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The Oregon Administrative Rules contain OARs filed through March 15, 2014

 

Oregon Health Authority

Division of Medical Assistance Programs

Division number quick links Delta 001-050 | 120 | 121 | 122 | 123-124 | 125 | 127-129 | 130 | 131-132 | 133-136 |
138-140
| 141 | 142-143 | 145-146 | 147 | 148-150 | 160-500

DIVISION 1

PROCEDURAL RULES

410-001-0000 Model Rules of Procedure

410-001-0005 Notice of Proposed Rule

410-001-0020 Delegation of Rulemaking Authority

DIVISION 14

PRIVACY OF PROTECTED INFORMATION

 

DIVISION 30

CLIENT CIVIL RIGHTS

410-030-0010 Purpose

410-030-0020 Review Requirements

410-030-0030 Implementation

410-030-0040 Penalties for Non-Compliance

DIVISION 50

TAX RULES

Medicaid Managed Care Tax

410-050-0100 Definitions

410-050-0110 General Administration

410-050-0120 Disclosure of Information

410-050-0130 The Medicaid Managed Care Tax: Calculation; Report; Due Date; Verification of Report

410-050-0140 Filing an Amended Report

410-050-0150 Determining the Date Filed

410-050-0160 Departmental Authority to Audit Records

410-050-0170 Assessing Tax on Failure to File

410-050-0180 Financial Penalty for Failure to File a Report or Failure to Pay Tax When Due

410-050-0190 Notice of Proposed Action

410-050-0200 Required Notice

410-050-0210 Hearing Process

410-050-0220 Final Order of Payment

410-050-0230 Remedies Available after Final Order of Payment

410-050-0240 Director Determines the Tax Rate

410-050-0250 Sunset Provisions

Hospital Tax

410-050-0700 Definitions

410-050-0710 General Administration

410-050-0720 Disclosure of Information

410-050-0730 Entities subject to the Hospital Tax

410-050-0740 The Hospital Tax: Calculation, Report, Due Date

410-050-0750 Reporting Total Net Revenue, Use of Estimated Revenue for Quarterly Reports

410-050-0760 Filing an Amended Report

410-050-0770 Determining the Date Filed

410-050-0780 Departmental Authority to Audit Records

410-050-0790 Assessing Tax on Failure to File

410-050-0800 Financial Penalty for Failure to File a Report or Failure to Pay Tax When Due

410-050-0810 Notice of Proposed Action

410-050-0820 Required Notice

410-050-0830 Hearing Process

410-050-0840 Final Order of Payment

410-050-0850 Remedies Available after Final Order of Payment

410-050-0860 Director Determines Rate of Tax

410-050-0861 Tax Rate

410-050-0870 Sunset Provisions

DIVISION 120

MEDICAL ASSISTANCE PROGRAMS

410-120-0000 Acronyms and Definitions

410-120-0003 OHP Standard Benefit Package

410-120-0006 Medical Eligibility Standards

410-120-0025 Administration of Division of Medical Assistance Programs' Regulation and Rule Precedence

410-120-0030 Children’s Health Insurance Program

410-120-0035 Public Entity

410-120-0045 Applications for Medical Assistance at Provider locations

410-120-0250 PHP or Coordinated Care Organizations

410-120-1140 Verification of Eligibility and Coverage

410-120-1160 Medical Assistance Benefits and Provider Rules

410-120-1180 Medical Assistance Benefits: Out-of-State Services

410-120-1190 Medically Needy Benefit Program

410-120-1195 SB 5548 Population

410-120-1200 Excluded Services and Limitations

410-120-1210 Medical Assistance Benefit Packages

410-120-1230 Client Copayment

410-120-1260 Provider Enrollment

410-120-1280 Billing

410-120-1295 Non-Participating Provider

410-120-1300 Timely Submission of Claims

410-120-1320 Authorization of Payment

410-120-1340 Payment

410-120-1350 Buying-Up

410-120-1360 Requirements for Financial, Clinical and Other Records

410-120-1380 Compliance with Federal and State Statutes

410-120-1385 Compliance with Public Meetings Law

410-120-1390 Premium Sponsorships

410-120-1395 Program Integrity

410-120-1397 Recovery of Overpayments to Providers — Recoupments and Refunds

410-120-1400 Provider Sanctions

410-120-1460 Type and Conditions of Sanction

410-120-1510 Fraud and Abuse

410-120-1560 Provider Appeals

410-120-1570 Claim Re-Determinations

410-120-1580 Provider Appeals — Administrative Review

410-120-1600 Provider Appeals — Contested Case Hearings

410-120-1855 Client's Rights and Responsibilities

410-120-1860 Contested Case Hearing Procedures

410-120-1865 Denial, Reduction, or Termination of Services

410-120-1870 Client Premium Payments

410-120-1875 Agency Hearing Representatives

410-120-1880 Contracted Services

410-120-1920 Institutional Reimbursement Changes

410-120-1940 Interest Payments on Overdue Claims

410-120-1960 Payment of Private Insurance Premiums

410-120-1980 Requests for Information and Public Records

DIVISION 121

PHARMACEUTICAL SERVICES

410-121-0000 Foreward and Definition of Terms

410-121-0021 Organizations Authorized to Provide Pharmaceutical Prescription Services

