. (See definition “Education records”.)

(67) Nurse practitioner – A person licensed as a registered nurse and certified by the Board of Nursing to practice as a nurse practitioner pursuant to State law.

(68) Nursing services – Services provided by a nurse practitioner (NP), registered professional nurse (RN), a licensed practical nurse (LPN) or delegated health care aide, within the scope of practice as defined by State law. Nursing services include preparation and maintenance of the health assessment plan, nursing diagnosis and management plan, nursing plan of care, consultation, and coordination and integration of health service activities, as well as direct patient care and supervision.

(69) Observation – Surveillance or visual monitoring performed by medically qualified staff as part of an evaluation, assessment, direct service, or care coordination for a necessary and appropriate Medicaid covered health service specified on a Medicaid-eligible student’s Individualized Education Program (IEP) or Individualized Family Service Plan (IFSP) to better understand the child’s medical needs and progress in their natural environment. An observation by itself is not billable.

(70) Occupational therapist (OT) – A person licensed by the State’s Occupational Therapy Licensing Board.

(71) Occupational Therapist Assistant – A person who is licensed as an occupational therapy assistant assisting in the practice of occupational therapy under the supervision of a licensed occupational therapist.

(72) Occupational therapy – Assessing, improving, developing, or restoring functions impaired or lost through illness, injury or deprivation, to improve the ability to perform tasks for independent functioning when functions are lost or impaired, preventing through early intervention, initial or further impairment or loss of function. Obtaining and interpreting information, coordinating care, and integrating necessary and appropriate occupational therapy services relative to the Medicaid-eligible student.

(73) Oregon Department of Education (ODE) – The state agency that provides oversight to public educational agencies for ensuring compliance with Federal and State laws relating to the provision of services required by the individuals with disabilities education act (IDEA).

(74) Orientation and mobility training – Services provided to blind or visually impaired students by qualified personnel to enable those students to attain systematic orientation to and safe movement within their environments in school, home, and community. These services are not covered under School-Based Health Services (SBHS) (See OAR 410-133-0200 Not Covered Services).

(75) Performing provider – A person, agent, business, corporation, clinic, group, institution, or other entity that is the provider of a service or item with the authority to delegate fiduciary responsibilities to a billing provider, also termed billing agent, to obligate or act on the behalf of the performing provider regarding claim submissions, receivables, and payments relative to the Medical Assistance Program. For the purposes of these SBHS rules, the school medical (SM) provider is the performing provider.

(76) Physical Therapist – A person licensed by the relevant State licensing authority to practice physical therapy (See OAR chapter 848, division10 Licensed Physical Therapists and Licensed Physical therapist Assistants; chapter 848 division, 040 Minimum Standards For Physical therapy Practice and Records

(77) Physical Therapy – Assessing, preventing or alleviating movement dysfunction and related functional problems. Obtaining and interpreting information: coordinating care and integrating necessary and appropriate physical therapy services relative to the student receiving treatments.

(78) Prime Number – See definition of ID Number.

(79) Prioritized List of Health Services – Also referred to as the Prioritized List, the Oregon Health Services Commission’s (HSC) listing of health services with “expanded definitions’ of ancillary services and preventative services and the HSC practice guidelines, as presented to the Oregon Legislative Assembly. The Prioritized List is generated and maintained by the HSC. The Prioritized List governs medical assistance programs’ health services and Benefit Packages pursuant to the Division of Medical Assistance Programs’ General Rules OAR 410-120-0000 et seq., and OAR 410-141-0480 through 410-141-0520 (for the listing of condition and treatment pairs).

(80) Procedure code – See definition of HCPC healthcare common procedure code.

(81) Provider – An individual, facility, institution, corporate entity, or other organization which supplies health care services or items, also termed a performing provider, or bills, obligates and receives reimbursement on behalf of a performing provider of services, also termed a billing provider (BP). The term “Provider” refers to both performing providers and billing providers unless otherwise specified. Payment can only be made to DMAP-enrolled providers who have by signature on the provider enrollment forms and attachments, agreed to provide services and to bill in accordance with General Rules OAR 410-120-1260, and the SBHS OAR 410-133-0140. If a provider submits claims electronically, the provider must become a trading partner with the Authority and comply with the requirements of the Electronic Data Interchange (EDI) rules pursuant to OAR 407-120-0100 through 407-120-0200.

(82) Provider enrollment agreement – An agreement between the provider and the Oregon Health Authority (Authority) that sets forth the conditions for being enrolled as a provider with the Authority and to receive a provider number in order to submit claims for reimbursement for covered SBHS provided to Medicaid-eligible students. Payment can only be made to Division of Medical Assistance Programs’ (Division)-enrolled providers who have by signature on the provider enrollment forms and program applicable attachments agree to provide services and to bill in accordance with Provider Rules chapter 407, division 120 and the Division’s General Rules chapter 410, division 120, and these SBHS rules. Also see definitions for Trading Partner and Trading Partner Agreement in these rules.

(83) Psychiatrist – A person licensed to practice medicine and surgery in the state of Oregon and possesses a valid license from the Oregon Licensing Board for the Healing Arts.

(84) Psychologist – A person with a doctoral degree in psychology and licensed by the State Board of Psychologist Examiners See 858-010-0010.

(85) Psychologist Associate – A person who does not possess a doctoral degree that is licensed by the Board of Psychologists Examiners, to perform certain functions within the practice of psychology under the supervision of a psychologist. See 858-010-0037 through 858-010-0038.An exception would be psychologist associate with the authority to function without immediate supervision, see OAR 858-010-0039.

(86) Recordkeeping requirements – A SBHS SM provider is required to keep and maintain the supporting documentation for Medicaid reimbursed health services described in a Medicaid-eligible student’s Individualized Education Program (IEP) or Individualized Family Service Plan (IFSP) for a period of seven (7) years, as part of the student’s education record, which may be filed and kept separately by school health professionals (See OAR 410-133-0320).

(87) Re-evaluation – Procedures used to measure a Medicaid-eligible student’s health status compared to an initial or previous evaluation, are focused on evaluation of progress toward current goals, modifying goals or treatment, or making a professional judgment to determine whether or not the student will continue to receive continued care for a covered service pursuant to an IEP or IFSP under the Individuals with Disabilities Education Act (IDEA). Continuous assessment of the student’s progress as a component of ongoing therapy services is not billable as a re-evaluation.

(88) Regional program – Regional program services are provided on a multi-county basis, under contract from the Oregon Department of Education (ODE) to eligible children (birth to 21) visually impaired, hearing impaired, deaf-blind, autistic, and/or severely orthopedically impaired. A regional program may be reimbursed for covered health services it provides to Medicaid-eligible students through the school medical (SM) provider (e.g., public school district or ESD) that administers the program.

(89) Registered Nurse (RN) – A person licensed and certified by the Oregon Board of Nursing to practice as a registered nurse pursuant to State law.

(90) Rehabilitative services – For purposes of the School-Based Health Services (SBHS) program, any health service that is covered by the Medical Assistance Program and that is a medical, psychological or remedial health service recommended by a physician or other licensed health care practitioner within the scope of practice under State law, and provided to a Medicaid-eligible student pursuant to an Individualized Education Program/Individualized Family Service Plan (IEP/IFSP) under the Individuals with Disabilities Education Act (IDEA), for reduction, correction, stabilization or functioning improvement of physical or mental disability of a Medicaid-eligible student (See 410-133-0060).

(91) Related services – For purposes of this rule, related services as listed on an Individualized Education Program (IEP) or Individualized Family Service Plan (IFSP) may include: transportation and such developmental, corrective and other supportive services (e.g., speech language, audiology services, psychological services, physical therapy, occupational therapy, social work services in schools, and nursing services) as are required to assist a child or student with a disability to benefit from special education; and includes early identification and assessment of disabling conditions in children. NOTE: Not all “related services” are covered for payment by Medicaid. To determine whether a particular related service is a covered health service for a Medicaid-eligible student (see OAR 410-133-0080, Coverage and OAR 410-133-0200, Not Covered Services).

(92) School-Based Health Services (SBHS) – Health services provided in the educational setting, meeting the requirements of these rules, and applicable federal and state laws and rules.

(93) School medical (SM) provider – An enrolled provider type established by the Division to designate the provider of school-based health services eligible to receive reimbursement from the Division. See the Authority’s general rules chapter 943 division 120, the Division’s General Rules OAR 410-120-1260, and School-Based Health Services Program OAR 410-133-0140 (School Medical (SM) Provider Enrollment Provisions).

(94) Screening – A limited examination to determine a Medicaid-eligible student’s need for a diagnostic medical evaluation. See OAR 410-133-0200 (Not Covered Services).

(95) Special Education Services – Specially designed instruction to meet the unique needs of a child with a disability, including regular classroom instruction, instruction in physical education, home instruction, and instruction in hospitals, institutions, special schools, and other settings.

(96) Speech Language Pathology Assistant (SLPA) – A person who is licensed by the Oregon State Board of Examiners for Speech Pathology and Audiology and provides speech-language pathology services under the direction and supervision of a speech-language pathologist licensed under ORS 681.250.

(97) Speech-Language Pathologist – A person licensed by the Oregon Board of Examiners for Speech Pathology and Audiology or holds a Certificate of Clinical Competency (CCC) from the American Speech and Hearing Association (ASHA) (See Medically Qualified Staff 410-133-0120).

(98) Speech-language pathology services – Assessment of children with speech/language disorders, diagnosis and appraisal of specific speech/language disorders, referral for medical and other professional attention necessary for the rehabilitation of speech/language disorders and provision of speech/language services for the prevention of communicative disorders. Obtaining and interpreting information, coordinating care, and integrating necessary and appropriate speech-language pathology services relative to the student receiving services.

(99) State Education Agency (SEA) – See “Oregon Department of Education (ODE)”.

(100) State-operated school – The Oregon School for the Deaf. See “Educational Agency.”

(101) Student health/medical/nursing records – Education records that document, for Medical Assistance Program purposes, the Medicaid-eligible student’s diagnosis or the results of tests, screens or treatments, treatment plan, the Individualized Education Program (IEP) or Individualized Family Service Plan (IFSP), and the record of treatments or health services provided to the child or student.

(102) Teachers’ Standards and Practices Commission (TSPC) – The Commission that governs licensing of teachers, personnel, service specialists, and administrators as set forth in OAR chapter 584. In order for schools or school providers to participate in the Medicaid program and receive Medicaid reimbursement, they must meet the Medicaid provider qualifications. It is not sufficient for a state to use Department of Education provider qualifications for reimbursement of Medicaid-covered health services provided in an education setting.

(103) Testing – See “Assessment”.

(104) Testing Technician – A person/technician adequately trained to administer and score specific tests, as delegated under the direction and supervision of a licensee, and maintains standards for the testing environment and testing administration as set forth in the American Psychological Association Standards for Educational and Psychological Tests (1999) and Ethical Principles for Psychologists (2002). See ORS 675.010(4), OAR 858-010-0001, and 858-010-0002.

(105) Third-party billing - A process of sending a bill to a public or private insurance company for a medical or health service given to someone who is insured.

(106) Trading partner – means a provider, prepaid health plan (PHP), clinic, or allied agency that has entered into a trading partner agreement with the Department in order to satisfy all or part of its obligations under a contract by means of electronic data interchange (EDI), electronic remittance advice (ERA), or electronic media claims (EMC), or any other mutually agreed means of electronic exchange or transfer of data. EDI transactions must comply with the requirements of the EDI rules OAR 407-120-0100 through 407-120-0200 for the purposes of these rules EDI does not include electronic transmission by web portal.

(107) Trading partner agreement (TPA) – means a specific request by a provider, PHP, clinic, or allied agency to conduct EDI transactions that governs the terms and conditions for EDI transactions in the performance of obligations under a contract. A provider, PHP, clinic, or allied agency that has executed a TPA will be referred to as a trading partner in relation to those functions.

