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The Oregon Administrative Rules contain OARs filed through August 15, 2014
 
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OREGON HEALTH AUTHORITY, DIVISION OF MEDICAL ASSISTANCE PROGRAMS

 

DIVISION 133

SCHOOL-BASED HEALTH SERVICES

410-133-0000

Purpose

(1) School-Based Health Services (SBHS) rules describe the Medicaid covered services available to Medicaid-eligible students receiving health services on a fee-for-service basis when “Necessary and Appropriate” and within the limitations established by the Medical Assistance Program and these rules, consistent with the requirements of the Individuals with Disabilities Education Act (IDEA). These rules are to be used in conjunction with the General Rules governing the Division of Medical Assistance Programs (Division) (OAR 410 division 120) and the Oregon Health Plan (OHP) rules (OAR 410 division 141). The School-Based Health Services rules are also a user's manual designed to assist the Educational Agency (EA) in matching state and federal funds for Oregon's Medicaid-eligible students with disabilities.

(2) The Oregon Administrative Rules (OARs) in Chapter 581, Division 15 for the Oregon Department of Education (ODE) outline Oregon's program to meet the federal provisions of the IDEA. These SBHS rules define Oregon's fee-for-service program to reimburse publicly funded education agencies for the health services provided under the IDEA to Oregon's Medicaid-eligible children.

(3) The Department of Human Services (DHS) and ODE recognize the unique intent of health services provided for Medicaid-eligible students with disabilities in the special education setting. The School-Based Health Services rules address the health aspects of special education services that are covered by Medicaid or the Children’s Health Insurance Program (CHIP).

(4) DHS endeavors to furnish School Medical (SM) providers with up-to-date billing, procedural information, and guidelines to keep pace with program changes and governmental requirements. DHS does so by providing information on its website.

(5) Enrolled School-Based Health Services providers are responsible to maintain current publications provided by DHS and the Division, and to comply with the OARs in effect on the date of service the health service is provided.

(6) In order for DHS to reimburse for health services provided in the school, the health services must be included as a covered service under the Oregon Health Plan (OHP). There is no benefit category in the Medicaid statute titled “school health services” or “early intervention services.” These rules do not create a new category of health benefits for this fee for service program.

(7) These rules describe health services that are covered services for Medicaid-eligible students, which are authorized and provided consistent with these rules.

(8) Medicaid-eligible students retain the ability to obtain services from any qualified Medicaid provider that undertakes to provide services to them. These rules do not require a Medicaid-eligible student to receive their health services solely from school medical providers.

Stat. Auth.: ORS 413.042
Stats. Implemented: ORS 414.065
Hist.: HR 39-1991, f. & cert. ef. 9-16-91; 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 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

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. the Division 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 Division-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

410-133-0060

Health Services

(1) A School-based Health Service is a health service for a Medicaid-eligible student that meets the coverage requirements in OAR 410-133-0080 and that:

(a) Addresses physical or mental disabilities of the child or student; and

(b) Is identified in a student's Individualized Education Program (IEP), or the Individualized Family Service Plan (IFSP); and

(c) Is recommended by a physician or other licensed health care practitioner within the scope of practice under State law.

(2) School-based health services that meet the requirements of subsection (1) of this rule may include:

(a) Physical Therapy Evaluations and Treatments which include assessing, preventing or alleviating movement dysfunction and related functional problems, obtaining and interpreting information, and coordinating care and integrating services relative to the student receiving treatments such as:

(A) Neuromotor or neurodevelopmental assessment;

(B) Assessing and treating problems related to musculo-skeletal status;

(C) Gait, balance, and coordination skills;

(D) Oral motor assessment;

(E) Adaptive equipment assessment;

(F) Gross and fine motor development;

(G) Observation of orthotic devices; and

(H) Prosthetic training.

(b) Occupational Therapy Evaluations and Treatments which include assessing, improving, developing, or restoring functions impaired or lost through illness, injury or deprivation, improving 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 services relative to the student receiving services such as:

(A) Neuromuscular and musculo-skeletal status (muscle strength and tone, reflex, joint range of motion, postural control, endurance);

(B) Gross and fine motor development;

(C) Feeding or oral motor function;

(D) Adaptive equipment assessment;

(E) Prosthetic or orthotic training;

(F) Neuromotor or neurodevelopmental assessment;

(G) Gait, balance, and coordination skills;

(c) Speech Evaluation and Therapy Treatments, which include assessment of children with speech and/or language disorders, diagnosis and appraisal of specific speech or language disorders, referral for medical and other professional attention, necessary for the rehabilitation of speech/language disorders, provision of speech/language services for the prevention of communicative disorders, obtaining and interpreting information, coordinating care and integrating services relative to the student receiving services such as:

(A) Expressive language;

(B) Receptive language;

(C) Auditory processing, discrimination, perception and memory;

(D) Vocal quality;

(E) Resonance patterns;

(F) Phonological;

(G) Pragmatic language;

(H) Rhythm or fluency; and

(I) Feeding and swallowing assessment;

(d) Audiological Evaluation and Services which include 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, coordinating care and integrating services relative to the student receiving services such as:

(A) Auditory acuity (including pure tone air and bone conduction), speech detection, and speech reception threshold;

(B) Auditory discrimination in quiet and noise;

(C) Impedance audiometry, including tympanometry and acoustic reflex;

(D) Central auditory function; 

(E) Testing to determine the child’s need for individual amplification;

(F) Auditory training; and

(G) Training for the use of augmentative communication devices;

(e) Nurse Evaluation and Treatment Services which include assessments, treatment services, and supervision of delegated health care services provided to prevent disease, disability, other health conditions or their progression, prolong life, and promote physical and mental health and efficiency. This includes any medical or remedial services recommended by a physician or other licensed health care practitioner, within the scope of practice under state law for maximum reduction of physical or mental disability and restoration of a recipient to his or her best possible functional level. The RN is responsible for periodic supervision for services provided to coordinating care and integrating nursing tasks and services that can be performed in the educational setting such as:

(A) Monitoring patient’s seizure activity for breathing patterns, onset/duration of seizure, triggers/auras, level of consciousness, support after seizure, administering medication as ordered;

(B) Monitoring/providing treatment for high and low blood sugar, checking urine keytones, blood glucose testing, carbohydrate calculations, assisting with insulin administration;

(C) Ventilator Care, suctioning, and equipment management;

(D) Tracheotomy Care, changing dressings, emergency trach replacement, suctioning, changing “nose”, and providing humidification as necessary;

(E) Catheterization, assisting with or performing procedure for catheterization, monitor urinary tract infections, and performing skin integrity checks;

(F) Gastrostomy Tube feeding, administering tube feedings per physician order, monitoring skin status around the tube, and emergency treatment for button dislodgement;

(G) Medication pumps, e.g., insulin pump, calculate carbohydrate amounts in food/snacks, provide insulin bolus per physician order, emergency disconnect procedure and monitoring blood sugar; and

(H) Medication management, e.g., monitoring signs and symptoms for medication administration, administering medications, observing for side effects;

(f) Mental Health Evaluation and Treatment Services -- Assessment and treatment services provided by or under the supervision and direction of a Psychiatrist, Psychologist, a Mental Health Nurse Practitioner, or by a Social Worker qualified and licensed to deliver the service, and who may provide care coordination and integration for services relative to the student for out patient mental health services received in the educational setting to prevent disease, disability, other health conditions or their progression, to prolong life and promote physical and mental health and efficiency. This includes any medical or remedial services recommended by a physician or other licensed health care practitioner, within the scope of practice under state law, for maximum reduction of physical or mental disability and restoration of a recipient to his or her best possible functional level, such as:

(A) Mental health assessment;

(B) Psychological testing (non-educational cognitive and adaptive testing);

(C) Assessment of motor language, social, adaptive, and/or cognitive functioning by standardized developmental instruments;

(D) Behavioral health counseling and therapy; and

(E) Psychotherapy (group/individual).

(3) Services for physical, occupational, and speech therapy, hearing, nursing, and mental health services must be recommended as set out, and provided by medically qualified individuals as defined in OAR 410-133-0120.

(4) Medicaid covered services and treatments are provided in accordance with the Oregon Medicaid program’s Prioritized List of Health Services to recipients receiving services pursuant to an IEP/IFSP eligible under Individuals with Disabilities Education Act in the educational setting. The above-listed therapy services and treatments are examples of services that may be provided to eligible recipients in an educational setting under the Oregon Medicaid program. The current Prioritized List of services can be found on the Health Services Commission web site.

Stat. Auth.: ORS 413.042 & 414.065
Stats. Implemented: ORS 414.065
Hist.: HR 39-1991, f. & cert. ef. 9-16-91; HR 22-1995, f. & cert. ef. 12-1-95; OMAP 38-1999, f. & cert. ef. 10-1-99; 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

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
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

410-133-0090

Public Education Agency School Medical Provider Payment Requirements

These rules are designed to assist the public Education Agency (EA) School Medical (SM) provider in matching state and federal funds for services defined by Section 1915(g) of the Social Security Act, 42 USC ¦ 1396n(g) and are to be used in conjunction with the Division of Medical Assistance Programs (Division) General Rules (chapter 410 division 120).

(1) Payment will be made in accordance with Department of Human Services Provider Rules Chapter 407 Division 120 and Division General Rules Chapter 410 Division 120 to the enrolled School Medical (SM) provider with the Oregon Health Authority (Authority), also termed Department, meeting the requirements set forth in the provider enrollment agreement for those covered health services provided by medically qualified staff working within the scope of their practice. Medically qualified staff must meet the qualifications as outlined in OAR 410-133-0120 Medically Qualified Staff.

(2) Signing the school medical provider enrollment agreement sets forth the relationship between the State of Oregon, the Authority, and the SM provider and constitutes agreement by the SM provider to comply with all applicable rules of the Authority, the Division, and federal and state laws or regulations. (See OARs chapter 407 division120 and Division General Rules chapter 410 division 120).