410-121-0030 Practitioner-Managed Prescription Drug Plan

410-121-0032 Supplemental Rebate Agreements

410-121-0033 Polypharmacy Profiling

410-121-0040 Prior Authorization Required for Drugs and Products

410-121-0060 How to Get Prior Authorization for Drugs

410-121-0061 Durable Medical Equipment, Medical Supplies, and Medical Surgical Services (Physician Administered Drugs)

410-121-0100 Drug Use Review

410-121-0111 Pharmacy and Therapeutics Committee

410-121-0135 Pharmacy Management Program Requirements

410-121-0143 Client Confidentiality

410-121-0145 Prescription Requirements

410-121-0146 Dispensing Limitations

410-121-0147 Exclusions and Limitations

410-121-0148 Dispensing in a Nursing Facility or Community Based Care Living Facility

410-121-0149 Medicaid Temporary Prescription Drug Assistance for Fully Dual Eligible Medicare Part D Clients

410-121-0150 Billing Requirements

410-121-0155 Reimbursement

410-121-0157 Participation in the Medicaid Drug Rebate Program

410-121-0160 Dispensing Fees

410-121-0185 Pharmacy Based Immunization Delivery

410-122-0188 DMEPOS Rebate Agreements

410-121-0190 Medication Therapy Management Services and Clozapine Therapy Monitoring

410-121-0200 Billing Forms

410-121-0220 Instructions for Completion of the Prescription Drug Invoice

410-121-0280 Billing Quantities, Metric Quantities and Package Sizes

410-121-0300 CMS Federal Upper Limits for Drug Payments

410-121-0420 DESI Less-Than-Effective Drug List

410-121-0580 Oregon Medicaid and Pharmaceutical Manufacturers' Dispute Resolution Procedures

410-121-0625 Items Covered in the All-Inclusive Rate for Nursing Facilities

Oregon Prescription Drug Program

410-121-2000 Definitions

410-121-2005 General Administration

410-121-2010 Pharmacy Providers

410-121-2020 Program Price

410-121-2030 Preferred Drug List

410-121-2050 Enrollment

410-121-2065 Contracted Services

Non-Medicaid Rules CAREAssist

410-121-3000 AIDS Drug Assistance Program

Non-Medicaid Rules Prescription Drug Monitoring Program

410-121-4000   Purpose

410-121-4005   Definitions

410-121-4010   Reporting Requirements

410-121-4015   Notification to Patients

410-121-4020   Information Access

DIVISION 122

DURABLE MEDICAL EQUIPMENT AND MEDICAL SUPPLIES

410-122-0010 Definitions

410-122-0020 Orders

410-122-0040 Prior Authorization

410-122-0055 OHP Standard Benefit Package Limitations

410-122-0080 Conditions of Coverage, Limitations, Restrictions and Exclusions

410-122-0180 Healthcare Common Procedure Coding System (HCPCS) Level II Coding

410-122-0182 Legend

410-122-0184 Repairs, Maintenance, Replacement, Delivery and Dispensing

410-122-0186 Payment Methodology

410-122-0200 Pulse Oximeter for Home Use

410-122-0202 Positive Airway Pressure (PAP) Devices for Adult Obstructive Sleep Apnea (OSA)

410-122-0203 Oxygen and Oxygen Equipment

410-122-0204 Nebulizer

410-122-0205 Respiratory Assist Devices

410-122-0206 Intermittent Positive Pressure Breathing (IPPB)

410-122-0207 Respiratory Supplies

410-122-0208 Suction Pumps

410-122-0209 Tracheostomy Care Supplies

410-122-0210 Ventilators

410-122-0211 Cough Stimulating Device

410-122-0220 Pacemaker Monitor

410-122-0240 Apnea Monitors for Infants

410-122-0250 Breast Pumps

410-122-0260 Home Uterine Monitoring

410-122-0280 Heating/Cooling Accessories

410-122-0300 Light Therapy

410-122-0320 Manual Wheelchair Base

410-122-0325 Motorized/Power Wheelchair Base

410-122-0330 Power-Operated Vehicle

410-122-0340 Wheelchair Options/Accessories

410-122-0360 Canes and Crutches

410-122-0365 Standing and Positioning Aids

410-122-0375 Walkers

410-122-0380 Hospital Beds

410-122-0400 Pressure Reducing Support Surfaces

410-122-0420 Hospital Bed Accessories

410-122-0475 Therapeutic Shoes for Diabetics

410-122-0480 Pneumatic Compression Devices (Used for Lymphedema)

410-122-0500 Transcutaneous Electrical Nerve Stimulator (TENS)

410-122-0510 Osteogenesis Stimulator

410-122-0515 Neuromuscular Electrical Stimulator (NMES)