(108) Transportation Aide – An individual trained for health and safety issues to accompany a Medicaid-eligible student transported to and from a covered Health Service as specified in the Individualized Education Program/individualized Family Service Plan (IEP/IFSP). The School Medical (SM) Provider must maintain documentation of the training, supervision and provision of the services billed to Medicaid. For the purposes of these rules, individual transportation aides are included in the cost calculation for transportation costs and will not be billed separately. This computation will not include delegated health care aides for whom costs are direct costs.

(109) Transportation as a related service – Specialized transportation adapted to serve the needs of a Medicaid-eligible student to and from a covered health service that is necessary and appropriate, and described in the Individualized Education Program/individualized Family Service Plan (IEP/IFSP) as outlined in OAR 410-133-0080 (Coverage).

(110) Transportation vehicle trip log – A record or log kept specifically for tracking each transportation trip a Medicaid-eligible student receives transportation to or from a covered health service. (See OAR 410-136-0280 Medical Transportation rules – Required Documentation and SBHS OAR 410-133-0245, Cost Determination and Payment).

(111) Treatment Plan – A written plan of care services, including treatment with proposed location, frequency and duration of treatment as required by the health care practitioner’s health licensing agency.

(112) Unit – Is a service measurement of time for billing and reimbursement efficiency. One (1) unit equals 15 minutes unless otherwise stated.

(113) Web Portal submitter – means an individual or entity authorized to establish an electronic media connection with the Department of Human Services to conduct a direct data entry transaction. A web portal submitter may be a provider or a provider’s agent.

Stat. Auth.: ORS 413.042

Stats. Implemented: 413.042, 414.065

Hist.: HR 39-1991, f. & cert. ef. 9-16-91; HR 29-1993, f. & cert. ef. 10-1-93; HR 21-1995, f. & cert. ef. 12-1-95;OMAP 31-1998, f. & cert. ef. 9-1-98; OMAP 38-1999, f. & cert. ef. 10-1-99; OMAP 15-2000, f. 9-28-00, cert. ef 10-1-00; OMAP 31-2003, f. & cert. ef. 4-1-03; OMAP 53-2003, f. 8-13-03 cert. ef. 9-1-03; OMAP 24-2005(Temp), f. & cert. ef. 4-5-05 thru 10-1-05; OMAP 53-2005, f. 9-30-05, cert. ef. 10-1-05; DMAP 43-2008, f. 12-17-08, cert. ef. 12-28-08; DMAP 19-2009, f. 6-12-09, cert. ef. 7-1-09; DMAP 15-2011, f. 6-29-11, cert. ef. 7-1-11

410-133-0080

Coverage

The Oregon Health Authority (Authority) may reimburse school medical (SM) providers for covered health services that meet all of the following criteria:

(1) The health service(s) must be “necessary and appropriate” and covered under the Oregon Health Plan (OHP) as a service that is above the funding line of the Prioritized List of health services and the health services must not be excluded under OAR 410-133-0200 (Not Covered Services).

(2) The health service(s) must be required by a Medicaid-eligible student’s physical or mental condition(s) as specified on the Individualized Education Program (IEP) or Individualized Family Service Plan (IFSP) and further described in the treatment plan and the evaluation of the student.

(3) The health service, individual or group, may include corrective health services treatments and Medicaid-covered related services as described in a student’s IEP or IFSP.

(a) The payment rate for health services includes case management and necessary supplies for these services. Additional reimbursement for such services, are not paid separately from the health service.

(b) These services must be provided by medically qualified staff that meet the standards of licensing or certification for the health service being provided as described in OAR 410-133-0120 and comply with the respective medical provider’s governing definitions, scope of practice, documentation requirements, and licensure or certification.

(4) Evaluation and assessment for SBHS are reimbursed for the part of the evaluation or assessment regarding a Medicaid-eligible student’s “necessary and appropriate” SBHS needs for the purpose of establishing, re-establishing, or terminating a Medicaid covered service on a Medicaid-eligible student’s IEP or IFSP; or to develop, review, or revise components of a covered health service currently provided to a Medicaid-eligible student for continuation of those covered services pursuant to an IEP or IFSP under the Individuals with Disabilities Education Act (IDEA).

(a) Evaluation services are procedures used to determine a SBHS covered health-related need, diagnosis, or eligibility under IDEA.

(b) Re-evaluation services are procedures used to measure a Medicaid-eligible student’s health status compared to an initial or previous evaluation and is focused on evaluation of progress toward current goals, modifying goals or treatment or making a professional judgment to determine whether or not a Medicaid-eligible student will continue to receive continued care for a SBHS covered service pursuant to the IEP or IFSP under IDEA. Continuous assessment of the student’s progress as a component of ongoing therapy services is not billable as a re-evaluation.

(5) Assistive technology services directly assist a Medicaid-eligible student with a disability, eligible under IDEA, to receive assistive technology covered SBHS as specified on the IEP or IFSP, in the selection, acquisition, or use of an assistive technology device, including:

(a) The assistive technology assessment with one-to-one student contact time by medically qualified staff within the scope of practice performing the assessment of the need, suitability, and benefits of the use of an assistive technology device or adaptive equipment that will help restore, augment, or compensate for existing functional ability in the Medicaid-eligible student or that will optimize functional tasks and/or maximize the Medicaid-eligible student’s environmental accessibility. This requires and includes the preparation of a written report;

(b) Care coordination with the Medicaid-eligible student’s physician, parent/guardian, and the Division of Medical Assistance Programs (Division) for the parent/guardian’s acquisition of a personal assistive technology device for their Medicaid-eligible student through the student’s Medicaid plan for the benefit of the Medicaid-eligible student to maximize his/her functional ability and environmental accessibility; and

(c) Training or technical assistance provided to or demonstrated with the Medicaid-eligible student by medically qualified staff, instructing the use of an assistive technology device or adaptive equipment in the educational setting with professionals (including individuals providing education and rehabilitation services) or where appropriate the family members, guardians, advocates, or authorized representative of the Medicaid-eligible student. In order to bill Medicaid for this service, the student must be present.

(6)The Authority may reimburse physical therapy services provided by:

(a) A physical therapist authorized to administer physical therapy to an individual, when the individual is a Medicaid-eligible student eligible for special education, as defined by state or federal law, and is being seen pursuant to the Medicaid-eligible student’s individual education plan or individual family service plan (see Oregon administrative rules chapter 848, division 010, Licensed Physical therapist and Licensed Physical Therapist Assistants; Division 015 Physical Therapist Assistants; and Division 040 Minimum Standards For Physical therapy Practice and Records);

(b) A physical therapist assistant providing treatment under the supervision of a physical therapist that is available and readily accessible for consultation with the assistant, at all times, either in person or by means of telecommunications (see OAR chapter 848, division 015, Physical Therapist Assistants). Physical therapy services must be provided by medically qualified staff that meet the standards of licensing or certification for the health service being provided as described in OAR 410-133-0120.

(c) Reimbursement time may include:

(A) Preparation of the written initial evaluation or initial assessment report to establish necessary and appropriate physical therapy services on a Medicaid-eligible student’s IEP or IFSP.

(B) Obtaining and interpreting medical information for the part of an evaluation or assessment performed by the physical therapist to establish necessary and appropriate physical therapy services on a Medicaid-eligible student’s IEP or IFSP; or to determine whether or not necessary and appropriate physical therapy services will continue to be specified on the Medicaid-eligible student’s IEP or IFSP under IDEA (cannot be delegated).

(C) Care coordination and integrating services, within the scope of practice, for providing necessary and appropriate physical therapy services relative to the Medicaid-eligible student pursuant to an IEP or IFSP.

(D) Direct treatment and supervision of services provided to a Medicaid-eligible student by the physical therapist and defined in the individual plan; when

(E) Documentation by the supervising physical therapist supporting the appropriate supervision of the assistant is maintained and kept by the School Medical Provider for a period of seven years (See OAR chapter 848, division 40, Minimum Standards for Physical Therapy Practice and Records).

(F) Individual or group physical therapy services provided to a Medicaid-eligible student by or under the supervision and direction of a Licensed physical therapist pursuant to the Medicaid-eligible student’s IEP or IFSP; when the documentation describing physical therapy services provided are signed by the therapist providing the service in accordance with their board licensing requirements and documentation for supervision of services performed by or under the supervision and direction of the supervising physical therapist supporting the services provided is maintained and kept by the school medical provider for seven (7) years (See Minimum Standards for Physical Therapy Practice and Records OARs 848-040-0100 through 848-040-0170).

(G) Other covered physical therapy services within the scope of practice and subsections (1) and (2) of this rule.

(7) The Authority may reimburse occupational therapy services provided by:

(a) A licensed Occupational Therapist (OT) authorized to administer occupational therapy to an individual, when the individual is a Medicaid-eligible student eligible for special education, as defined by state or federal law, and is being seen pursuant to the Medicaid-eligible student’s individual education plan or individual family service plan; and

(b) A licensed occupational therapy assistant assisting in the practice of occupational therapy under the general supervision of a licensed occupational therapist. (General supervision requires the supervisor to have at least monthly direct contact in person with the supervisee at the work site with supervision available as needed by other methods); and

(c) Before an occupational therapy assistant assists in the practice of occupational therapy, he/she must file with the Board a signed, current statement of supervision of the licensed occupational therapist that will supervise the occupational therapy assistant (See OAR 339-010-0035 Statement of Supervision for Occupational Therapy Assistant). Occupational therapy services must be provided by medically qualified staff that meet the standards of licensing or certification for the health service being provided as described in OAR 410-133-0120.

(d) Reimbursement time may include:

(A) Preparation of the written initial evaluation or initial assessment reports that establish necessary and appropriate occupational therapy services on a Medicaid eligible students IEP or IFSP.

(B) Obtaining and interpreting medical information for the part of the evaluation or assessment performed by the occupational therapist to establish necessary and appropriate occupational therapy services on a Medicaid-eligible student’s IEP or IFSP; or to determine whether or not necessary and appropriate occupational therapy services will continue to be specified on the Medicaid eligible student’s IEP or IFSP under IDEA (cannot be delegated).

(C) Development of the initial occupational therapy treatment plan by the OT (cannot be delegated).

(D) Coordinating care and integrating services, within the scope of practice, relative to the Medicaid-eligible student receiving necessary and appropriate occupational therapy services as specified on the IEP or IFSP.

(E) Individual or group occupational therapy services provided to a Medicaid-eligible student by or under the supervision and direction of a licensed occupational therapist as specified on Medicaid-eligible student’s IEP or IFSP,

(F) Direct treatment and supervision of services provided to a Medicaid-eligible student by the occupational therapist and defined in the individual plan; when documentation supporting the appropriate supervision of the assistant is kept and maintained by the school medical provider for a period of seven years;

(G) The occupational therapy services provided are consistent with OAR 339-010-0050 Occupational Therapy Services for Children and Youth in Education and Early childhood Programs regulated by federal laws; and

(H) Documentation describing occupational therapy treatment provided must be signed including credentials by the occupational therapist providing the service. Where appropriate, services provided by an occupational therapist assistant shall be reviewed and co signed by the supervising occupational therapist. All documentation describing treatment provided by an occupational therapy assistant must name the assistant therapist and the supervising therapist including credentials as reflected on the current statement of supervision filed with the Occupational Therapist Licensing Board. Supervision and documentation of supervision by the supervising therapist for therapy provided by the occupational therapy assistant must meet general supervision requirements or closer supervision where professionally appropriate. See OAR 339-010-0005, 339-010-0035, and 339-010-0050. Also, see 410-133-0320, Documentation and Recordkeeping Requirements in these rules.

(I) Other covered occupational therapy services within the scope of practice and subsections (1) and (2) of this rule.