(3) The school medical (SM) provider will bill for covered services provided to Medicaid-eligible students in accordance with Authority chapter 407 division 120 Provider rules, the Division rules chapter 410 division 120 and these School-Based Health Services (SBHS) rules. Payments will be made through the Medicaid Management Information System (MMIS) and the SM provider must retain the full payment for the covered services provided. The SM provider must have a Trading Partner Agreement (TPA) with the Authority prior to submission of electronic transactions.

(4) School-based health services (SBHS) authorized under these rules is a cost-sharing Federal Financial Participation (FFP) matching program in which the Education Agency (EA) SM provider that is a public entity unit of government, is responsible for paying the non-federal matching share of the amount of the SBHS claims, calculated using the Federal Medical Assistance Percentage (FMAP) rates in effect during the quarter when the SBHS claims will be paid:

(a) The unit of government public education agency SM provider's share means the public funds share of the Medicaid payment amount. Pursuant to 42 CFR 433.51, public funds may be considered as the State's share in claiming federal financial participation (FFP) if the public funds meet the following conditions:

(A) The public funds are transferred to the Authority from public entities that are units of government;

(B) The public funds are not federal funds or they are federal funds authorized by federal law to be used to match other federal funds;

(C) All sources of funds must be allowable under 42 CFR 433.51 Subpart B;

(b) The unit of government EA SM provider must pay its non-federal matching share portion for claims submitted to the Authority in accordance with OAR 410-120-0035.

(5) Before the Authority pays for SBHS claims, the Authority must receive the SM provider’s corresponding local match payment as described in this rule. Failure to timely pay the non-federal matching funds to the Authority will delay reimbursement of claims and may require the SM provider to resubmit the claims.

(6) The Authority will not be financially responsible for payment of any claim that the Centers for Medicare and Medicaid Services (CMS) disallows under the Medicaid program. If the Authority has previously paid the SM provider for any claim which the CMS disallows, the SM provider must reimburse the Authority the amount of the claim that the Authority has paid to the SM provider, less any amount previously paid by the unit of government EA SM Provider to the Authority for purposes of reimbursing the Authority for the non-federal match portion of that claim.

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 41-1992, f. 12-31-92, cert. ef. 1-1-93; OMAP 31-1998, f. & cert. ef. 9-1-98; OMAP 88-2003(Temp), f. & cert. ef. 12-15-03 thru 5-15-04; OMAP 4-2004, f. 1-23-04, cert. ef. 2-1-04; 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 28-2008(Temp), f. 6-30-08, cert. ef. 7-1-08 thru 12-28-08; DMAP 32-2008(Temp), f. & cert. ef. 10-2-08 thru 3-27-09; DMAP 43-2008, f. 12-17-08, cert. ef. 12-28-08; DMAP 19-2009, f. 6-12-09, cert.ef. 7-1-09

410-133-0100

School Medical Provider Requirements

The School Medical (SM) provider is responsible to:

(1) Enroll with the Oregon Health Authority’s (Authority) Division of Medical Assistance Programs (Division) to provide health services, and comply with all the requirements in the Authority's rules OAR 407-120-0300 to 407-120-0380, OAR 410-120-1260 and 410-133-0140 in these rules applicable to enrollment as a provider.

(2) Provide health services pursuant to the Medicaid-eligible student's Individualized Education Program (IEP) or Individualized Family Service Plan (IFSP) for special education under OAR Chapter 581, Division 15

(3) Provide health services using medically qualified staff (see 410-133-0120 Medically Qualified Staff in these rules).

(4) Provide appropriate medical supervision by licensed medically qualified staff consistent with their licensing board requirements.

(5) Document health services in writing as required in OAR 410-133-0320.

(6) Maintain adequate medical and financial records as part of the Medicaid-eligible student's education record necessary to fully disclose the extent of the covered health services provided.

(7) Make the records required by these rules and specifically OAR 410-133-0320 available for a period of seven years.

(8) Document costs and establish a schedule of cost rates per discipline in accordance with OAR 410-133-0245.

(9) Provide access for on-site review of IDEA Medicaid-eligible students' education records directly related to payments for claims to the SM provider for Medicaid covered health related services specified on an IEP or IFSP and furnish such information to any state or federal agency responsible for administration or oversight of the medical assistance program as the state or federal agency may from time to time request in compliance with OAR 943-120-0310.

(10) Document any changes in the Individualized Education Program/Individualized Family Service Plan (IEP/IFSP) related to the provision of Medicaid covered health services under School-Based Health Services (SBHS).

(11) Assure that SBHS services billed are billed in accordance with OAR 410-120-0035, reflect covered health services and do not reimburse for non-covered education services or administrative activities;

(12) Retain the full payment amount for Medicaid-covered services provided.