410-122-0520 Glucose Monitors and Diabetic Supplies

410-122-0525 External Insulin Infusion Pump

410-122-0540 Ostomy Supplies

410-122-0560 Urological Supplies

410-122-0580 Bath Supplies

410-122-0590 Patient Lifts

410-122-0600 Toilet Supplies

410-122-0620 Miscellaneous Supplies

410-122-0625 Surgical Dressing

410-122-0630 Incontinent Supplies

410-122-0640 Eye Prosthetics

410-122-0655 External Breast Prostheses

410-122-0658 Gradient Compression Stockings

410-122-0660 Orthotics and Prosthetics

410-122-0662 Ankle-Foot Orthoses and Knee-Ankle-Foot Orthoses

410-122-0678 Dynamic Adjustable Extension/Flexion Device

410-122-0680 Facial Prostheses

410-122-0700 Negative Pressure Wound Therapy Pumps

410-122-0720 Pediatric Wheelchairs

DIVISION 123

DENTAL/DENTURIST SERVICES

410-123-1000 Eligibility, Providing Services and Billing

410-123-1060 Definition of Terms

410-123-1100 Services Reviewed by the Division of Medical Assistance Programs (DMAP)

410-123-1160 Prior Authorization

410-123-1200 Services Not To Be Billed Separately

410-123-1220 Coverage according to the Prioritized List of Health Services

410-123-1230 Buying-Up

410-123-1240 The Dental Claim Invoice

410-123-1260 OHP Plus Dental Benefits

410-123-1490 Hospital Dentistry

410-123-1540 Citizen/Alien-Waived Emergency Medical (CAWEM)

410-123-1600 Managed Care Organizations

410-123-1620 Procedure and Diagnosis Codes

410-123-1640 Prescriptions

410-123-1670 OHP Standard Limited Emergency Dental Benefit

DIVISION 124

TRANSPLANT SERVICES

410-124-0000 Transplant Services

410-124-0005 Donor Services

410-124-0010 Eligibility for Transplant Services

410-124-0020 Prior Authorization for All Covered Transplants, Except Cornea and Kidney

410-124-0040 Emergency Transplants

410-124-0060 Criteria and Contraindications for Heart Transplants

410-124-0063 Criteria and Contraindications for Heart-Lung Transplants

410-124-0065 Criteria and Contraindications for Single Lung Transplants

410-124-0070 Criteria and Contraindications for Bilateral Lung Transplants

410-124-0080 Criteria and Contraindications for Autologous and Allogeneic Bone Marrow, Autologous and Allogeneic Peripheral Stem Cell and Allogeneic Cord Blood Transplant

410-124-0090 Criteria and Contraindications for Harvesting Autologous Bone Marrow and Peripheral Stem Cells

410-124-0100 Criteria and Contraindications for Liver and Liver-Kidney Transplants

410-124-0105 Criteria and Contraindications for Intestine and Intestine-Liver Transplants

410-124-0120 Criteria and Contraindications for Simultaneous Pancreas-Kidney and Pancreas After Kidney Transplants

410-124-0140 Kidney Transplants

410-124-0160 Cornea Transplants

DIVISION 125

HOSPITAL SERVICES

410-125-0000 Determining When the Patient Has Medical Assistance

410-125-0020 Retroactive Eligibility

410-125-0030 Hospital Hold

410-125-0040 Title XIX/Title XXI Clients

410-125-0041 Non-Title XIX/XXI Clients

410-125-0045 Coverage and Limitations

410-125-0047 Limited Hospital Benefit for the OHP Standard Population

410-125-0050 Client Copayments

410-125-0080 Prior Authorization/Prior Notification

410-125-0085 Outpatient Services

410-125-0086 Prior Authorization for FCHP/MHO Clients

410-125-0090 Inpatient Rate Calculations — Type A, Type B, and Critical Access Oregon Hospitals

410-125-0095 Hospitals Providing Specialized Inpatient Services

410-125-0101 Hospital-Based Nursing Facilities and Medicaid Swing Beds

410-125-0102 Medically Needy Clients

410-125-0103 Medicare Clients

410-125-0115 Non-Contiguous Area Out-of-State Hospitals

410-125-0120 Transportation To and From Medical Services

410-125-0121 Contiguous Area Out-of-State Hospitals

410-125-0124 Retroactive Authorization

410-125-0125 Free-Standing Inpatient Psychiatric Facilities (IMDS)

410-125-0140 Prior Authorization Does not Guarantee Payment

410-125-0141 DRG Rate Methodology

410-125-0142 Graduate Medical Education Reimbursement for Public Teaching Hospitals

410-125-0146 Supplemental Reimbursement for Public Academic Teaching University Medical Practitioners

410-125-0150 Disproportionate Share (Effective for services rendered on or after January 1, 2001)

410-125-0155 Upper Limits on Payment (UPL) of Hospital Claims

410-125-0165 Transfers and Reimbursement

410-125-0170 Death Occurring on Day of Admission

410-125-0175 Hospitals Providing Specialized Outpatient Services

410-125-0180 Public Rates

410-125-0181 Non-Contiguous and Contiguous Area Out-of-State Hospitals

410-125-0190 Outpatient Rate Calculations — Type A, Type B, and Critical Access Oregon Hospitals

410-125-0195 Outpatient Services In-State DRG Hospitals

410-125-0200 Time Limitation for Submission of Claims

410-125-0201 Independent ESRD Facilities

410-125-0210 Third Party Resources and Reimbursement

410-125-0220 Services Billed on the Electronic 837I or on the Paper UB-04 and Other Claim Forms

