Oregon Bulletin
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.
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