(13) Utilize procedures to confirm that all individuals providing health services to Medicaid-eligible students, whether as employees or under contract with the SM provider, are eligible to provide Medicaid services and are not excluded from providing Medicaid services. Exclusion means the Authority will not reimburse an SM provider (allied agency) who employs a medically licensed individual who has defrauded or abused the Authority for items or services furnished by that individual. (See OAR 410-120-1400 Provider Sanctions, OAR 410-133-0120 Medically Qualified Staff and 410-133-0200 Not Covered Services); and

(14) Comply with all applicable provisions of the Authority’s rules chapter 943 division 120 and the Division General Rules Chapter 410 Division 120, including rules related to the use of billing providers. If the SM provider seeks to submit claims to the Authority electronically, it must comply with the applicable provisions of the Department’s Electronic Data Interchange (EDI) rules for EDI transactions OAR 407-120-0100 through 407-120-0200, EDI does not include electronic transmission by web portal.

Stat. Auth.: ORS 413.042 & 414.065
Stats. Implemented: ORS 413.042 & 414.065
Hist.: HR 39-1991, f. & cert. ef. 9-16-91; OMAP 31-1998, f. & cert. ef. 9-1-98; 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 28-2008(Temp), f. 6-30-08, cert. ef. 7-1-08 thru 12-28-08; DMAP 43-2008, f. 12-17-08, cert. ef. 12-28-08; DMAP 19-2009, f. 6-12-09, cert.ef. 7-1-09

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
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

410-133-0140

School Medical Provider Enrollment Provisions

(1) This rule applies only to providers seeking reimbursement from the Division, except as otherwise provided in OAR 410-120-1295.

(2) Only Educational Agency (EA) providers of SBHS that meet the criteria for the provision of special education programs approved by the State Superintendent of Public Instruction qualifying such programs for state reimbursement under OAR 581-015-2005 will be enrolled with the Division as school medical (SM) providers allowed to seek reimbursement for the provision of covered health services pursuant to a Medicaid eligible child’s Individualized Education Program (IEP) or Individualized Family Service Plan (IFSP).

(3) The provider enrollment process will consist of: The completion and submission of the School Medical (SM) provider enrollment application and the required attachments, disclosure documents, and provider agreement with the Division of Medical Assistance Programs.

(4) An approved enrollment application by the Division or the Authority unit responsible for enrolling the SM provider is a contractual agreement that binds the SM provider to comply with the Authority administrative rules OAR 943-120-0300 through 943-120-0380, the Division General Rules 410-120-1260 and School-Based Health Services (SBHS) rules.

(5) Signing the SM provider agreement enclosed in the application package constitutes agreement by performing, and billing providers for provision of SBHS to comply with all applicable rules of the Medical Assistance Program and federal and state laws and regulations.

(6) An SM provider is a performing provider. A performing provider is the provider of a service or item. A billing provider is an individual, agent, business, corporation, clinic, group, institution, or other entity who in connection with the submission of claims to the Authority, receives or directs the payment (either in the name of the performing provider or the name of the billing provider) from the Authority, on behalf of a performing provider and has been delegated the authority to obligate or act on behalf of the performing provider (See OAR 410-120-1260):

(a) A billing provider is responsible for identifying to the Division and keeping current the identification of all performing providers for whom they bill, or receive or direct payments. This identification must include the providers’ names, Authority provider numbers, NPIs, and either the performing provider’s Social Security Number (SSN) or Employer Identification Number (EIN). The SSN or EIN of the performing provider cannot be the same as the Tax Identification Number (TIN) of the billing provider. In order to facilitate timely claims processing and claims payment consistent with applicable privacy and security requirements, the Authority requires billing providers to be enrolled consistent with the provider enrollment process described in OAR 410-120-1260(7);

(b) If the SM performing provider uses electronic media to conduct transactions with the Authority, or authorizes a billing provider to conduct such electronic transactions, the SM performing provider must comply with the Electronic Data Interchange (EDI).. Enrollment as a SM performing provider or billing provider is a necessary requirement for submitting electronic claims, but the provider must also register as a trading partner and identify the EDI Submitter;

(c) A school medical (SM) performing provider that uses electronic media to conduct transaction with the Authority or authorizes a billing provider to conduct such electronic transactions, must comply with the electronic data interchange (EDI). Enrollment as an SM performing provider or billing provider is a necessary requirement for submitting electronic claims. If the SM provider intends to use an electronic data interchange (EDI) submitter, the SM performing provider must register with the Authority as a trading partner and shall complete the “Trading Partner Authorization of EDI Submitter” and the EDI submitter information required in the application in compliance with the trading partner requirements of identifying the authority of the EDI submitter to submit claims on its behalf. The EDI submitter must sign the EDI certification and meet other Authority EDI submission requirements pursuant to the EDI rules, before the Authority may accept an electronic submission from the EDI submitter on behalf of the performing provider. Information about the EDI transaction requirements is available on the Authority's web site.

(7) To be enrolled and able to bill as an SM provider, an EA, must meet applicable licensing and regulatory requirements set forth by federal and state statutes, regulations, and rules and must comply with all Oregon statutes and regulations for provision of Medicaid and State Children’s Health Insurance program (SCHIP) services. In addition, all providers of services within the State of Oregon must have a valid Oregon business license if such a license is a requirement of the state, federal, county or city government to operate a business or to provide services.

(8) An EA, individual, or organization that is currently subject to sanction by the Medical Assistance Program or Federal government is not eligible for enrollment.