410-125-0221 Payment in Full

410-125-0360 Definitions and Billing Requirements

410-125-0400 Discharge

410-125-0401 Definitions: Emergent, Urgent, and Elective Admissions

410-125-0410 Readmission

410-125-0450 Provider Preventable Conditions

410-125-0550 X-Ray or EKG Procedures Furnished in Emergency Room

410-125-0600 Non-Contiguous Out-of-State Hospital Services

410-125-0620 Special Reports and Exams and Medical Records

410-125-0640 Third Party Payers — Other Resources, Client Responsibility and Liability

410-125-0641 Medicare

410-125-0720 Adjustment Requests

410-125-1020 Filing of Cost Statement

410-125-1040 Accounting and Record Keeping

410-125-1060 Fiscal Audits

410-125-1070 Type A and Type B Hospitals

410-125-1080 Documentation

410-125-2000 Access to Records

410-125-2020 Post Payment Review

410-125-2030 Recovery of Payments

410-125-2040 Provider Appeals — Administrative Review

410-125-2060 Provider Appeals — Hearing Request

410-125-2080 Administrative Errors

DIVISION 127

HOME HEALTH CARE SERVICES

410-127-0020 Definitions

410-127-0040 Coverage

410-127-0050 Client Copayments

410-127-0055 Copayment for Standard Benefit Package

410-127-0060 Reimbursement and Limitations

410-127-0065 Signature Requirements

410-127-0080 Prior Authorization

410-127-0200 Home Health Revenue Center Codes

DIVISION 129

SPEECH-LANGUAGE PATHOLOGY, AUDIOLOGY AND HEARING AID SERVICES

410-129-0020 Therapy Goals/Outcome

410-129-0040 Maintenance

410-129-0060 Prescription Required

410-129-0065 Licensing Requirements

410-129-0070 Limitations

410-129-0080 Prior Authorization

410-129-0100 Medicare/Medicaid Claims

410-129-0180 Procedure Codes

410-129-0190 Client Copayments

410-129-0195 Standard Benefit Package

410-129-0200 Speech-Language Pathology Procedure Codes

410-129-0220 Augmentative Communications System or Device

410-129-0240 Audiologist and Hearing Aid Procedure Codes

410-129-0260 Hearing Aids and Hearing Aid Technical Service and Repair

410-129-0280 Hearing Testing for Diagnostic Purposes (On Physician's Referral Only)

DIVISION 130

MEDICAL- SURGICAL SERVICES

410-130-0000 Foreword

410-130-0005 Federally Qualified Primary Care Provider

410-130-0015 Doula Services

410-130-0160 Codes

410-130-0163 Standard Benefit Package

410-130-0180 Drugs

410-130-0190 Tobacco Cessation

410-130-0200 Prior Authorization

410-130-0220 Not Covered/BundledServices

410-130-0225 Teaching Physicians

410-130-0230 Administrative Medical Examinations and Reports

410-130-0240 Medical Services

410-130-0245 Early and Periodic Screening, Diagnostic and Treatment Program

410-130-0255 Immunizations and Immune Globulins

410-130-0365 Ambulatory Surgical Center and Birthing Center Services

410-130-0368 Anesthesia Services

410-130-0380 Surgery Guidelines

410-130-0562 Abortion

410-130-0580 Hysterectomies and Sterilization

410-130-0585 Family Planning Services

410-130-0587 Family Planning Clinic Services

410-130-0595 Maternity Case Management (MCM)

410-130-0610 Telemedicine

410-130-0670 Death With Dignity

410-130-0680 Laboratory and Radiology

410-130-0700 HCPCS Supplies and DME

DIVISION 131

PHYSICAL AND OCCUPATIONAL THERAPY SERVICES

410-131-0040 Foreword for Physical and Occupation Therapy

410-131-0080 Therapy Plan of Care and Record Requirements

410-131-0100 Maintenance

410-131-0120 Limitations of Coverage and Payment

410-131-0160 Prior Authorization for Payment

DIVISION 132

PRIVATE DUTY NURSING SERVICES

410-132-0020 Private Duty Nursing Services

410-132-0030 Definitions

410-132-0050 Client Copayments

410-132-0055 Copayment for Standard Benefit Package

410-132-0060 Private Duty Nursing Transition Into Maintenance

410-132-0070 Documentation Requirements

410-132-0080 Limitations

410-132-0100 Prior Authorization

410-132-0120 Billing Information

410-132-0180 Procedure Codes

410-132-0200 Provider Enrollment

DIVISION 133

SCHOOL-BASED HEALTH SERVICES

410-133-0000 Purpose

410-133-0040 Definitions

410-133-0060 Health Services

410-133-0080 Coverage

410-133-0090 Public Education Agency School Medical Provider Payment Requirements