(8) The Authority may reimburse speech therapy services provided by:

(a) A licensed speech pathologist licensed by the Oregon Board of Examiners for Speech Pathology and Audiology or holds a Certificate of Clinical Competency (CCC) from the American Speech and Hearing Association (ASHA), authorized to administer speech therapy to an individual, when the individual is a Medicaid-eligible student eligible for special education, as defined by state or federal law, receiving speech therapy services pursuant to an individual education plan or individual family service plan; or

(b) A graduate speech pathologist in their Clinical Fellowship Year (CFY) practicing under the supervision of an ASHA licensed speech pathologist with CCC meeting the standards of licensing or certification for the health service provided as described in OAR 410-133-0120 medically qualified staff; and when

(A) A standardized system for reviewing the clinical work of the clinical fellow is performed at regularly scheduled intervals, using the Skills Inventory Rating (CFSI) form addressing the fellow’s attainment of skills for independent practice;

(B) The clinical fellow supervisor maintains and documents the supervision of the clinical fellow to be kept by the school medical provider for a period of seven years.

(C) Documentation describing the treatment provided are signed and initialed by the clinical fellow for review and co-signature by the supervising clinical fellow.

(c) Speech-language pathology assistants (SLPA), licensed by the Oregon State Board of Examiners for Speech Pathology and Audiology, under the supervision of a supervising speech-language pathologist and who meet the standards of licensing or certification for the health service provided as described in OAR 410-133-0120 Medically Qualified Staff, when the following conditions are met:

(A) The supervising speech-language pathologist must have at least two years of full-time professional speech-language pathology experience (see OAR 335-095-0040 and 335-095-0050, Requirements for Supervising Licensed Speech-Language Pathology Assistants);

(B) The supervising speech therapist does not supervise more than the equivalent of two full-time speech-language pathology assistants;

(C) The supervising speech-language pathologist maintains documentation supporting the appropriate supervision of the assistant(s) to be kept by the school medical provider for a period of seven (7) years;

(D) The caseload of the supervising clinician allows for administration, including assistant supervision, evaluation of students and meeting times. (All students assigned to an assistant are considered part of the caseload of the supervising clinician);

(E) The supervising speech-language pathologist must be able to be reached at all times (A temporary supervisor may be designated as necessary);

(F) The services provided by the assistants are consistent with the Scope of Duties for the Speech-Language Pathology Assistant (SLPA) pursuant to OAR 335-095-0060;

(G) Documentation describing the treatment provided are signed and initialed by the SLPA for review and co-signature by the supervising speech-language pathologist to be kept by the school medical provider for a period of seven (7) years.

(d) Reimbursement time may include:

(A) Preparation of the written initial evaluation or initial assessment report, including obtaining and interpreting medical information for the part of the evaluation or assessment performed by the speech pathologist to establish necessary and appropriate speech therapy services on a Medicaid-eligible student’s IEP or IFSP; or determine whether or not necessary and appropriate speech therapy services will continue to be specified on the Medicaid-eligible student’s IEP or IFSP under IDEA (cannot be delegated);

(B) Development of the initial speech therapy treatment plan by the speech pathologist (cannot be delegated);

(C) Care coordination and integrating services, within the scope of practice, relative to the Medicaid-eligible student receiving necessary and appropriate speech therapy services specified on the IEP or IFSP;

(D) Direct individual or group speech therapy services provided to a Medicaid-eligible student for speech services specified on the IEP or IFSP delivered by or under the supervision and direction of a speech pathologist who is medically qualified to deliver the service see 410-133-0120 Medically Qualified Staff;

(E) Direct training and supervision of services provided to a Medicaid-eligible student by the medically qualified supervising speech pathologist to be kept by the school medical provider for a period of seven (7) years; and

(F) Other covered speech therapy services within the scope of practice and subsections (1) and (2) of this rule.

(9) The Authority may reimburse audiology services provided by:

(a) A licensed audiologist within the scope of practice as defined by state or federal law who meet the standards of licensing or certification for the health service provided as described in OAR 410-133-0120, Medically Qualified Staff

(b) Reimbursement time may include:

(A) Preparation of the written initial evaluation or initial assessment report, including obtaining and interpreting medical information for the part of the evaluation or assessment performed by the audiologist within the scope of practice, to establish necessary and appropriate hearing services on a Medicaid-eligible student’s IEP or IFSP; or determine whether or not necessary and appropriate hearing impairment services will continue to be specified on the Medicaid-eligible student’s IEP or IFSP under IDEA.

(B) Periodic hearing evaluations and assessments of a Medicaid-eligible student with hearing loss found eligible under IDEA pursuant to services as specified on the IEP or IFSP, for determination of the range, nature and degree of hearing loss.

(C) Care coordination and integration of services for medical or other professional attention relative to Medicaid-eligible student receiving services for restoration or rehabilitation due to hearing and communication disorders as specified on the IEP or IFSP.

(D) Provision of rehabilitative activities, such as language restoration or rehabilitation, auditory training, hearing evaluation and speech conversation, and determination of the Medicaid-eligible-student’s need for individual amplification in accordance with the student’s IEP or IFSP.

(10) The Authority may reimburse nurse services provided by:

(a) A Nurse practitioner (NP), registered nurse (RN), licensed practical nurse (LPN) or delegated health care aid under the supervision of an RN or NP who meet the standards of licensing or certification for the health service provided as described in OAR 410-133-0120 Medically Qualified Staff

(b) Nursing services under this program are not intended to reimburse nursing activities of a private duty RN or LPN that is otherwise billing Medicaid directly for those services.

(c) Reimbursement time may include:

(A) Preparation of the written initial evaluation or initial assessment report to establish nursing services including obtaining and interpreting medical information for the part of the evaluation or assessment performed to establish Necessary and Appropriate nursing services on the Medicaid-Eligible student’s IEP or IFSP; or determine whether or not necessary and appropriate nursing services will continue to be specified on the Medicaid-eligible students IEP or IFSP under IDEA.

(B) Coordinated care for other specified care management for a chronic medical condition that is not addressed on the current IEP or IFSP that will result in amending nursing services specified in the IEP or IFSP and requires an updated nursing plan of care. This may result in an increase in supervision, monitoring and training of DHC staff to provide new nursing tasks related to the change in condition. For example: a child with seizure disorder that develops diabetes.

(C) Care coordination and integration of necessary and appropriate nursing services relative to the Medicaid–eligible student’s covered health service specified on the IEP or IFSP.

(D) Nurse to student interactive services that are covered health services provided to a Medicaid-eligible student with a chronic medical condition receiving nursing services pursuant to an IEP or IFSP.

(E) Oversight of delegated health care aides performing delegated nursing services directly with the student as specified on the IEP or IFSP.

(F) Student observation by medically qualified staff for medical reasons of a Medicaid-eligible student with a chronic medical condition as part of an evaluation, assessment, or care coordination. An observation by itself is not a billable activity.

(G) Other covered nursing care services within the scope of practice and subsections (1) and (2) of this rule.

(11) The Authority may reimburse mental health services provided by:

(a) A Psychiatrist who meets the standards of licensing or certification for the health service being provided as described in OAR 410-133-0120(2)(f)(A), or a psychologist who meets the standards of licensing or certification for the health service being provided as described in OAR 410-133-0120(2)(f)(B), or a mental health nurse practitioner who meets the standards of licensing or certification for the health service being provided as described in OAR 410-133-0120(2)(e)(A); or

(b) A Psychologist Associate with authority to function without immediate supervision, performing functions that may include but are not restricted to administering tests of mental abilities, conducting personality assessments and counseling (see OAR 858-010-0039 Application for Independent Status). These services must be provided by medically qualified staff who meet the standards of licensing or certification for the health service being provided as described in OAR 410-133-0120(2)(f)(C); or

(c) A Psychologist Associate under the supervision of a psychologist as specified by the Board of Psychologists Examiners, OAR chapter 858, division 010. These services must be provided by medically qualified staff who meet the standards of licensing or certification for the health service being provided as described in OAR 410-133-0120(2) (f) (D); or

(d) A technician under the supervision of a psychologist as specified by the Board of Psychologists Examiners, chapter 858, division 010, OAR 858-010-0002, Guidelines for Supervising Technicians, and who meet the standards of licensing or certification for the health service being provided as described in OAR 410-133-0120 (f) (E); or

(e) A Licensed (LCSW) qualified and licensed to deliver the service, or a Clinical Social Work Associate (CSWA) under the supervision of an LCSW specified by the Board of Clinical Social Workers, chapter 877, division 020, OAR 877-020-0000 through 877-020-0060 and who meet the standards of licensing or certification for the health service being provided as described in OAR 410-133-0120 (f) (F).

(f) Reimbursable time may include:

(A) Preparation of the written initial evaluation or initial assessment report for a suspected disability per the referral process for determining IDEA eligibility, including obtaining and interpreting medical information for the part of the evaluation or assessment performed by the mental health care practitioner within the scope of practice, to establish necessary and appropriate mental health services on the Medicaid-eligible student’s IEP or IFSP; or to determine whether or not necessary and appropriate mental health services will continue to be specified on the Medicaid-eligible student’s IEP or IFSP under IDEA.

(B) Care coordination and integrating services, within the scope of practice, relative to the Medicaid-eligible student receiving mental health services as specified on the IEP or IFSP;

(C) Direct individual therapy services provided within the scope of practice under state law and covered under subsections (1) and (2) of this rule to a Medicaid-eligible student by or under the supervision and direction of a psychologist, a psychiatrist, or mental health nurse practitioner, or a Licensed Clinical Social Worker qualified and licensed to deliver the service pursuant to the Medicaid-eligible student’s IEP or IFSP.

(12) Medicaid reimbursed transportation:

(a) Transportation to a covered health service as documented in the child’s IEP/IFSP and defined in these rules (see 410-133-0245, Cost Determination and Payment).

(b) Ongoing transportation specified, as a related service, on the Medicaid-eligible student’s IEP or IFSP may be claimed as a Medicaid service on the days a Medicaid-eligible student receives a covered health service that is also specified on the IEP or IFSP,

(c) The Authority may only reimburse for transportation as a related service to and from a Medicaid-covered service for a Medicaid-eligible student when the student receives a Medicaid covered health service other than transportation on that day when either of the following situations exist:

(A) The Medicaid-eligible student requires specialized transportation adapted to serve the needs of the disabled student, there is documentation to support specialized transportation is “necessary and appropriate”, and transportation is listed as a related service on the student’s IEP or IFSP; or

(B) The Medicaid-eligible student has a medical need for transportation that is documented in the IEP or IFSP, and resides in an area that does not have regular school bus transportation such as those areas in close proximity to a school.

(d) If a Medicaid-eligible student is able to ride on a regular school bus, but requires the assistance of a delegated health care aide, trained by an RN to provide a delegated nursing task specific to the student, who cannot be transported safely without the delegated health care aide, the service provided by the delegated healthcare aide is reimbursed under the delegated healthcare code. See the standards for delegation of a Nursing Care Task as outlined in the Nurse Practice Act, OAR 851-047-0000 through 851-047-0040.

(e) If a Medicaid-eligible student requires the assistance of a delegated health care aide and transportation adapted to serve the needs of the disabled student, both the necessary and appropriate transportation and the service provided by the delegated healthcare aide may be reimbursed when both are specified on the Medicaid-eligible student’s current IEP or IFSP.

(f) If an education agency provides special transportation to a Medicaid-eligible student to a covered service outside the district or the Medicaid-eligible student’s resident school and the student cannot be transported safely without a transportation aide as specified on the IEP or IFSP, the transportation is billable. However, a transportation aide who is not a delegated healthcare aide trained by an RN cannot be billed as a separate cost because the cost of the transportation aide is included in the cost of the transportation.