(9) The Authority requires compliance with the National Provider Identification (NPI) requirements in 45 CFR Part 142. Providers that obtain an NPI should update their records with the Division Provider Enrollment. Provider applicants that have been issued an NPI must include that NPI number with the Division provider enrollment application.

(10) A performing provider number will be issued to an EA providing covered health care services or items upon:

(a) Completion of the application and submission of the required School-Based Health Services SM Provider Attachment, disclosure documents, and provider agreement;

(b) The signing of the SM provider application by the authorized representative for the EA to bind the EA SM provider to compliance with these rules;

(c) Verification of licensing or certification. Loss of the appropriate licensure or certification or failure to meet the criteria for the provision of special education programs approved by the State Superintendent of Public Instruction qualifying such programs for state reimbursement under OAR 581-015-2005 will result in immediate dis-enrollment of the provider and recovery of payments made subsequent to the loss of licensure or certification;

(d) Approval of the application and required documentation for an SM provider by the Division or the Division responsible for enrolling the provider.

(11) An SM performing provider may be enrolled retroactive to the date services were provided to a medical assistance client/child if:

(a) The SM provider met the criteria for the provision of special education programs approved by the State Superintendent of Public Instruction qualifying such programs for state reimbursement under OAR 581-015-2005, was appropriately licensed, certified, and otherwise met all Medical Assistance Program requirements at the time services were provided; and

(b) Services were provided less than 12 months prior to the date of application for medical assistance provider status as evidenced by the first date stamped on the paper claims(s) submitted with application materials for those services either manually or electronically; or

(c) Extenuating circumstances existed outside the control of the EA SM provider consistent with federal Medicaid regulations, with approval of the Division's Provider Services Unit Manager.

(12) Issuance of an Authority-assigned SM provider number establishes enrollment of an EA as a provider for limited categories of services for the Medical Assistance Program applicable to the provision of Medicaid covered School-Based Health Services (SBHS).

(13) An SM provider is required for providing and continuing to provide to the Authority accurate, complete and truthful information regarding their qualification for enrollment. The SM provider is responsible for notifying the Division in writing of a material change in any status or condition that relates to their qualifications or eligibility to provide SBHS including but not limited to change in any of the following information: changes address, business affiliation, licensure, ownership, certification, NPI, billing agents or Federal Tax Identification Number (TIN), change in status for meeting the criteria for the provision of special education programs approved by the State Superintendent of Public Instruction qualifying the EA’s programs for state reimbursement under OAR 581-015-2005, if the SM provider or a person with an ownership or control interest, or an agent or managing employee of the SM provider has been convicted of a criminal offense related to that person’s involvement in any program under Medicare, Medicaid, or Title XX services program, the SM provider must notify the Division in writing within 30 calendar days of the change:

(a) Failure to notify the Division of a change of federal tax identification number (TIN) may result in the imposing of a $50 fine;

(b) Changes in business affiliation, ownership and control of information, criminal convictions, NPI, or federal tax identification number may require the submission of a new application;

(c) Payments made to providers who have not furnished such notification as required by this rule or to a provider that has failed to submit a new application as required by this rule and OAR 410-120-1260 may be denied or recovered.

(14) For information regarding enrollment of Billing Providers (BP) and issuance of an Authority assigned BP Provider ID in compliance with OAR 943-120-0300 through 943-120-0380, OAR 410-120-1260 and 407-120-0100 through 407-120-0200.

(15) Provider termination:

(a) The SM provider may terminate enrollment at any time. The request must be in writing, via certified mail, return receipt requested. The notice shall specify the provider number to be terminated and the effective date of termination. Termination of the SM provider enrollment does not terminate any obligations of the SM provider for dates of services during which the enrollment was in effect;

(b) The Division provider terminations or suspensions may be for, but are not limited to the following:

(A) Breaches of provider agreement;

(B) Failure to comply with the statutes, regulations and policies of the Authority, Federal and State regulations that are applicable to the provider;

(C) When no claims have been submitted in an 18-month period. The provider must reapply for enrollment.

(16) When one or more of the requirements governing a provider's participation in the medical assistance program are no longer met, the provider's medical assistance program provider number may be immediately suspended. The provider is entitled to a contested case hearing as outlined in 410-120-1600 to determine whether the provider's medical assistance program number will be revoked.

Stat. Auth.: ORS 413.042 & 414.065
Stats. Implemented: ORS413.042 & 414.065
Hist.: HR 39-1991, f. & cert. ef. 9-16-91; OMAP 31-1998, f. & cert. ef. 9-1-98; 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

410-133-0160

Licensed Practitioner Recommendation

Requests for payment for covered health services required by a Medicaid-eligible student's Individualized Education Program (IEP) or Individualized Family Service Plan (IFSP) must be supported by written recommendation from a physician or a licensed health care practitioner acting within the scope of their practice for the treatment provided. The recommendation must be current for the treatment provided as specified on the IEP or IFSP.