410-133-0100 School Medical Provider Requirements

410-133-0120 Medically Qualified Staff

410-133-0140 School Medical Provider Enrollment Provisions

410-133-0160 Licensed Practitioner Recommendation

410-133-0180 Duplication of Service

410-133-0200 Not Covered Services

410-133-0220 Billing and Payment

410-133-0245 Cost Determination and Payment

410-133-0280 Rebilling

410-133-0300 Procedure Codes

410-133-0320 Documentation and Record keeping Requirements

410-133-0340 Client Rights and Record Confidentiality

DIVISION 136

MEDICAL TRANSPORTATION SERVICES

410-136-3000 Responsibility for Providing Non-emergent Medical Transportation

410-136-3020 General Requirements for NEMT

410-136-3040 Vehicle Equipment and Subcontractor Standards

410-136-3060 Insurance Requirements

410-136-3080 Out-of-State Transportation

410-136-3100 Attendants for Child Transports

410-136-3120 Secured Transports

410-136-3140 Transports of Clients Changing Hospitals or Other Facilities

410-136-3160 Ground and Air Ambulance Transports

410-136-3180 Reimbursement for Ground and Air Ambulance Transports

410-136-3200 Reimbursement and Accounting for all Modes of Transports

410-136-3220 Brokerage Reimbursements to Subcontractors

410-136-3240 Client Reimbursed Mileage, Meals and Lodging

410-136-3260 Modifications Based on Client Circumstances

410-136-3280 Client Rights and Confidentiality

410-136-3300 Reports and Documentation

410-136-3320 Audits

410-136-3340 Brokerage Service Areas

410-136-3360 Discontinuation of Brokerage as Enrolled Provider

DIVISION 138

TARGETED CASE MANAGEMENT

410-138-0000 Targeted Case Management Definitions

410-138-0005 Payment for Targeted Case Management Services Eligible for Federal Financial Participation

410-138-0007 Targeted Case Management — Covered Services

410-138-0009 Targeted Case Management — Services Not Covered

410-138-0020 Targeted Case Management Programs

410-138-0040 Targeted Case Management Babies First/CaCoon Program Risk Criteria

410-138-0060 Targeted Case Management Program — Provider Requirements

410-138-0080 Targeted Case Management Program Billing Policy

410-138-0390 Targeted Case Management Retroactive Payments

410-138-0420 Targeted Case Management Asthma/Healthy Home — Risk Criteria

DIVISION 140

VISUAL SERVICES

410-140-0000 Foreword

410-140-0020 Managed Health Care Organizations

410-140-0040 Prior Authorization

410-140-0050 Eligibility

410-140-0060 Health Insurance Claim Form (HCFA-1500)

410-140-0080 Medicare/Medicaid Assistance Program Claims

410-140-0110 Client Copayments

410-140-0120 Procedure Codes

410-140-0140 Ophthalmological Diagnostic and Treatment Services Coverage

410-140-0160 Contact Lens Services

410-140-0180 Ocular Prosthetics, Artificial Eye

410-140-0200 Fitting and Repair

410-140-0210 Buy-Ups

410-140-0220 Other Procedures

410-140-0240 Prescription Required

410-140-0260 Purchase of Ophthalmic Materials

410-140-0280 Vision Therapy Services

410-140-0300 Postsurgical Care

410-140-0320 Radiological Services

410-140-0380 Administrative Exam Services Authorized by the Branch Office -- Effective for Services Provided on or After December 15, 1992

410-140-0400 Contractor Services/Provider Ordering

DIVISION 141

OREGON HEALTH PLAN

410-141-0000 Definitions

410-141-0010 Prepaid Health Plan Contract Procurement Screening and Selection Procedures

410-141-0020 Administration of Oregon Health Plan Regu lation and Rule Precedence

410-141-0050 MHO Enrollment for Children Receiving Child Welfare Services

410-141-0060 Oregon Health Plan Managed Care Enrollment Requirements

410-141-0065 Fully Capitated Health Plan or Physician Care Organization (FCHP or PCO) Enrollment Requirements for Individuals Receiving Residential Substance Use Disorder (SUD) Treatment Services

410-141-0070 Managed Care Fully Capitated Health Plan and Physician Care Organization Pharmaceutical Drug List Requirements

410-141-0080 Managed Care Disenrollment from Prepaid Health Plans

410-141-0085 Oregon Health Plan Disenrollment from Primary Care Managers

410-141-0120 Managed Care Prepaid Health Plan Provision of Health Care Services

410-141-0140 Oregon Health Plan Prepaid Health Plan Emergency and Urgent Care Services

410-141-0160 Oregon Health Plan Prepaid Health Plan (PHP) Coordination and Continuity of Care

410-141-0180 Oregon Health Plan Prepaid Health Plan Record Keeping

410-141-0200 Oregon Health Plan Prepaid Health Plan Quality Improvement (QI) System

410-141-0220 Managed Care Prepaid Health Plan Accessibility

410-141-0260 Managed Care Prepaid Health Plan Complaint or Grievance and Appeal Procedures

410-141-0261 PHP Complaint Procedures

410-141-0262 The Prepaid Health Plan Appeal Procedures

410-141-0263 Notice of Action by a Prepaid Health Plan

410-141-0264 Administrative Hearings

410-141-0265 Request for Expedited Appeal or Expedited Administrative Hearing

410-141-0266 PHP’s Responsibility for Documentation and Quality Improvement Review of the Grievance System

410-141-0270 Oregon Health Plan Marketing Requirements

410-141-0280 Managed Care Prepaid Health Plan Potential Member Informational Requirements

410-141-0300 Managed Care Prepaid Health Plan Member Education Requirements

410-141-0320 Oregon Health Plan Prepaid Health Plan Member Rights and Respon sibilities

410-141-0340 Oregon Health Plan Prepaid Health Plan Financial Solvency

410-141-0400 Oregon Health Plan Prepaid Health Plan Case Management Services

410-141-0405 Oregon Health Plan Fully Capitated Health Plan and Physician Care Organization Exceptional Needs Care Coordination (ENCC)