(g) Transportation is not reimbursable by the Division when provided by the parent or relative of the child.

(h)Transportation to an “evaluation” service is covered as long as:

(A) Medically necessary transportation is listed and included in the Medicaid-eligible student’s current IEP or IFSP and the evaluation is to establish, re-establish, or terminate a SBHS covered service under IDEA;

(B) The evaluation is a SBHS covered health service;

(C) The medical provider conducting the evaluation, if not employed or contracted by the school medical provider, is an enrolled provider with the Division and meets applicable medical licensing standards necessary to conduct the evaluation.

(13) Medicaid may reimburse for contracted consultation health services for furnishing consultations regarding a Medicaid-eligible student’s covered health service(s) specified on the IEP or IFSP for an evaluation or assessment to establish, re-establish, or terminate a covered SBHS on an IEP or IFSP. Contracted consultation services must be provided by a licensed medical professional other than school medical provider staff.

(a) This service may be on a contracted basis for a number of students;

(b) Allowable services must be furnished through a personal service contract between the school medical provider and the licensed health care practitioner;

(c) This service would only be a SBHS covered health service by the school medical provider when the licensed health care practitioner did not bill Medicaid directly under other programs for the same services.

(14) Reimbursed coordinated care, performed by medically qualified staff as described in OAR 410-133-0120 directly related to health services required by a Medicaid-eligible student’s physical or mental condition as described in the IEP or IFSP; and must be one of the following:

(a) Managing integration of those Medicaid covered health services for treatment provided in the education setting;

(b) The portion of a conference between interested parties and medically qualified staff for developing, reviewing, or revising a Medicaid covered health service, or therapy treatment plan, for services provided pursuant to a Medicaid-eligible student’s IEP or IFSP, or to establish, re-establish, or terminate a covered health service under IDEA for eligibility purposes;

(c) Consultation from medically qualified staff providing technical assistance to or conferring with special education providers, physician, or families to assist them in providing covered health services to Medicaid-eligible students for treatment provided in the educational setting related to specific health services, and the goals and objectives in the student’s IEP or IFSP. Consultation services must be completed by a licensed health care practitioner within the scope of practice under their licensure;

Stat. Auth.: ORS 413.042, 414.065

Stats. Implemented: ORS 413.042, 414.065

Hist.: HR 39-1991, f. & cert. ef. 9-16-91; HR 21-1995, f. & cert. ef. 12-1-95; OMAP 31-1998, f. & cert. ef. 9-1-98; OMAP 31-2003, f. & cert ef. 4-1-03; OMAP 53-2003, f. 8-13-03 cert. ef. 9-1-03; OMAP 24-2005(Temp), f. & cert. ef. 4-5-05 thru 10-1-05; OMAP 53-2005, f. 9-30-05, cert. ef. 10-1-05; DMAP 19-2009, f. 6-12-09, cert. ef. 7-1-09; DMAP 15-2011, f. 6-29-11, cert. ef. 7-1-11

410-133-0120

Medically Qualified Staff

(1) The school medical (SM) provider shall furnish covered health services through the medically qualified staff who provide health services within the scope of their licensure. The SM provider shall document the credentials and qualifications, updated periodically, of all medically qualified staff. The SM provider credential file shall document the manner in which the provider checked, and periodically re-checked, the Medicaid provider exclusion list to confirm that the medically qualified staff is eligible to provide health services to Medicaid-eligible students. Special education teachers are not recognized as medically qualified staff for these services. See http://oig.hhs.gov/fraud/exclusions.asp

(2) School-based health services are delivered by providers who meet the federal requirements listed below and who operate within the scope of their health care practitioner’s license or certification pursuant to state law as follows:

(a) Evaluation and physical therapy treatments shall be provided by licensed physical therapists, that meet the federal requirements of 42 CFR 440.110, and are licensed by the State Physical Therapist Licensing Board. Licensed physical therapists assistants who’s function is to assist the physical therapist in patient-related activities and to perform delegated procedures that are commensurate with the licensed therapist assistant’s education and training may provide therapy treatments under the supervision and direction of a State licensed physical therapist within the scope of the health care practitioner’s license and accreditation pursuant to State law;

(b) Occupational therapy evaluation and treatments shall be provided by licensed occupational therapists that meet the federal requirements of 42 CFR 440.110, and are licensed by the State Occupational Therapy Licensing Board. Licensed occupational therapist assistants who’s function is to assist the occupational therapist in patient-related activities and to perform delegated procedures that are commensurate with the licensed therapist assistant’s education and training may provide therapy treatments under the supervision and direction of a State licensed occupational therapist within the scope of the health care practitioner’s license and accreditation pursuant to State law;

(c) Speech therapy evaluation and treatments shall be provided by speech pathologists that meet the federal requirements at 42 CFR 440.110, and are licensed by the State Board of Examiners for Speech Pathology and Audiology or hold a Certificate of Clinical Competency from the American Speech and Hearing Association;

(A) Speech therapy services may be provided by a graduate speech pathologist being supervised in the Clinical Fellowship Year (CFY) under the supervision of an ASHA licensed speech-language pathologist; or

(B) A Certified Speech-language Pathology Assistant (SLPA) performing within the scope of practice may provide therapy under the supervision of a State licensed speech-language pathologist within the scope of the health care practitioner’s license and accreditation pursuant to State law. Excludes services described in OAR 335-095-0055, Permit for Supervisors of Speech-language Pathology Assistants in Schools; see OAR 410-133-0200, Not Covered Services;

(d) Audiology evaluation and services shall be provided by audiologists that meet the federal requirements at 42 CFR 440.110;

(e) Nurse evaluation and treatments shall be provided by or under the direction of registered nurses (RN) licensed to practice in Oregon by the Oregon State Board of Nursing; or nurse practitioners that meet the federal requirements at 42 CFR 440.166, and are licensed by the Oregon State Board of Nursing to practice in Oregon as a Nurse Practitioner (See Oregon State Board of Nursing Nurse Practice Act, OAR 851-047-0000 through 851-047-0040 and Nurse Practitioners, OAR 851-050-0000 through 851-050-0142;

(A) Licensed practical nurses (LPN) may participate in the implementation of the plan of care for providing care to clients under the supervision of a licensed registered nurse, nurse practitioner, or physician pursuant to the Oregon State Board of Nursing Practice Act, OAR divisions 045 and 047;

(B) Treatment may also be provided by a delegated health care aide that is a non-licensed person trained and supervised by a licensed registered nurse (RN) or nurse practitioner (NP) to perform selected tasks of nursing care pursuant to The Oregon State Board of Nursing administrative rules, division 047 of the Nurse Practice Act;

(f) Psychological/mental health evaluations, testing, psychological services and treatments shall be provided by individuals who meet the relevant requirements of their respective professional state licensure as follows:

(A) Psychiatrists must be licensed to practice medicine and surgery in the State of Oregon; and possess a valid license from the Oregon Licensing Board for the Healing Arts;

(B) Psychologists must have one of the following: a doctoral degree in psychology obtained from an approved doctoral program in psychology accredited by the American Psychological Association (APA); or a doctoral degree in psychology from a program at a college or university that is regionally accredited at the doctoral level that meet the requirements approved by the State Board of Psychologist Examiners (Board) by rule (see OAR Chapter 858 Division010); and have two years of supervised employment under the direction of a psychologist licensed in Oregon or under the direction of a person considered by the board to have equivalent supervisory competence;

(C) Psychologists Associates granted independent status by the Board for authority to function without immediate and direct supervision in compliance with OAR 858-010-0039. Until the psychologist associate successfully obtains independent status, the “psychologist associate resident” must not practice without immediate supervision, but must at all times be under the periodic direct supervision of a licensed psychologist or under the direction of a person considered by the board to have equivalent supervisory competency who shall continue to be responsible for the practice of the associate see OAR 858-010-0037and 858-010-0038;

(D) Psychologists Associates who do not possess a doctoral degree, and are deemed competent to perform certain functions within the practice of psychology under the periodic direct supervision of a psychologist licensed by the Board:

(i) Has complied with all the applicable provisions of ORS 675.010 to 675.150;

(ii) Has received a master’s degree in psychology from a psychology program approved by the Board by rule;

(iii) Has completed an internship in an approved educational institution or one year of other training experience acceptable to the Board, such as supervised professional experience under the direction of a psychologist licensed in Oregon, or under the direction of a person considered by the Board to have equivalent supervisory competence; and

(iv) Furnishes proof acceptable to the Board of at least 36 months, exclusive of internship, of full-time experience satisfactory to the board under the direct supervision of a licensed psychologist in Oregon, or under the direct supervision of a person considered by the Board to have equivalent supervisory competence.

(E) Testing Technicians under the supervision of a licensed psychologist. A licensee may delegate administration and scoring of tests to technicians as provided in ORS 675.010(4) and OAR 858-010-0001, if the licensee ensures the technicians are adequately trained to administer and score the specific test being used; and ensures that the technicians maintain standards for the testing environment and testing administration as set forth in the American Psychological Association Standards for Educational and Psychological Tests (1999) and Ethical Principles for Psychologists (2002). See OAR 858-010-0002, Guidelines for Supervising Technicians;

(F) Services provided by Clinical Social Work Associate (CSWA) or Licensed Clinical Social Worker (LCSW): must possess a master’s degree from an accredited college or university accredited by the Council on Social Work Education and have completed the equivalent of two years of full-time experience in the field of clinical social work in accordance with rules of the Oregon State Board of Clinical Social Workers for a LCSW or whose plan of practice and supervision has been approved by the board, for a CSWA working toward LCSW licensure under the supervision of a LCSW for two years of post masters clinical experience and is licensed by the State Board of Clinical Social Workers to practice in Oregon. See Board of Clinical Social Workers, Chapter 877, Division 20, Procedure for Certification and Licensing.

Stat. Auth.: ORS 413.042, 414.065

Stats. Implemented: ORS 413.042, 414.065

Hist.: HR 39-1991, f. & cert. ef. 9-16-91; HR 49-1991(Temp), f. & cert. ef. 10-24-91; HR 3-1992, f. & cert. ef. 1-2-92; HR 29-1993, f. & cert. ef. 10-1-93; HR 19-1994, f. & cert. ef. 4-1-94; HR 21-1995, f. & cert. ef. 12-1-95; OMAP 38-1999, f. & cert. ef. 10-1-99; OMAP 31-2003, f. & cert ef. 4-1-03 ; OMAP 53-2003, f. 8-13-03 cert. ef. 9-1-03; OMAP 24-2005(Temp), f. & cert. ef. 4-5-05 thru 10-1-05; OMAP 53-2005, f. 9-30-05, cert. ef. 10-1-05; DMAP 19-2009, f. 6-12-09, cert. ef. 7-1-09; DMAP 15-2011, f. 6-29-11, cert. ef. 7-1-11

 

Rule Caption: Hospital Provider Tax Rate Increase.

Adm. Order No.: DMAP 16-2011(Temp)

Filed with Sec. of State: 7-1-2011

Certified to be Effective: 7-1-11 thru 11-1-11

Notice Publication Date:

Rules Amended: 410-050-0861

Subject: The rule is being amended to implement an increase in the hospital provider tax rate from 2.32% to 5.25% effective July 1, 2011 through a temporary rule.

      This temporary rule is available on the DHS Website: http://www.oregon.gov/DHS/admin/dwssrules/index.shtml

      For hardcopy requests, call: (503) 947-5250.

Rules Coordinator: Jennifer Bittel—(503) 947-5250

410-050-0861

Tax Rate

(1) The tax rate for the period beginning January 1, 2005 and ending June 30, 2006 is .68 percent.

(2) The tax rate for the period beginning July 1, 2006 and ending December 31, 2007 is .82 percent.

(3) The tax rate for the period beginning January 1, 2008 and ending June 30, 2009 is .63 percent.