Stat.Auth.: ORS 413.042
Stats. Implemented: ORS 414.065
Hist.: HR 39-1991, f. & cert. ef. 9-16-91; HR 22-1995, f. & cert. ef. 12-1-95; 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

410-133-0180

Duplication of Service

(1) The School Medical (SM) provider that utilizes a contractor to provide health services may only bill Oregon Health Authority or the Division of Medical Assistance Programs (Division) for health services when the school medical (SM) provider and the contracted provider have previously agreed that the contractor will not also bill for the same service.

(2) Duplicate billings are not allowed and payments will be recovered. Billings for health services to Medicaid-eligible students will be considered as duplicate if the same services are billed by more than one Educational Agency (EA) to address the same need. For example: an Education Service District (ESD) and a local school district cannot both bill the same services provided to the student.

(3) A unit of service can only be billed once; under one procedure code, under one provider number.

Stat. Auth.: ORS 413.042
Stats. Implemented: ORS 414.065
Hist.: HR 39-1991, f. & cert. ef. 9-16-91; OMAP 38-1999, f. & cert. ef. 10-1-99; 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

410-133-0200

Not Covered Services

(1) Education-based costs normally incurred to operate a school and provide an education are not covered for payment by the Oregon Health Authority (Authority).

(2) Health services and treatment not documented on the Medicaid-eligible student's IEP or IFSP is not covered for payment by the Authority under the School-Based Health Services (SBHS) rules.

(3) Reviewing records (exception: reviewing records as part of an evaluation to establish, re-establish, or terminate a SBHS covered health service on a Medicaid-eligible student's IEP or IFSP).

(4) Meeting preparation.

(5) Health services preparation including materials preparation.

(6) Report writing (exception: report writing as part of preparation of initial evaluation and initial treatment plan to establish a covered health service on a Medicaid-eligible student's IEP or IFSP).

(7) Correspondence.

(8) Treatment and care coordination for an acute medical condition.

(9) Medication management not specific to mental health related services listed in the IEP/IFSP.

(10) Purchase of an assistive technology device is not covered through SBHS.

(11) Activities related to researching student names, determining Medical Assistance Program eligibility status, administrative activities such as data entry of billing claim forms, and travel time by service providers.

(12) Family therapy where the focus of treatment is the family.

(13) Routine health nursing services provided to all students by school nurses; nursing intervention for acute medical issues in the school setting, e.g. students who become ill or are injured.

(14) Educational workshops, training classes, and parent training workshops.

(15) Regular transportation services to and from school.

(16) Vocational services.

(17) Screening services.

(18) Evaluation services that are not performed by Medically Qualified Staff within the scope of practice to establish, re-establish, or terminate a covered SBHS under IDEA.

(19) Service provided to non-Medicaid students in a group, class, or school free of charge. If only Medicaid-eligible students are charged for the service, the care is free and Medicaid will not reimburse for the service. The free care limitation does not apply to health services provided as a result of an educational agency's obligation to provide FAPE services and the health service is identified on the Medicaid-eligible student's IEP/IFSP. This means that school medical providers may bill for covered health services provided to Medicaid-eligible students under IDEA even though they may be provided to non-Medicaid-eligible students for free as a part of FAPE.

(20) Any non-medical unit of time spent on evaluations.

(21) Recreational services.

(22) Early and Periodic Screening, Diagnostic and Treatment (EPSDT) comprehensive examinations described in OAR 410-130-0245 are not authorized to be provided by school medical providers.

(23) Services provided by an entity that employs an excluded provider. It is the obligation of the education agency to utilize the excluded provider web site to check for providers who have been excluded from receiving any monies affiliated with Medicaid and Medicare service reimbursements.

(24) Covered health service(s) listed on an IEP or IFSP for those dates of service when the IEP/IFSP has lapsed.

(25) Covered health service(s) that do not have a current recommendation by Medically Qualified Staff within the scope of practice for the treatment provided as specified on the IEP or IFSP.

(26) 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.

(27) Using a rubber stamp to authenticate any entry for documentation of therapy provided to a student and billed to Medicaid for reimbursement for SBHS.

(28) Services provided by staff in an education setting licensed solely by Teachers' Standards and Practices Commission (TSPC). 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.

(29) Services provided by speech language pathology assistants in schools under the supervision of a speech language pathologist who does not hold a license under ORS Chapter 681 but instead holds either a basic, initial, standard, or continuing license in speech impaired issued by the Teacher Standards and Practices Commission, and has obtained a permit from the Oregon Board of Examiners for Speech-Language Pathology and Audiology to supervise SLPA’s in education settings under OAR 335-095-0055.

Stat. Auth.: ORS 413.042
Stats. Implemented: ORS 414.065
Hist.: HR 39-1991, f. & cert. ef. 9-16-91; HR 21-1995, f. & cert. ef. 12-1-95; 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 19-2009, f. 6-12-09, cert.ef. 7-1-09

410-133-0220

Billing and Payment

(1) The School Medical (SM) provider must bill the Oregon Health Authority (Authority), in accordance with OAR 410-120-0035; and must bill at a cost rate no greater than the education agency's cost rate for the applicable discipline reviewed and accepted by the Authority based on the cost determination process described in OAR 410-133-0245.