410-141-0407 Oregon Health Plan Ombudsman Services

410-141-0410 Oregon Health Plan Primary Care Managers

410-141-0420 Managed Care Prepaid Health Plan Billing and Payment under the Oregon Health Plan

410-141-0440 Prepaid Health Plan Hospital Contract Dispute Resolution

410-141-0480 Oregon Health Plan Benefit Package of Covered Services

410-141-0500 Excluded Services and Limitations for Oregon Health Plan Clients and/or Division Members

410-141-0520 Prioritized List of Health Services

410-141-0660 Oregon Health Plan Primary Care Manager Provision of Health Care Services

410-141-0680 Oregon Health Plan Primary Care Manager Emergency and Urgent Care Medical Services

410-141-0700 OHP PCM Continuity of Care

410-141-0720 Oregon Health Plan Primary Care Manager Medical Record Keeping

410-141-0740 Oregon Health Plan Primary Care Case Manager Quality Assurance System

410-141-0760 Oregon Health Plan Primary Care Managers Accessibility

410-141-0780 Oregon Health Plan Primary Care Manager Complaint Procedures

410-141-0800 Oregon Health Plan Primary Care Manager Informational Requirements

410-141-0820 Oregon Health Plan Primary Care Manager Member Education

410-141-0840  Oregon Health Plan Primary Care Manager Member Rights And Responsibilities

410-141-0860 Oregon Health Plan Primary Care Manager and Patient Centered Primary Care Home Provider Qualification and Enrollment

410-141-3000 Definitions

410-141-3010 CCO Application, Certification, and Contracting Procedures

410-141-3015 Certification Criteria for Coordinated Care Organizations

410-141-3020 Administration of Oregon Integrated and Coordinated Health Care Delivery System Regulation and Rule Precedence

410-141-3030 Implementation and Transition

410-141-3050 CCO Enrollment for Certain Children Receiving Health Services

410-141-3060 Enrollment Requirements in a CCO

410-141-3065 Coordinated Care Organization (CCO) Enrollment Requirements for Individuals Receiving Residential Substance Abuse Disorder (SUD) Treatment Services

410-141-3070 Pharmaceutical Drug List Requirements

410-141-3080 Disenrollment from Coordinated Care Organizations

410-141-3120 Operations and Provision of Health Services

410-141-3140 Emergency and Urgent Care Services

410-141-3145 Community Health Assessment and Community Health Improvement Plans

410-141-3160 Integration and Care Coordination

410-141-3170 Intensive Care Coordination Services (Exceptional Needs Care Coordination (ENCC))

410-141-3180 Record Keeping and Use of Health Information Technology

410-141-3200 Outcome and Quality Measures

410-141-3220 Coordinated Care Organization Member Rights and Responsibilities

410-141-3260 Grievance and Appeal System

410-141-3261 Requirements for CCO Grievance Process

410-141-3262 Requirements for CCO Appeal

410-141-3263 Notice of Action

410-141-3264 Contested Case Hearings

410-141-3268 Process for Resolving Disputes on Formation of CCO

410-141-3270 Marketing Requirements

410-141-3280 Potential Member Information Requirements

410-141-3300 Member Education Requirements

410-141-3320 Coordinated Care Organization Member Rights and Responsibilities

410-141-3340 Procedure for General Financial Reporting and for Determining Financial Solvency Matters

410-141-3345 General Financial Reporting and Financial Solvency Matters; CCO Reporting Method

410-141-3350 Assets, Liabilities, Reserves — DCBS REPORTING CCOs ONLY

410-141-3355 Restricted Reserves, Capital and Surplus — DCBS Reporting CCOs Only

410-141-3360 Risk-based capital — DCBS Reporting CCOs Only

410-141-3365 Financial Reporting — DCBS Reporting CCOs Only

410-141-3370 Solvency Monitoring and Corrective Actions

410-141-3375 Hazardous Operations

410-141-3380 Disallowance of Transactions – DCBS Reporting CCOs Only

410-141-3385 Holding Company

410-141-3390 Transparency

410-141-3395 Member Protection Provisions

410-141-3420 Billing and Payment

410-141-3430 Coordinated Care Organization Encounter Claims Data Reporting

DIVISION 142

HOSPICE SERVICES

410-142-0020 Definitions

410-142-0040 Eligibility for Hospice Services

410-142-0060 Certification of Terminal Illness

410-142-0080 Informed Consent

410-142-0100 Election of Hospice Care

410-142-0110 Concurrent Care for Children

410-142-0120 Duration of Hospice Care

410-142-0140 Changing the Designated Hospice

410-142-0160 Revoking the Election of Hospice Care

410-142-0180 Plan of Care

410-142-0200 Interdisciplinary Group

410-142-0220 Requirements for Coverage

410-142-0225 Signature Requirements

410-142-0240 Hospice Core Services

410-142-0260 Hospice Level of Care

410-142-0280 Recipient Benefits

410-142-0290 Hospice Services in a Nursing Facility

410-142-0300 Hospice Reimbursement and Limitations

410-142-0380 Death With Dignity

DIVISION 143

HIV/AIDS PREVENTION SERVICES PROGRAM

410-143-0020 Definitions -- Effective for Services Provided on or After February 1, 1994