(4) The tax rate for the period of January 1, 2008 through June 30, 2009 does not apply to the period beginning July 1, 2009.

(5) The tax rate for the period beginning July 1, 2009 and ending September 30, 2009 is .15 percent.

(6) The tax rate for the period beginning October 1, 2009 and ending June 30, 2010 is 2.8 percent.

(7) The tax rate for the period beginning July 1, 2010 and ending June 30, 2011 is 2.32 percent.

(8) The tax rate for the period beginning July 1, 2011 is 5.25 percent.

Stat. Auth.: ORS 413.042

Stats. Implemented: 2009 OL Ch. 867 §17, 2007 OL Ch. 780 §1 & 2003 OL Ch. 736 § 2 & 3

Hist.: OMAP 28-2005(Temp), f. & cert. ef. 5-10-05 thru 11-5-05; OMAP 34-2005, f. 7-8-05, cert. ef. 7-11-05; OMAP 14-2006, f. 6-1-06, cert. ef. 7-1-06; DMAP 29-2007, f. 12-31-07, cert. ef. 1-1-08; DMAP 3-2008, f. & cert. ef. 1-25-08; DMAP 24-2009, f. & cert. ef. 7-1-09; DMAP 25-2009(Temp), f. & cert. ef. 7-15-09 thru 1-10-10; DMAP 27-2009, f. & cert. ef. 9-1-09; DMAP 33-2009, f. & cert. ef. 10-1-09; DMAP 21-2010, f. 6-30-10, cert. ef. 7-1-10; DMAP 16-2011(Temp), f. & cert. ef. 7-1-11 thru 11-1-11

 

Rule Caption: July 2011 – stainless steel crowns, pulpal regeneration, prefabricated post and core services, other clarifications.

Adm. Order No.: DMAP 17-2011

Filed with Sec. of State: 7-12-2011

Certified to be Effective: 7-12-11

Notice Publication Date: 5-1-2011

Rules Amended: 410-123-1220, 410-123-1260

Subject: The Dental Services Program administrative rules govern Division payment for services to certain clients. The Division amended rules 410-123-1220 and 410-123-1260 as follows:

      • To cover stainless steel crowns on anterior primary teeth in addition to posterior primary and permanent teeth for clients under age 21 or who are pregnant; to list coverage of a newly created dental code for pulpal regeneration that is limited to clients under age 21 or who are pregnant; to clarify that prefabricated post and core services are covered only for clients under 21 or pregnant; to reference the updated “Covered and Non-Covered Services document” and other minor clarifications.

      • To clarify current policies and procedures to ensure these rules are not open to interpretation by the provider or outside parties and to help eliminate confusion possibly resulting in non-compliance and help facilitate provider compliance with eligibility, service coverage and limitations, and billing requirements.

      • To reflect the Oregon Health Authority name change and updated statutory reference.

      • Other text may be revised to improve readability and to take care of necessary “housekeeping” corrections.

Rules Coordinator: Darlene Nelson—(503) 945-6927

410-123-1220

Coverage According to the Prioritized List of Health Services

(1) This rule incorporates by reference the “Covered and Non-Covered Dental Services” document, dated July 1, 2011, and located on the Division of Medical Assistance Programs (Division) Website at: www.dhs.state.or.us/policy/healthplan/guides/dental/main.html.

(a) The “Covered and Non-Covered Dental Services” document lists coverage of Current Dental Terminology (CDT) procedure codes according to the Oregon Health Services Commission (HSC) Prioritized List of Health Services (HSC Prioritized List) and the client’s specific Oregon Health Plan benefit package;

(b) This document is subject to change if there are funding changes to the HSC Prioritized List.

(2) Changes to services funded on the HSC Prioritized List are effective on the date of the HSC Prioritized List change:

(a) The Division administrative rules (chapter 410, division 123) will not reflect the most current HSC Prioritized List changes until they have gone through the Division rule filing process;

(b) For the most current HSC Prioritized List, refer to the HSC Web site at www.oregon.gov/OHPPR/HSC/current_prior.shtml;

(c) In the event of an alleged variation between a Division-listed code and a national code, the Division shall apply the national code in effect on the date of request or date of service.

(3) Refer to OAR 410-123-1260 for information about limitations on procedures funded according to the HSC Prioritized List. Examples of limitations include frequency and client’s age.

(4) The HSC Prioritized List does not include or fund the following general categories of dental services and the Division does not cover them for any client. Several of these services are considered elective or “cosmetic” in nature (i.e., done for the sake of appearance):

(a) Desensitization;

(b) Implant and implant services;

(c) Mastique or veneer procedure;

(d) Orthodontia (except when it is treatment for cleft palate);

(e) Overhang removal;

(f) Procedures, appliances or restorations solely for aesthetic/ cosmetic purposes;

(g) Temporomandibular joint dysfunction treatment; and

(h) Tooth bleaching.

Stat. Auth.: ORS 413.042 & 414.065

Stats. Implemented: ORS 414.065

Hist.: HR 3-1994, f. & cert. ef. 2-1-94; HR 21-1994(Temp), f. 4-29-94, cert. ef. 5-1-94; HR 32-1994, f. & cert. ef. 11-1-94; HR 20-1995, f. 9-29-95, cert. ef. 10-1-95; HR 9-1996, f. 5-31-96, cert. ef. 6-1-96; OMAP 13-1998(Temp), f. & cert. ef. 5-1-98 thru 9-1-98; OMAP 28-1998, f. & cert. ef. 9-1-98; OMAP 23-1999, f. & cert. ef. 4-30-99; OMAP 8-2000, f. 3-31-00, cert. ef. 4-1-00; OMAP 17-2000, f. 9-28-00, cert. ef. 10-1-00; OMAP 48-2002, f. & cert. ef. 10-1-02; OMAP 3-2003, f. 1-31-03, cert. ef. 2-1-03; OMAP 65-2003, f. 9-10-03 cert. ef. 10-1-03; DMAP 25-2007, f. 12-11-07, cert, ef. 1-1-08; DMAP 38-2008, f. 12-11-08, cert. ef. 1-1-09; DMAP 16-2009 f. 6-12-09, cert. ef. 7-1-09; DMAP 41-2009, f. 12-15-09, cert. ef. 1-1-10; DMAP 14-2010, f. 6-10-10, cert. ef. 7-1-10; DMAP 31-2010, f. 12-15-10, cert. ef. 1-1-11; DMAP 17-2011, f. & cert. ef. 7-12-11

410-123-1260

OHP Plus Dental Benefits

(1) GENERAL:

(a) Early and Periodic Screening, Diagnosis and Treatment (EPSDT):

(A) Refer to Code of Federal Regulations (42 CFR 441, Subpart B) and OAR chapter 410, division 120 for definitions of the EPSDT program, eligible clients, and related services. EPSDT dental services includes, but are not limited to:

(i) Dental screening services for eligible EPSDT individuals; and

(ii) Dental diagnosis and treatment which is indicated by screening, at as early an age as necessary, needed for relief of pain and infections, restoration of teeth and maintenance of dental health;

(B) Providers must provide EPSDT services for eligible Division of Medical Assistance Programs (Division) clients according to the following documents:

(i) The Dental Services Program administrative rules (OAR chapter 410, division 123), for dentally appropriate services funded on the Oregon Health Services Commission Prioritized List of Health Services (HSC Prioritized List); and

(ii) The “Oregon Health Plan (OHP) – Recommended Dental Periodicity Schedule,” dated January 1, 2010, incorporated by reference and posted on the Division Web site in the Dental Services Supplemental Information document at www.dhs.state.or.us/policy/healthplan/guides/
dental/main.html;

(b) Restorative, periodontal and prosthetic treatments:

(A) Such treatments must be consistent with the prevailing standard of care, documentation must be included in the client’s charts to support the treatment, and may be limited as follows:

(i) When prognosis is unfavorable;

(ii) When treatment is impractical;

(iii) A lesser-cost procedure would achieve the same ultimate result; or

(iv) The treatment has specific limitations outlined in this rule;

(B) Prosthetic treatment (including porcelain fused to metal crowns) are limited until rampant progression of caries is arrested and a period of adequate oral hygiene and periodontal stability is demonstrated; periodontal health needs to be stable and supportive of a prosthetic.

(2) DIAGNOSTIC SERVICES:

(a) Exams:

(A) For children (under 19 years of age):

(i) The Division shall reimburse exams (billed as D0120, D0145, D0150, or D0180) a maximum of twice every 12 months with the following limitations:

(I) D0150: once every 12 months when performed by the same practitioner;

(II) D0150: twice every 12 months only when performed by different practitioners;

(III) D0180: once every 12 months;

(ii) The Division shall reimburse D0160 only once every 12 months when performed by the same practitioner;

(B) For adults (19 years of age and older) – The Division shall reimburse exams (billed as D0120, D0150, D0160, or D0180) by the same practitioner once every 12 months;

(C) For each emergent episode, use D0140 for the initial exam. Use D0170 for related dental follow-up exams;

(D) The Division only covers oral exams by medical practitioners when the medical practitioner is an oral surgeon;

(E) As the American Dental Association’s Current Dental Terminology (CDT) codebook specifies the evaluation, diagnosis and treatment planning components of the exam are the responsibility of the dentist, the Division does not reimburse dental exams when furnished by a dental hygienist (with or without a limited access permit);

(b) Radiographs:

(A) The Division shall reimburse for routine radiographs once every 12 months;

(B) The Division shall reimburse bitewing radiographs for routine screening once every 12 months;

(C) The Division shall reimburse a maximum of six radiographs for any one emergency;

(D) For clients under age six, radiographs may be billed separately every 12 months as follows:

(i) D0220 – once;

(ii) D0230 – a maximum of five times;

(iii) D0270 – a maximum of twice, or D0272 once;

(E) The Division shall reimburse for panoramic (D0330) or intra-oral complete series (D0210) once every five years, but both cannot be done within the five-year period;

(F) Clients must be a minimum of six years old for billing intra-oral complete series (D0210). The minimum standards for reimbursement of intra-oral complete series are:

(i) For clients age six through 11— a minimum of 10 periapicals and two bitewings for a total of 12 films;

(ii) For clients ages 12 and older – a minimum of 10 periapicals and four bitewings for a total of 14 films;

(G) If fees for multiple single radiographs exceed the allowable reimbursement for a full mouth complete series (D0210), the Division shall reimburse for the complete series;

(H) Additional films may be covered if dentally or medically appropriate, e.g., fractures (Refer to OAR 410-123-1060 and 410-120-0000);

(I) If the Division determines the number of radiographs to be excessive, payment for some or all radiographs of the same tooth or area may be denied;

(J) The exception to these limitations is if the client is new to the office or clinic and the office or clinic was unsuccessful in obtaining radiographs from the previous dental office or clinic. Supporting documentation outlining the provider’s attempts to receive previous records must be included in the client’s records;

(K) Digital radiographs, if printed, should be on photo paper to assure sufficient quality of images.