(2) Services must be billed on a CMS-1500 or by electronic media claims (EMC) submission using only those procedure codes specified for the School-Based Health Services (SBHS) program. If the SM provider submits their claims electronically, the SM provider must become a trading partner with the Authority and comply with the requirements for Electronic Data Interchange (EDI) pursuant to OAR 407-120-0100 through 407-120-0200 and 410-010-0000 et seq.

(3) The Authority will accept a claim up to 12 months from the date of service. See OAR 943-120-0340 Claim and PHP Encounter Submission and OAR 410-120-1300 Timely Submission of Claims.

(4) Third party liability. In general, the Medicaid program is the payor of last resort and a provider is required to bill other resources before submitting the claim to Medicaid. This requirement means that other payment sources, including other federal or state funding sources, must be used first before the Authority can be billed for covered health services. However, the following exceptions apply to the requirement to pursue third party resources:

(a) For health services provided under the Individuals with Disabilities Education Act (IDEA), Medicaid pays before Oregon Department of Education (ODE) or the Educational Agency (EA), to the extent the health service is a covered service provided to a Medicaid-eligible student documented as required under these rules, and subject to the applicable reimbursement rate;

(b) If School-Based Health Services (SBHS) are provided under Title V of the Social Security Act (Maternal and Child Health Services Block Grant), Medicaid-covered Health Services provided by a Title V grantee are paid by Medicaid before the Title V funds;

(c) The Centers for Medicare and Medicaid Services (CMS) recognize that while schools are legally liable to provide IDEA-related health services at no cost to the eligible students, Medicaid reimbursement is available for these services because section 1903 (c) of the ACT requires Medicaid to be primary to the U.S. Department of Education for payment of the health-related services provided under IDEA.

Stat. Auth.: ORS 413.042 & 414.065
Stats. Implemented: ORS 413.042 & 414.065
Hist.: HR 39-1991, f. & cert. ef. 9-16-91; OMAP 31-2003, f. & cert. ef. 4-1-03; 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 28-2008(Temp), f. 6-30-08, cert. ef. 7-1-08 thru 12-28-08; DMAP 32-2008(Temp), f. & cert. ef. 10-2-08 thru 3-27-09; DMAP 43-2008, f. 12-17-08, cert. ef. 12-28-08; DMAP 19-2009, f. 6-12-09, cert.ef. 7-1-09

410-133-0245

Cost Determination and Payment

(1) The Authority will make rate determinations for the purposes of payment under OAR 410-133-0220 based on annual cost determinations submitted by local education agencies (EA's).

(2) Cost determinations will:

(a) Be based on the EA's prior year's annual audited costs;

(b) Establish an hourly and 15-minute increment rate for the current year billed;

(c) Use the current year ODE-approved indirect rate for the EA;

(3) An EA shall not bill for more than its prior year's annual audited cost incurred during the previous year. There will be no required annual cost settlement for each EA, although the Authority may conduct reviews or audits of cost reports.

(4) Data for cost determinations shall be submitted in a format prescribed by the Authority and in accordance with Oregon's State Plan approved by the Centers for Medicare and Medicaid Services (CMS).

(5) Cost determinations shall be completed for each service discipline eligible for Medicaid billing. If an EA does not receive a confirmation from the Authority indicating costs have been received and accepted, the EA may not submit payment requests for those services. Costs for services include: Nursing, Occupational Therapy, Physical Therapy, Speech Language Pathology, Audiology, Psychological, Delegated Health Care, and Clinical Social Work. The Authority's acceptance of the cost calculations submitted by the SBHS provider for rates per discipline based upon the SBHS provider's previous year's audited costs and, if applicable, the current years indirect rates does not imply or validate the accuracy of the data submitted.

(6) Transportation costs for Medicaid-eligible children will be reimbursed when the IEP or IFSP for the Medicaid eligible child documents the need for necessary and appropriate transportation. Transportation cost reimbursement rates are based on the EA's prior year's audited costs for special education transportation and will be submitted in a format prescribed by the Authority and in accordance to Oregon's State Plan approved by the Centers for Medicare and Medicaid Services (CMS).

Stat. Auth.: ORS 413.042
Stats. Implemented: ORS 414.065
Hist.: 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

410-133-0280

Rebilling

In order to correct a claim reimbursed for services provided to a Medicaid-eligible student, the School Medical (SM) provider must request an adjustment. The paid claim must be corrected on the Individual Adjustment Request Form (DMAP 1036) to allow revision of the original claim. Providers may perform online claim submissions and adjustments using the Authority’s web portal. The link can be found at: http://www.oregon.gov/DHS/healthplan/tools_prov/main.shtml Rebilling additional units of service on a CMS-1500 for the same timeframe would be denied as duplicate services. See OAR 410-120-1300 Timely Submission of Claims and 410-120-1397 Recovery of Overpayments to Providers -- Recoupments and Refunds

[ED. NOTE: Forms referenced available from the agency.]