410-143-0040 Provider Qualification -- Effective for Services Provided on or After February 1, 1994

410-143-0060 Procedure Codes -- Effective for Services Provided on or After February 1, 1994

DIVISION 145

COOPERATIVE TRANSPLANT PROGRAM APPROVAL AND MONITORING

410-145-0000 Definitions

410-145-0010 Application Procedures

410-145-0020 Board of Governors

410-145-0030 Annual Report

410-145-0040 Review and Evaluation of Annual Report

410-145-0050 Complaint Procedure

410-145-0060 Action on Complaints

410-145-0070 Confidentiality of Information

410-145-0080 Reconsideration and Judicial Review

DIVISION 146

AMERICAN INDIAN/ALASKA NATIVE

410-146-0000 Foreword

410-146-0020 Memorandum of Agreement Reimbursement Methodology

410-146-0021 American Indian/Alaska Native (AI/AN) Provider Enrollment

410-146-0022 OHP Standard Benefit for AI/AN Clients

410-146-0040 ICD-9-CM Diagnosis Codes and CPT/HCPCs Procedure Codes

410-146-0060 Prior Authorization

410-146-0075 Client Copayments

410-146-0085 Encounter and Recognized Practitioners

410-146-0086 Multiple Encounters

410-146-0100 Vaccines for Children (VFC)

410-146-0120 Maternity Case Management Services

410-146-0130 Modifiers

410-146-0160 Administrative Medical Examinations and Reports

410-146-0200 Pharmacy

410-146-0220 Death With Dignity

410-146-0240 Transportation

410-146-0380 OHP Standard Emergency Dental Benefit

410-146-0440 Prepaid Health Plan Supplemental Payments

410-146-0460 Compensation for Outstationed Eligibility Workers

DIVISION 147

FQHC AND RHC SERVICES

410-147-0000 Foreword

410-147-0020 Professional Ambulatory Services

410-147-0040 ICD-9-CM Diagnosis and CPT/HCPCs Procedure Codes

410-147-0060 Prior Authorization

410-147-0080 Prepaid Health Plans (PHPs)

410-147-0085 Client Copayments

410-147-0120 Division Encounter and Recognized Practitioners

410-147-0125 OHP Standard Emergency Dental Benefit

410-147-0140 Multiple Encounters

410-147-0160 Modifiers

410-147-0180 Vaccines for Children (VFC) Program

410-147-0200 Maternity Case Management Services

410-147-0240 Administrative Medical Examinations and Reports

410-147-0260 Death With Dignity

410-147-0280 Drugs

410-147-0320 Federally Qualified Health Center Rural Health Clinics Enrollment

410-147-0340 Federally Qualified Health Centers (FQHC) and Rural Health Clinics (RHC) /Provider Numbers

410-147-0360 Encounter Rate Determination

410-147-0362 Change in Scope of Services

410-147-0365 Rural Health Clinic Obstetrics Care Delivery Procedures Reimbursement

410-147-0380 Accounting and Record Keeping

410-147-0400 Compensation for Outstationed Outreach Activities

410-147-0420 Rebasing

410-147-0440 Medicare Economic Index (MEI)

410-147-0460 Prepaid Health Plan Supplemental Payments

410-147-0480 Cost Statement Instructions

410-147-0500 Total Encounters for Cost Reports

410-147-0520 Depreciation

410-147-0540 Related Party Transactions

410-147-0560 Sanctions

DIVISION 148

HOME ENTERAL/PARENTERAL NUTRITION AND IV SERVICES

410-148-0000 Foreword

410-148-0020 Home Enteral/Parenteral Nutrition and IV Services

410-148-0040 Requirements for Home Enteral/Parenteral Nutrition and IV Services

410-148-0060 Authorization

410-148-0080 Equipment Rental/Purchase/Repair

410-148-0090 Standard Benefit Package

410-148-0095 Client Copayments

410-148-0100 Reimbursement

410-148-0120 Reimbursement Limitations for Clients in a Nursing Facility

410-148-0140 Billing Information

410-148-0160 Billing for Clients Who Have Both Medicare and Basic Health Care Coverage

410-148-0260 Home Enteral Nutrition

410-148-0280 Home Parenteral Nutrition

410-148-0300 Other Home IV and Enteral/Parenteral Administration Services

410-148-0320 Billing Quantities, Metric Quantities and Package Sizes

DIVISION 150

ADMINISTRATIVE EXAMINATION AND BILLING SERVICES

410-150-0040 Request Requirements

DIVISION 160

LAW ENFORCEMENT LIABILITY ACCOUNT (LEMLA)

410-160-0000 Definitions

410-160-0100 Process and Procedure

DIVISION 165

OREGON MEDICAID ELECTRONIC HEALTH RECORD (EHR) INCENTIVE PROGRAM

410-165-0000 Basis and Purpose

410-165-0020 Definitions

410-165-0040 Application

410-165-0060 Eligibility

410-165-0080 Meaningful Use

410-165-0100 Participation and Incentive Payments

410-165-0120 Appeals

410-165-0140 Oversight and Audits

DIVISION 170

BEHAVIOR REHABILITATION SERVICES PROGRAM GENERAL RULES

410-170-0000 Effective Date and Administration of the BRS Program

410-170-0010 Purpose

410-170-0020 Definitions

410-170-0030 BRS Contractor and BRS Provider Requirements

410-170-0040 Prior Authorization for the BRS Program; Appeal Rights

410-170-0050 Program Referrals and Admission to BRS Provider

410-170-0060 Discharge from the BRS Contractor or BRS Provider

410-170-0070 BRS Service Planning

410-170-0080 Services

410-170-0090 BRS Types of Care

410-170-0100 Placement Related Activities for the Authority’s BRS Contractors and BRS Providers