(3) PREVENTIVE SERVICES:

(a) Prophylaxis:

(A) For children (under 19 years of age) – Limited to twice per 12 months;

(B) For adults (19 years of age and older) – Limited to once per 12 months;

(C) Additional prophylaxis benefit provisions may be available for persons with high risk oral conditions due to disease process, pregnancy, medications or other medical treatments or conditions, severe periodontal disease, rampant caries and/or for persons with disabilities who cannot perform adequate daily oral health care;

(D) Are coded using the appropriate Current Dental Terminology (CDT) coding:

(i) D1110 (Prophylaxis – Adult) – Use for clients 14 years of age and older; and

(ii) D1120 (Prophylaxis – Child) – Use for clients under 14 years of age;

(b) Topical fluoride treatment:

(A) For adults (19 years of age and older) – Limited to once every 12 months;

(B) For children (under 19 years of age) – Limited to twice every 12 months;

(C) For children under 7 years of age who have limited access to a dental practitioner, topical fluoride varnish may be applied by a medical practitioner during a medical visit:

(i) Bill the Division directly regardless of whether the client is fee-for-service (FFS) or enrolled in a Fully Capitated Health Plan (FCHP) or Physician Care Organization (PCO);

(ii) Bill using a professional claim format with the appropriate CDT code (D1206 – Topical Fluoride Varnish);

(iii) An oral screening by a medical practitioner is not a separate billable service and is included in the office visit;

(D) Additional topical fluoride treatments may be available, up to a total of 4 treatments per client within a 12-month period, when high-risk conditions or oral health factors are clearly documented in chart notes for the following clients who:

(i) Have high-risk oral conditions due to disease process, medications, other medical treatments or conditions, or rampant caries;

(ii) Are pregnant;

(iii) Have physical disabilities and cannot perform adequate, daily oral health care;

(iv) Have a developmental disability or other severe cognitive impairment that cannot perform adequate, daily oral health care; or

(v) Are under seven year old with high-risk oral health factors, such as poor oral hygiene, deep pits and fissures (grooves) in teeth, severely crowded teeth, poor diet, etc;

(c) Sealants:

(A) Are covered only for children under 16 years of age;

(B) The Division limits coverage to:

(i) Permanent molars; and

(ii) Only one sealant treatment per molar every five years, except for visible evidence of clinical failure;

(d) Tobacco cessation:

(A) For services provided during a dental visit, bill as a dental service using CDT code D1320 when the following brief counseling is provided:

(i) Ask patients about their tobacco-use status at each visit and record information in the chart;

(ii) Advise patients on their oral health conditions related to tobacco use and give direct advice to quit using tobacco and a strong personalized message to seek help; and

(iii) Refer patients who are ready to quit, utilizing internal and external resources to complete the remaining three A’s (assess, assist, arrange) of the standard intervention protocol for tobacco;

(B) The Division allows a maximum of 10 services within a three-month period;

(C) For tobacco cessation services provided during a medical visit follow criteria outlined in OAR 410-130-0190;

(e) Space management:

(A) The Division shall cover fixed and removable space maintainers (D1510, D1515, D1520, and D1525) only for clients under 19 years of age;

(B) The Division may not reimburse for replacement of lost or damaged removable space maintainers.

(4) RESTORATIVE SERVICES:

(a) Restorations – amalgam and composite:

(A) Resin-based composite crowns on anterior teeth (D2390) are only covered for clients under 21 years of age or who are pregnant;

(B) The Division limits payment to the maximum restoration fee of four surfaces per tooth. Refer to the American Dental Association (ADA) CDT codebook for definitions of restorative procedures;

(C) Combine and bill one line per tooth using the appropriate code. For example, if tooth #30 has a buccal amalgam and a mesial-occlusal-distal (MOD) amalgam, then bill MOD, B, using code D2161 (four or more surfaces);

(D) The Division may not reimburse for an amalgam or composite restoration and a crown on the same tooth;

(E) The Division reimburses for a surface once in each treatment episode regardless of the number or combination of restorations;

(F) The restoration fee includes payment for occlusal adjustment and polishing of the restoration;

(G) The Division reimburses for posterior composite restorations at the same rate as amalgam restorations;

(H) The Division limits payment for replacement of posterior composite restorations to once every five years;

(b) Crowns and related services:

(A) General payment policies:

(i) The fee for the crown includes payment for preparation of the gingival tissue;

(ii) The Division shall cover crowns only when:

(I) There is significant loss of clinical crown and no other restoration will restore function; and

(II) The crown-to-root ratio is 50:50 or better and the tooth is restorable without other surgical procedures;

(iii) Reimbursement of retention pins (D2951) is per tooth, not per pin;

(B) The Division shall not cover the following services:

(i) Endodontic therapy alone (with or without a post);

(ii) Aesthetics (cosmetics);

(iii) Crowns in cases of advanced periodontal disease or when a poor crown/root ratio exists for any reason;

(C) The Division shall cover acrylic heat or light cured crowns (D2970 temporary crown, fractured tooth) – allowed only for anterior permanent teeth;

(D) The Division shall cover the following only for clients under 21 years of age or who are pregnant:

(i) Prefabricated plastic crowns (D2932) – allowed only for anterior teeth, permanent or primary;

(ii) Stainless steel crowns (D2930/D2931) – allowed only for anterior primary teeth and posterior permanent or primary teeth;

(iii) Prefabricated stainless steel crowns with resin window (D2933) – allowed only for anterior teeth, permanent or primary;

(iv) Prefabricated post and core in addition to crowns (D2954/D2957);

(v) Permanent crowns (resin-based composite – D2710, and porcelain fused to metal (PFM) – D2751 and D2752) as follows:

(I) Limited to teeth numbers 6-11, 22 and 27 only, if dentally appropriate;

(II) Limited to four (4) in a seven-year period. This limitation includes any replacement crowns allowed according to (E)(i) of this rule;

(III) Only for clients at least 16 years of age ; and

(IV) Rampant caries are arrested and the client demonstrates a period of oral hygiene before prosthetics are proposed;

(vi) PFM crowns (D2751 and D2752) must also meet the following additional criteria:

(I) The dental practitioner has attempted all other dentally appropriate restoration options, and documented failure of those options;

(II) Written documentation in the client’s chart indicates that PFM is the only restoration option that will restore function;

(III) The dental practitioner submits radiographs to the Division for review; history, diagnosis, and treatment plan may be requested. See OAR 410-123-1100 (Services Reviewed by the Division of Medical Assistance Programs);

(IV) The client has documented stable periodontal status with pocket depths within 1 – 3 millimeters. If PFM crowns are placed with pocket depths of 4 millimeter and over, documentation must be maintained in the client’s chart of the dentist’s findings supporting stability and why the increased pocket depths will not adversely affect expected long term prognosis;

(V) The crown has a favorable long-term prognosis; and

(VI) If tooth to be crowned is clasp/abutment tooth in partial denture, both prognosis for crown itself and tooth’s contribution to partial denture must have favorable expected long-term prognosis;

(E) Crown replacement:

(i) Permanent crown replacement limited to once every seven years;

(ii) All other crown replacement limited to once every five years; and

(iii) The Division may make exceptions to crown replacement limitations due to acute trauma, based on the following factors:

(I) Extent of crown damage;

(II) Extent of damage to other teeth or crowns;

(III) Extent of impaired mastication;

(IV) Tooth is restorable without other surgical procedures; and

(V) If loss of tooth would result in coverage of removable prosthetic.

(5) ENDODONTIC SERVICES:

(a) Pulp capping:

(A) The Division includes direct and indirect pulp caps in the restoration fee; no additional payment shall be made for clients with the OHP Plus benefit package;

(B) The Division covers direct pulp caps as a separate service for clients with the OHP Standard benefit package because restorations are not a covered benefit under this benefit package;

(b) Endodontic therapy:

(A) Endodontic therapy (D3230, D3240, D3330) is covered only for clients under 21 years of age or who are pregnant;

(B) The Division covers endodontics only if the crown-to-root ratio is 50:50 or better and the tooth is restorable without other surgical procedures;

(c) Endodontic retreatment and apicoectomy/periradicular surgery:

(A) The Division does not cover retreatment of a previous root canal or apicoectomy/periradicular surgery for bicuspid or molars;

(B) The Division limits either a retreatment or an apicoectomy (but not both procedures for the same tooth) to symptomatic anterior teeth when:

(i) Crown-to-root ratio is 50:50 or better;

(ii) The tooth is restorable without other surgical procedures; or

(iii) If loss of tooth would result in the need for removable prosthodontics;

(C) Retrograde filling (D3430) is covered only when done in conjunction with a covered apicoectomy of an anterior tooth;

(d) The Division does not allow separate reimbursement for open-and-drain as a palliative procedure when the root canal is completed on the same date of service, or if the same practitioner or dental practitioner in the same group practice completed the procedure;

(e) The Division does not cover root canal therapy for third molars;

(f) The Division covers endodontics if the tooth is restorable within the OHP benefit coverage package;

(g) Apexification/recalcification and pulpal regeneration procedures:

(A) The Division limits payment for apexification to a maximum of five treatments on permanent teeth only;

(B) Apexification/recalcification and pulpal regeneration procedures are covered only for clients under 21 years of age or who are pregnant;

(h) Canal preparation and fitting of preformed dowel or post (D3950) should not be reported in conjunction with D2952, D2953, D2954, or D2957 by the same practitioner.

(6) PERIODONTIC SERVICES:

(a) Surgical periodontal services (includes six months routine postoperative care):

(A) D4210 and D4211 – limited to coverage for severe gingival hyperplasia where enlargement of gum tissue occurs that prevents access to oral hygiene procedures, e.g., Dilantin hyperplasia;

(B) The Division covers the following services only for clients under 21 years of age or who are pregnant:

(i) D4240, D4241, D4260 and D4261 – allowed once every three years unless there is a documented medical/dental indication;

(ii) D4245 and D4268;

(b) Non-surgical periodontal services:

(A) D4341 and D4342 – allowed once every two years. A maximum of two quadrants on one date of service is payable, except in extraordinary circumstances. Quadrants are not limited to physical area, but are further defined by the number of teeth with pockets 5 mm or greater;

(B) D4355 – allowed only once every 2 years;

(c) Other periodontal services – D4910 – limited to following periodontal therapy and allowed once every six months. For further consideration of more frequent periodontal maintenance benefits, office records must clearly reflect clinical indication, i.e., chart notes, pocket depths and radiographs;

(d) Records must clearly document the clinical indications for all periodontal procedures, including current pocket depth charting and/or radiographs;

(e) The Division may not reimburse for procedures identified by the following codes if performed on the same date of service:

(A) D1110 (Prophylaxis – adult);

(B) D1120 (Prophylaxis – child);

(C) D4210 (Gingivectomy or gingivoplasty – four or more contiguous teeth or bounded teeth spaces per quadrant);

(D) D4211 (Gingivectomy or gingivoplasty – one to three contiguous teeth or bounded teeth spaces per quadrant);

(E) D4260 (Osseous surgery, including flap entry and closure – four or more contiguous teeth or bounded teeth spaces per quadrant);

(F) D4261 (Osseous surgery, including flap entry and closure – one to three contiguous teeth or bounded teeth spaces per quadrant);

(G) D4341 (Periodontal scaling and root planning – four or more teeth per quadrant);

(H) D4342 (Periodontal scaling and root planning – one to three teeth per quadrant);

(I) D4355 (Full mouth debridement to enable comprehensive evaluation and diagnosis); and

(J) D4910 (Periodontal maintenance).