Stat. Auth.: ORS 413.042 & 414.065
Stats. Implemented: ORS 413.042 & 414.065
Hist.: HR 39-1991, f. & cert. ef. 9-16-91; 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

410-133-0300

Procedure Codes

(1) The provider must use the procedure code from the School-Based Health Services table that best describes the specific service provided and a modifier that describes the discipline providing the service. Refer to 410-133-0080 Coverage for service requirements and limitations.

(2) Unit values equal 15 minutes of service unless otherwise stated. These time units must be documented in the Medicaid-eligible student's records under the services billed and accounted for under one code only.

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 29-1993, f. & cert. ef. 10-1-93; HR 21-1995, f. & cert. ef. 12-1-95; OMAP 1-1998, f. 1-30-98, cert. ef. 2-1-98; 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

410-133-0320

Documentation and Record keeping Requirements

(1) Record keeping must conform and adhere to federal, state, and local laws and regulations.

(2) Records must record- history taken, procedures performed, tests administered, results obtained, and conclusions and recommendations made. Documentation may be in the form of a “SOAP” (subjective Objective Assessment Plan) note, or equivalent.

(3) Providers will retain information necessary to support claims submitted to the Authority including: documentation and supervision of the specific health services provided, the extent of the health service provided, the dates and the name and credentials of medically qualified staff who provided the service to the Medicaid-eligible student for seven (7) years. This documentation must meet the requirements of and must be made available pursuant to the requirements in the General Rules, OAR 410-120-1360 (Requirements of Financial, Clinical and Other Records). These requirements may be met if the information is included in the IEP or IFSP and the school medical provider maintains adequate supporting documentation at the time the service is rendered, consistent with the requirements of OAR 410-120-1360.

(a) Supporting documentation should:

(A) Be accurate, complete and legible;

(B) Be typed or recorded using ink;

(C) Be signed by the individual performing the service including their credentials or position;

(D) Be signed and initialed in accordance with licensing board requirements for each clinical entry by the individual performing the service;

(E) Be reviewed and authenticated by the supervising therapist in compliance with their licensing board requirements (Also see covered services 410-133-0080 and not covered services 410-133-0200)

(F) Be for covered health services provided as specified for the service period indicated on the Medicaid-eligible student’s current IEP or IFSP.

(b) Corrections to entries must be recorded by:

(A) Striking out the entry with a single line which does not obliterate the original entry, or amend the electronic record preserving the original entry; and

(B) Dating and initialing the correction.

(c) Late entries or additions to entries shall be documented when the omission is discovered with the following written at the beginning of the entry: “late entry for (date)” or “addendum for (date)”.

(2) Supporting documentation for Medicaid reimbursed health services described in a Medicaid-eligible student’s IEP or IFSP must be kept 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 and must include:

(a) A copy of the Medicaid-eligible student's IEP or IFSP as well as any addendum to the plan that correlates with the covered health service(s) provided and reimbursed by Medicaid;

(b) A notation of the diagnosis or condition being treated or evaluated, using specific medical or mental health diagnostic codes;

(c) Results of analysis of any mental health or medical analysis, testing, evaluations, or assessments for which reimbursement is requested;

(d) Documentation of the location, duration, and extent of each health service provided, by the date of service, signed and initialed by Medically Qualified Staff in accordance with their licensing board requirements (electronic records can be printed);

(e) The record of who performed the service and their credentials or position;

(f) The medical recommendation to support the service;

(g) Periodic evaluation of therapeutic value and progress of the Medicaid-eligible student to whom a health service is being provided;

(h) Record of medical need for necessary and appropriate transportation to a covered health service, specific date transported, client name, ID number, and point of origin and destination consistent with the record-keeping requirements in the Transportation rules, OAR 410-136-0280 (Required Documentation); and

(i) Attendance records for Medicaid-eligible students to support dates for covered services billed to Medicaid.

(j) In supervisory situations, the record documenting therapy provided must name both the assistant providing services and the supervising therapist including credentials. The licensed health care practitioner who supervises and monitors the assessment, care, or treatment rendered by licensed or certified therapy assistants, shall meet the minimum standards required by their Licensing Board and shall co-sign for those services where appropriate with their name and professional titles (documentation may not be delegated except in emergency situations).

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 22-1995, f. & cert. ef. 12-1-95; 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

410-133-0340

Client Rights and Record Confidentiality

(1) School Medical (SM) providers are required to provide The Authority, the Division of Medical Assistance Programs (Division), the Department of Justice Medicaid Fraud Unit, Oregon Secretary of State, or the Department of Health and Human Services, or their authorized representatives, access to Medicaid-eligible student medical records when requested as a condition of accepting Medicaid reimbursement from he Authority.

(2) Medicaid client rights of confidentiality must be respected in accordance with the provisions of 42 CFR Part 431, Subpart F and ORS 411.320.

(3) School Medical providers are also subject to the confidentiality laws applicable to student records, including student medical records maintained as part of the education record.

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

Stat. Auth.: ORS 413.042
Stats. Implemented: ORS 192.410-192.505
Hist.: HR 39-1991, f. & cert. ef. 9-16-91; OMAP 15-2000, f. 9-28-00, cert. ef 10-1-00; 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

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