410-170-0110 Billing and Payment for Services and Placement Related Activities

410-170-0120 Compliance Reviews & Sanctions

DIVISION 180

TRADITIONAL HEALTH WORKERS

410-180-0300 Purpose

410-180-0305 Definitions

410-180-0310 Community Health Worker, Peer Wellness Specialist, Personal Health Navigator Certification Requirements

410-180-0312 Peer Support Specialist Certification Requirements

410-180-0315 Birth Doula Certification Requirements

410-180-0320 THW Continuing Education Requirements

410-180-0325 Application and Renewal Process for Traditional Health Worker (THW) Certification and Registry Enrollment

410-180-0326 Background Check Requirements

410-180-0327 Provisional THW Certification

410-180-0340 Standards of Professional Conduct

410-180-0345 Denial, Suspension or Revocation of Certification

410-180-0350 Training Program Requirements

410-180-0355 Application and Renewal Process for Authority Training Program Approval

410-180-0360 Denial, Suspension or Revocation of Training Program Approval

410-180-0370 Community Health Workers, Peer Wellness Specialists, Personal Health Navigators, and Peer Support Specialists Certification Curriculum Standards

410-180-0375 Birth Doula Certification Curriculum Standards

410-180-0380 THW and Training Program Complaints and Investigations

DIVISION 200

OFFICE OF CLIENT AND COMMUNITY SERVICES MEDICAL PROGRAMS

410-200-0010 Overview

410-200-0015 General Definitions

410-200-0100 Coordinated Eligibility and Enrollment Process with the Department of Human Services and Cover Oregon

410-200-0105 Hospital Presumptive Eligibility

410-200-0110 Application and Renewal Processing and Timeliness Standards

410-200-0111 Authorized Representatives

410-200-0115 Effective Dates — OCCS Medical Programs

410-200-0120 Notices

410-200-0125 Acting on Reported Changes

410-200-0130 Retroactive Medical

410-200-0135 Assumed Eligibility and Continuous Eligibility for Children and Pregnant Women

410-200-0140 Eligibility for Inmates

410-200-0145 Contested Case Appeals

410-200-0146 Final Orders, Dismissals and Withdrawals

410-200-0200 Residency Requirements

410-200-0205 Concurrent and Duplicate Program Benefits

410-200-0210 Requirement to Provide Social Security Number

410-200-0215 Citizenship and Alien Status Requirements

410-200-0220 Requirement to Pursue Assets

410-200-0225 Assignment of Rights

410-200-0230 Verification

410-200-0235 Changes That Must be Reported

410-200-0240 Citizen/Alien Waived Emergent Medical

410-200-0305 Household Group — Modified Adjusted Gross Income (MAGI) based Medicaid and CHIP

410-200-0310 Eligibility and Budgeting; MAGI Medicaid/CHIP; Not BCCTP or EXT

410-200-0315 Standards and Determining Income Eligibility

410-200-0400 Specific Requirements; Breast and Cervical Cancer Treatment Program (BCCTP)

410-200-0405 Specific Requirements; Substitute Care

410-200-0406 Specific Requirements; Former Foster Care Youth Medical

410-200-0410 Specific Requirements; MAGI CHIP

410-200-0415 Specific Requirements; MAGI Child

410-200-0420 Specific Requirements; MAGI Parent or Other Caretaker Relative

410-200-0425 Specific Requirements; MAGI Pregnant Woman

410-200-0435 Specific Requirements; MAGI Adult

410-200-0440 Specific Requirements; Extended Medical Assistance

410-200-0500 Transitioning Benefits — 2013 Programs

410-200-0505 Specific Requirements; SNAP-Based Eligibility for MAA, OHP-OPP, or MAGI Medicaid

410-200-0510 Specific Program Requirements; BCCM, CEC, CEM, EXT, MAA, MAF, OHP, and SAC

410-200-0515 OHP-OPU Premiums

DIVISION 500

RURAL MEDICAL PRACTITIONERS INSURANCE SUBSIDY PROGRAM

410-500-0000 Purpose

410-500-0010 Definitions

410-500-0020 Eligibility Criteria for Rural Practitioners

410-500-0030 Determination of Subsidy Amount

410-500-0040 Authorized Carriers

410-500-0050 Program Integrity

410-500-0060 Appeals: Administrative Review


Notes
1.) The OAR Compilation is updated on the first of each month to include all rule actions filed with the Secretary of State’s Office by the 15th of the previous month, or by the previous workday if the 15th is on a weekend or holiday.

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

Oregon Secretary of State • 136 State Capitol • Salem, OR 97310-0722
Phone: (503) 986-1523 • Fax: (503) 986-1616 • oregon.sos@state.or.us

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