(7) REMOVABLE PROSTHODONTIC SERVICES:

(a) Clients age 16 years and older are eligible for removable resin base partial dentures (D5211–D5212) and full dentures (complete or immediate, D5110–D5140);

(b) The Division limits full dentures for non-pregnant clients age 21 and older to only those clients who are recently edentulous:

(A) For the purposes of this rule:

(i) “Edentulous” means all teeth removed from the jaw for which the denture is being provided; and

(ii) “Recently edentulous” means the most recent extractions from that jaw occurred within six months of the delivery of the final denture (or, for fabricated prosthetics, the final impression) for that jaw;

(B) See OAR 410-123-1000 for detail regarding billing fabricated prosthetics;

(c) The fee for the partial and full dentures includes payment for adjustments during the six-month period following delivery to clients;

(d) Resin partial dentures (D5211-D5212):

(A) The Division may not approve resin partial dentures if stainless steel crowns are used as abutments;

(B) The client must have one or more anterior teeth missing or four or more missing posterior teeth per arch with resulting space equivalent to that loss demonstrating inability to masticate. Third molars are not a consideration when counting missing teeth;

(C) The dental practitioner must note the teeth to be replaced and teeth to be clasped when requesting prior authorization (PA);

(e) Replacement of removable partial or full dentures, when it cannot be made clinically serviceable by a less costly procedure (e.g., reline, rebase, repair, tooth replacement), is limited to the following:

(A) For clients at least 16 years and under 21 years of age or who are pregnant – the Division shall replace full or partial dentures once every ten years, only if dentally appropriate. This does not imply that replacement of dentures or partials must be done once every ten years, but only when dentally appropriate;

(B) For non-pregnant clients 21 years of age and older – the Division may not cover replacement of full dentures, but shall cover replacement of partial dentures once every 10 years only if dentally appropriate;

(C) The ten year limitations apply to the client regardless of the client’s OHP or Dental Care Organization (DCO) enrollment status at the time client’s last denture or partial was received. For example: a client receives a partial on February 1, 2002, and becomes a FFS OHP client in 2005. The client is not eligible for a replacement partial until February 1, 2012. The client gets a replacement partial on February 3, 2012 while FFS and a year later enrolls in a DCO. The client would not be eligible for another partial until February 3, 2022, regardless of DCO or FFS enrollment;

(D) Replacement of partial dentures with full dentures is payable ten years after the partial denture placement. Exceptions to this limitation may be made in cases of acute trauma or catastrophic illness that directly or indirectly affects the oral condition and results in additional tooth loss. This pertains to, but is not limited to, cancer and periodontal disease resulting from pharmacological, surgical and/or medical treatment for aforementioned conditions. Severe periodontal disease due to neglect of daily oral hygiene may not warrant replacement;

(f) The Division limits reimbursement of adjustments and repairs of dentures that are needed beyond six months after delivery of the denture as follows for non-pregnant clients 21 years of age and older:

(A) A maximum of 4 times per year for:

(i) Adjusting complete and partial dentures, per arch (D5410-D5422);

(ii) Replacing missing or broken teeth on a complete denture – each tooth (D5520);

(iii) Replacing broken tooth on a partial denture – each tooth (D5640);

(iv) Adding tooth to existing partial denture (D5650);

(B) A maximum of 2 times per year for:

(i) Repairing broken complete denture base (D5510);

(ii) Repairing partial resin denture base (D5610);

(iii) Repairing partial cast framework (D5620);

(iv) Repairing or replacing broken clasp (D5630);

(v) Adding clasp to existing partial denture (D5660);

(g) Denture rebase procedures:

(A) Rebase should only be done if a reline may not adequately solve the problem. The Division limits payment for rebase to once every three years;

(B) The Division may make exceptions to this limitation in cases of acute trauma or catastrophic illness that directly or indirectly affects the oral condition and results in additional tooth loss. This pertains to, but is not limited to, cancer and periodontal disease resulting from pharmacological, surgical and/or medical treatment for aforementioned conditions. Severe periodontal disease due to neglect of daily oral hygiene may not warrant rebasing;

(h) Denture reline procedures:

(A) The Division limits payment for reline of complete or partial dentures to once every three years;

(B) The Division may make exceptions to this limitation under the same conditions warranting replacement;

(C) Laboratory relines:

(i) Are not payable prior to six months after placement of an immediate denture; and

(ii) Are limited to once every three years;

(i) Interim partial dentures (D5820–D5821, also referred to as “flippers”):

(A) Are allowed if the client has one or more anterior teeth missing; and

(B) The Division shall reimburse for replacement of interim partial dentures once every 5 years, but only when dentally appropriate;

(j) Tissue conditioning:

(A) Is allowed once per denture unit in conjunction with immediate dentures; and

(B) Is allowed once prior to new prosthetic placement.

(8) MAXILLOFACIAL PROSTHETIC SERVICES:

(a) Maxillofacial prosthetics are medical services. Refer to the “Covered and Non-Covered Dental Services” document and OAR 410-123-1220;

(b) Bill for maxillofacial prosthetics using the professional (CMS-1500, DMAP 505 or 837P) claim format:

(A) For clients receiving services through an FCHP or PCO, bill maxillofacial prosthetics to the FCHP or PCO;

(B) For clients receiving medical services through FFS, bill the Division.

(9) Fixed Prosthodontics – The Division limits coverage of prefabricated post and core in addition to fixed partial denture retainer (D6972) only to clients under 21 years of age or who are pregnant.

(10) ORAL SURGERY SERVICES:

(a) Bill the following procedures in an accepted dental claim format using CDT codes:

(A) Procedures that are directly related to the teeth and supporting structures that are not due to a medical, including such procedures performed in an ambulatory surgical center (ASC) or an inpatient or outpatient hospital setting;

(B) Services performed in a dental office setting (including an oral surgeon’s office):

(i) Such services include, but are not limited to, all dental procedures, local anesthesia, surgical postoperative care, radiographs and follow-up visits;

(ii) Refer to OAR 410-123-1160 for any PA requirements for specific procedures;

(b) Bill the following procedures using the professional claim format and the appropriate American Medical Association (AMA) CPT procedure and ICD-9 diagnosis codes:

(A) Procedures that are a result of a medical condition (i.e., fractures, cancer);

(B) Services requiring hospital dentistry that are the result of a medical condition/diagnosis (i.e., fracture, cancer);

(c) Refer to the “Covered and Non-Covered Dental Services” document to see a list of CDT procedure codes on the HSC Prioritized List that may also have CPT medical codes. See OAR 410-123-1220. The procedures listed as “medical” on the table may be covered as medical procedures, and the table may not be all-inclusive of every dental code that has a corresponding medical code;

(d) For clients enrolled in a DCO, the DCO is responsible for payment of those services in the dental plan package;

(e) Oral surgical services performed in an ASC or an inpatient or outpatient hospital setting:

(A) Require PA;

(B) For clients enrolled in a FCHP, the facility charge and anesthesia services are the responsibility of the FCHP. For clients enrolled in a PCO, the outpatient facility charge (including ASCs) and anesthesia are the responsibility of the PCO. Refer to the current Medical Surgical Services administrative rules in OAR chapter 410, division 130 for more information;

(C) If a client is enrolled in a FCHP or a PCO, it is the responsibility of the provider to contact the FCHP or the PCO for any required authorization before the service is rendered;

(f) All codes listed as “by report” require an operative report;

(g) The Division covers payment for tooth re-implantation only in cases of traumatic avulsion where there are good indications of success;

(h) Biopsies collected are reimbursed as a dental service. Laboratory services of biopsies are reimbursed as a medical service;

(i) The Division does not cover surgical excisions of soft tissue lesions (D7410–D7415);

(j) Extractions – Includes local anesthesia and routine postoperative care, including treatment of a dry socket if done by the provider of the extraction. Dry socket is not considered a separate service;

(k) Surgical extractions:

(A) Include local anesthesia and routine post-operative care;

(B) The Division limits payment for surgical removal of impacted teeth or removal of residual tooth roots to treatment for only those teeth that have acute infection or abscess, severe tooth pain, and/or unusual swelling of the face or gums;

(C) The Division does not cover alveoloplasty in conjunction with extractions (D7310 and D7311) separately from the extraction;

(D) The Division covers alveoplasty not in conjunction with extractions (D7320) only for clients under 21 years of age or who are pregnant.

(11) ORTHODONTIA SERVICES:

(a) The Division limits orthodontia services and extractions to eligible clients:

(A) With the ICD-9-CM diagnosis of:

(i) Cleft palate; or

(ii) Cleft palate with cleft lip; and

(B) Whose orthodontia treatment began prior to 21 years of age; or

(C) Whose surgical corrections of cleft palate or cleft lip were not completed prior to age 21;

(b) PA is required for orthodontia exams and records. A referral letter from a physician or dentist indicating diagnosis of cleft palate/cleft lip must be included in the client’s record and a copy sent with the PA request;

(c) Documentation in the client’s record must include diagnosis, length and type of treatment;

(d) Payment for appliance therapy includes the appliance and all follow-up visits;

(e) Orthodontists evaluate orthodontia treatment for cleft palate/cleft lip as two phases. Stage one is generally the use of an activator (palatal expander) and stage two is generally the placement of fixed appliances (banding). The Division shall reimburse each phase individually (separately);

(f) The Division shall pay for orthodontia in one lump sum at the beginning of each phase of treatment. Payment for each phase is for all orthodontia-related services. If the client transfers to another orthodontist during treatment, or treatment is terminated for any reason, the orthodontist must refund to the Division any unused amount of payment, after applying the following formula: Total payment minus $300.00 (for banding) multiplied by the percentage of treatment remaining;

(g) The Division shall use the length of the treatment plan from the original request for authorization to determine the number of treatment months remaining;

(h) As long as the orthodontist continues treatment, the Division may not require a refund even though the client may become ineligible for medical assistance sometime during the treatment period;

(i) Code:

(A) D8660 – PA required (reimbursement for required orthodontia records is included);

(B) Codes D8010-D8999 – PA required.

(12) ADJUNCTIVE GENERAL AND OTHER SERVICES:

(a) Fixed partial denture sectioning (D9120) is covered only when extracting a tooth connected to a fixed prosthesis and a portion of the fixed prosthesis is to remain intact and serviceable, preventing the need for more costly treatment;

(b) Anesthesia:

(A) Only use general anesthesia or IV sedation for those clients with concurrent needs: age, physical, medical or mental status, or degree of difficulty of the procedure (D9220, D9221, D9241 and D9242);

(B) The Division reimburses providers for general anesthesia or IV sedation as follows:

(i) D9220 or D9241: For the first 30 minutes;

(ii) D9221 or D9242: For each additional 15-minute period, up to three hours on the same day of service. Each 15-minute period represents a quantity of one. Enter this number in the quantity column;

(C) The Division reimburses administration of Nitrous Oxide (D9230) per date of service, not by time;

(D) Oral pre-medication anesthesia for conscious sedation (D9248):

(i) Limited to clients under 13 years of age;

(ii) Limited to four times per year;

(iii) Includes payment for monitoring and Nitrous Oxide; and

(iv) Requires use of multiple agents to receive payment;

(E) Upon request, providers must submit a copy of their permit to administer anesthesia, analgesia and/or sedation to the Division;

(F) For the purpose of Title XIX and Title XXI, the Division limits payment for code D9630 to those oral medications used during a procedure and is not intended for “take home” medication;

(c) The Division limits reimbursement of house/extended care facility call (D9410) only for urgent or emergent dental visits that occur outside of a dental office. This code is not reimbursable for provision of preventive services or for services provided outside of the office for the provider or facilities’ convenience;

(d) Office visit for observation (D9430):

(A) Is covered only for clients under 21 years of age or who are pregnant; and

(B) The Division reimburses a maximum of three visits per year;

(e) Oral devices/appliances (E0485, E0486):

(A) These may be placed or fabricated by a dentist or oral surgeon, but are considered a medical service;

(B) Bill the Division or the FCHP/PCO for these codes using the professional claim format.

Stat. Auth.: ORS 413.042, 414.065 & 414.707

Stats. Implemented: ORS 414.065 & 414.707

Hist.: HR 3-1994, f. & cert. ef. 2-1-94; HR 20-1995, f. 9-29-95, cert. ef. 10-1-95; OMAP 13-1998(Temp), f. & cert. ef. 5-1-98 thru 9-1-98; OMAP 28-1998, f. & cert. ef. 9-1-98; OMAP 23-1999, f. & cert. ef. 4-30-99; OMAP 8-2000, f. 3-31-00, cert. ef. 4-1-00; OMAP 17-2000, f. 9-28-00, cert. ef. 10-1-00; OMAP 48-2002, f. & cert. ef. 10-1-02; OMAP 3-2003, f. 1-31-03, cert. ef. 2-1-03; OMAP 65-2003, f. 9-10-03 cert. ef. 10-1-03; OMAP 55-2004, f. 9-10-04, cert. ef. 10-1-04; OMAP 12-2005, f. 3-11-05, cert. ef. 4-1-05; DMAP 25-2007, f. 12-11-07, cert, ef. 1-1-08; DMAP 18-2008, f. 6-13-08, cert. ef. 7-1-08; DMAP 38-2008, f. 12-11-08, cert. ef. 1-1-09; DMAP 16-2009 f. 6-12-09, cert. ef. 7-1-09; DMAP 41-2009, f. 12-15-09, cert. ef. 1-1-10; DMAP 14-2010, f. 6-10-10, cert. ef. 7-1-10; DMAP 31-2010, f. 12-15-10, cert. ef. 1-1-11; DMAP 17-2011, f. & cert. ef. 7-12-11

 

Rule Caption: Align with chapter 461, division 155 eligibility rules.

Adm. Order No.: DMAP 18-2011(Temp)

Filed with Sec. of State: 7-15-2011

Certified to be Effective: 7-15-11 thru 1-11-12

Notice Publication Date:

Rules Amended: 410-120-0006

Subject: The General Rules Program administrative rules govern the Division’s payments for services provided to clients, and medical assistance eligibility determinations made by the Oregon Health Authority. In coordination with the Department of Human Services’ (Department), temporary revision of OAR 461-155-0575 and OAR 461-155-0693, the Division temporarily amended OAR 410-120-0006 to assure that the Division’s eligibility rule aligns with and reflects information found in Department eligibility rules. In OAR 410-120-0006, the Division adopts in rule by reference Department eligibility rules and must update OAR 410-120-0006 in coordination with Department revisions. The Division intends to file this rule permanently on or before January 11, 2012.

Rules Coordinator: Darlene Nelson—(503) 945-6927

410-120-0006

Medical Eligibility Standards

As the state Medicaid and CHIP agency, the Oregon Health Authority (Authority) is responsible for establishing and implementing eligibility policies and procedure consistent with applicable law. As outlined in 943-001-0020, the Authority, and the Department of Human Services (Department) work together to adopt rules to assure that medical assistance eligibility procedures and determinations are consistent across both agencies.

(1) The Authority adopts and incorporates by reference the rules established in OAR Chapter 461, and in effect July 15, 2011, for all medical eligibility requirements for medical assistance when the Authority conducts eligibility determinations.

(2) Any reference to OAR Chapter 461 in Oregon Administrative Rules or contracts of the Authority are deemed to be references to the requirements of this rule, and shall be construed to apply to all eligibility policies, procedures and determinations by or through the Authority.

(3) For purposes of this rule, references in OAR chapter 461 to the Department or to the Authority shall be construed to be references to both agencies.

(4) Effective on or after July 1, 2011 the Authority shall conduct medical eligibility determinations using the OAR chapter 461 rules which are in effect on the date the Authority makes the medical eligibility determination.

(5) A request for a hearing resulting from a determination under this rule, made by the Authority shall be handled pursuant to the hearing procedures set out in division 25 of OAR Chapter 461. References to “the Administrator” in division 25 of chapter 461 or “the Department” are hereby incorporated as references to the” Authority.”

[Publications: Publications referenced are available from the agency.]

Stat. Auth.: ORS 413.042

Stats. Implemented: ORS 413.042 & 414.065

Hist.: DMAP 10-2011, f. 6-29-11, cert. ef. 7-1-11; DMAP 18-2011(Temp), f. & cert. ef. 7-15-11 thru 1-11-12

 

Rule Caption: Updates and changes to the Preferred Drug List (PDL). 7/11 – Semi-Annual PDL updates, expansion of 90-day fill list of maintenance medications, changes to allow for the billing of certain diabetic supplies by pharmacies, and updates for vaccination billing, PA criteria update.

Adm. Order No.: DMAP 19-2011

Filed with Sec. of State: 7-15-2011

Certified to be Effective: 7-17-11

Notice Publication Date: 6-1-2011

Rules Amended: 410-121-0030

Rules Repealed: 410-121-0030(T)

Subject: The Division temporarily amended OAR 410-121-0030 effective March 1, 2011, to include the semi-annual changes to the current Preferred Drug List (PDL) classes. This filing will permanently amend this rule.

      The Division also filed Notice of Proposed Rulemaking/Hearing for this rule to allow exceptions for the dispensing of brand name prescriptions instead of the generic form when a brand manufacturer contracts with the State and the branded product’s Net Price to the Division becomes less than the generic Net price and it is listed as preferred on the PDL. This update is also included in the permanent rule.

      This rule reflects the Division’s agency authority from the Department of Human Services to the Oregon Health Authority and updated statutory reference. Other text may be revised to improve readability and to take care of necessary “housekeeping” corrections.

Rules Coordinator: Darlene Nelson—(503) 945-6927

410-121-0030

Practitioner-Managed Prescription Drug Plan

(1) The Practitioner-Managed Prescription Drug Plan (PMPDP) is a plan that ensures that fee-for-service clients of the Oregon Health Plan shall have access to the most effective prescription drugs appropriate for their clinical conditions at the best possible price:

(a) Licensed health care practitioners (informed by the latest peer reviewed research), make decisions concerning the clinical effectiveness of the prescription drugs;

(b) The licensed health care practitioners also consider the health condition of a client or characteristics of a client, including the client’s gender, race or ethnicity.

(2) PMPDP Preferred Drug List (PDL):

(a) The PDL is the primary tool that the Division developed to inform licensed health care practitioners about the results of the latest peer-reviewed research and cost effectiveness of prescription drugs;

(b) The PDL consists of prescription drugs in selected classes that the Division, in consultation with the Health Resources Commission (HRC), has determined represent the most effective drug(s) available at the best possible price;

(c) For each selected drug class, the PDL shall identify the drug(s) in the class that the Division determines to be the most effective drug(s) and determine the Net Price for each drug and Average Net Price of the class;

(d) The PDL shall include drugs in the class that are Medicaid reimbursable and the Food and Drug Administration (FDA) has determined to be safe and effective if the relative cost is less than the Average Net Price. If pharmaceutical manufacturers enter into supplemental rebate agreements with the Division that reduce the cost of their drug below that of the Average Net Price for the class, the Division, in consultation with the HRC recommendations, may include their drug on the PDL.

(3) PMPDP PDL Selection Process:

(a) The Division shall utilize the recommendations made by the HRC, that result from an evidence-based evaluation process, as the basis for identifying the most effective drug(s) within a selected drug class;

(b) The Division shall determine the drugs identified in (3)(a) that are available for the best possible price and shall consider any input from the HRC about other FDA-approved drug(s) in the same class that are available for a lesser relative price. The Division shall determine relative price using the methodology described in subsection (4);

(c) The Division shall evaluate drug classes and selected drugs for the drug classes periodically:

(A) Evaluation shall occur more frequently at the discretion of the Division if new safety information or the release of new drugs in a class or other information makes an evaluation advisable;

(B) New drugs in classes already evaluated for the PDL shall be non-preferred until the new drug has been reviewed by the HRC;

(C) The Division shall make all changes or revisions to the PDL, using the rulemaking process and shall publish the changes on the Division’s Pharmaceutical Services provider rules Web page.

(4) Relative cost and best possible price determination:

(a) The Division shall determine the relative cost of all drugs in each selected class that are Medicaid reimbursable and that the FDA has determined to be safe and effective;

(b) The Division may also consider dosing issues, patterns of use and compliance issues. The Division shall weigh these factors with any advice provided by the HRC in reaching a final decision;

(c) The Division shall determine the Average Net Price for each PDL drug class;

(d) The Division shall include drugs on the PDL based on all of the above and with a Net Price under the Average Net Price.

(5) Regardless of the PDL, pharmacy providers shall dispense prescriptions in the generic form, unless:

(a) The practitioner requests otherwise, subject to the regulations outlined in OAR 410-121-0155;

(b) The brand manufacturer contracts the Net Price to remain less than the generic Net Price and it is listed as preferred on the PDL.

(6) The exception process for obtaining non-preferred physical health drugs that are not on the PDL drugs shall be as follows:

(a) If the prescribing practitioner, in their professional judgment, wishes to prescribe a physical health drug not on the PDL, they may request an exception, subject to the requirements of OAR 410-121-0040;

(b) The prescribing practitioner must request an exception for physical health drugs not listed in the PDL subject to the requirements of OAR 410-121-0060;

(c) Exceptions shall be granted in instances:

(A) Where the prescriber in their professional judgment determines the non-preferred drug is medically appropriate after consulting with the Division or the Oregon Pharmacy Help Desk; or

(B) Where the prescriber requests an exception subject to the requirement of (6)(b) and fails to receive a report of PA status within 24 hours, subject to OAR 410-121-0060.

(7) Table 121-0030-1, PMPDP PDL.

[ED. NOTE: Tables referenced are available from the agency.]

Stat. Auth.: ORS 409.025, 409.040, 409.110, 414.065, 413.042 & 414.325

Stats. Implemented: ORS 414.065

Hist.: OMAP 25-2002, f. 6-14-02 cert. ef. 7-1-02; OMAP 31-2002, f. & cert. ef. 8-1-02; OMAP 36-2002, f. 8-30-02, cert. ef. 9-1-02; OMAP 29-2003, f. 3-31-03 cert. ef. 4-1-03; OMAP 35-2003, f. & cert. ef. 5-1-03; OMAP 47-2003, f. & cert. ef. 7-1-03; OMAP 57-2003, f. 9-5-03, cert. ef. 10-1-03; OMAP 70-2003(Temp), f. 9-15-03, cert. ef. 10-1-03 thru 3-15-04; OMAP 82-2003, f. 10-31-03, cert. ef. 11-1-03; OMAP 9-2004, f. 2-27-04, cert. ef. 3-1-04; OMAP 29-2004, f. 4-23-04 cert. ef. 5-1-04; OMAP 34-2004, f. 5-26-04 cert. ef. 6-1-04; OMAP 45-2004, f. 7-22-04 cert. ef. 8-1-04; OMAP 81-2004, f. 10-29-04 cert. ef. 11-1-04; OMAP 89-2004, f. 11-24-04 cert. ef. 12-1-04; OMAP 19-2005, f. 3-21-05, cert. ef. 4-1-05; OMAP 32-2005, f. 6-21-05, cert. ef. 7-1-05; OMAP 58-2005, f. 10-27-05, cert. ef. 11-1-05; OMAP 16-2006, f. 6-12-06, cert. ef. 7-1-06; OMAP 32-2006, f. 8-31-06, cert. ef. 9-1-06; OMAP 48-2006, f. 12-28-06, cert. ef. 1-1-07; DMAP 4-2007, f. 6-14-07, cert. ef. 7-1-07; DMAP 16-2008, f. 6-13-08, cert. ef. 7-1-08; DMAP 36-2008, f. 12-11-08, cert. ef. 1-1-09; DMAP 39-2009, f. 12-15-09, cert. ef. 1-1-10; DMAP 17-2010, f. 6-15-10, cert. ef. 7-1-10; DMAP 40-2010, f. 12-28-10, cert. ef. 1-1-11; DMAP 2-2011(Temp), f. & cert. ef. 3-1-11 thru 8-20-11; DMAP 19-2011, f. 7-15-11, cert. ef. 7-17-11

Notes
1.) This online version of the OREGON BULLETIN is provided for convenience of reference and enhanced access. The official, record copy of this publication is contained in the original Administrative Orders and Rulemaking Notices filed with the Secretary of State, Archives Division. Discrepancies, if any, are satisfied in favor of the original versions. Use the OAR Revision Cumulative Index found in the Oregon Bulletin to access a numerical list of rulemaking actions after November 15, 2010.

2.) Copyright 2011 Oregon Secretary of State: Terms and Conditions of Use

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