Loading
The Oregon Administrative Rules contain OARs filed through October 15, 2014
 
QUESTIONS ABOUT THE CONTENT OR MEANING OF THIS AGENCY'S RULES?
CLICK HERE TO ACCESS RULES COORDINATOR CONTACT INFORMATION

 

DEPARTMENT OF HUMAN SERVICES,
AGING AND PEOPLE WITH DISABILITIES AND DEVELOPMENTAL DISABILITIES

 

DIVISION 200

DISABILITY DETERMINATION SERVICES RATES OF PAYMENT — MEDICAL

411-200-0010

General Policy

(1) The Department of Human Services (Department) reimburses a vendor or consultant, for the costs of goods and services only if the Department has authorized payment before the provision of goods and services. The Department rejects all invoices for goods and services without the required prior authorization.

(2) Except as provided in OAR 411-200-0030 and 411-200-0035, the amount that the Department pays the vendor or consultant for previously authorized goods and services is:

(a) For a vendor: The rates set forth in OAR 411-200-0030; and

(b) For a consultant: No more than the maximum fee for the service prescribed in the United States Department of Health and Human Services' fee schedule.

Stat. Auth.: ORS 410.070
Stats. Implemented: ORS 410.070
Hist.: SDSD 4-2002, f. & cert. ef. 6-12-02; SPD 13-2003, f. & cert. ef. 7-1-03; SPD 7-2004, f. 3-23-04 cert. ef. 3-24-04; SPD 19-2004, f. & cert. ef. 6-23-04; SPD 12-2005, f. & cert. ef. 9-26-05; SPD 12-2006, f. 3-23-06, cert. ef. 4-1-06; SPD 9-2011, f. 4-29-11, cert. ef. 5-1-11; APD 1-2014, f. 1-27-14, cert. ef. 2-1-14

411-200-0020

Definitions

Unless the context indicates otherwise, the following definitions apply to the rules in OAR chapter 411, division 200.

(1) "Brief Narrative" means a document that summarizes claimant treatment to date and current status, briefly addresses three to five specific topics posed by the Department, if any, and is usually one or two pages.

(2) "Comprehensive Narrative" means a document that describes an extended claimant history, addresses six or more specific topics, and is usually three or more pages.

(3) "Consultant" means an individual whose professional credentials per the policy of the Social Security Administration identify the individual either as an acceptable medical source or qualified medical source.

(4) "Department" means the Department of Human Services.

(5) "DDS" means the Disability Determination Services program within the Department funded by, and subject to, the disability rating rules of the Social Security Administration.

(6) "Fee Schedule" means a complete listing of fees used by the United States Department of Health and Human Services to pay for goods and services. The fee schedule is maintained at: https://www.cms.gov/apps/physician-fee-schedule/license-agreement.aspx. Printed copies may be obtained by contacting the Centers for Medicare & Medicaid Services, 7500 Security Blvd., Baltimore, MD 21244.

(7) "HHS" means the United States Department of Health and Human Services.

(8) "These Rules" mean the rules in OAR chapter 411, division 200.

(9) "Vendor" means an individual or entity (such as hospitals, clinics, private practices) that provide medical evidence of record or other services at the Department's request and may, at the Department’s request and with the Department’s prior authorization, provide a brief or comprehensive narrative of medical treatment for the Department’s review.

Stat. Auth.: ORS 410.070
Stats. Implemented: ORS 410.070
Hist.: SDSD 4-2002, f. & cert. ef. 6-12-02; SPD 12-2005, f. & cert. ef. 9-26-05; SPD 12-2006, f. 3-23-06, cert. ef. 4-1-06; SPD 9-2011, f. 4-29-11, cert. ef. 5-1-11; APD 1-2014, f. 1-27-14, cert. ef. 2-1-14

411-200-0030

Medical Evidence of Record (MER) and Narrative Charges for Vendors

(1) Except as provided by section (4) of this rule, the Department pays the lesser of the following fees for existing medical records requested by the Department:

(a) The lowest fee for the records that the vendor charges the general public or other state or federal agencies for the records; or

(b) When the invoice itemizes the number of pages provided:

(A) For 10 or fewer pages, $18.00;

(B) For 11–20 pages, $18.00 for the first 10 pages plus $0.25 per page for each additional page;

(C) For 21–40 pages, $20.50 for the first 20 pages plus $0.10 per page for each additional page; and

(D) For more than 40 pages, a maximum payment of $22.50.

(c) If the invoice does not itemize the number of pages provided, the Department pays a total maximum payment of $18.00.

(2) Additional payment is not made to a vendor for second or subsequent requests when the information to be provided was available at the time the original request was processed.

(3) Records provided by a vendor, whether held in multiple locations or by multiple sources, are paid as a single record request regardless of whether the records are electronic or paper form, or both.

(4) The Department pays a vendor an additional $5.00 when the Department receives the requested records within seven days from the date of the Department's record request. Time is measured from the date indicated on the Department's written request until the date that the Department receipts the copies.

(5) The Department pays the vendor the amount billed up to a maximum payment of $35.00 for a brief narrative summarizing the medical treatment when requested by the Department.

(6) The Department pays the vendor the amount billed up to a maximum payment of $75.00 for a comprehensive narrative summarizing the medical treatment when requested by the Department.

Stat. Auth.: ORS 410.070
Stats. Implemented: ORS 410.070
Hist.: SDSD 4-2002, f. & cert. ef. 6-12-02; SPD 12-2005, f. & cert. ef. 9-26-05; SPD 12-2006, f. 3-23-06, cert. ef. 4-1-06; SPD 9-2011, f. 4-29-11, cert. ef. 5-1-11; APD 1-2014, f. 1-27-14, cert. ef. 2-1-14

411-200-0035

Consultative Examination (CE) and Related Charges for Consultants

(1) Except as provided in section (2) of this rule, the Department pays the lesser of the following fees for examinations and lab work when requested and pre-authorized by the Department:

(a) The lowest fee for services that the consultant charges the general public or other state or federal agencies; or

(b) The rate prescribed by HHS in the fee schedule.

(2) With prior written approval by a DDS manager, the Department may exceed the fee described in section (1) of this rule when financial or human considerations outweigh the difference in cost. Such considerations may include examinations in a remote geographic area or logistical concerns.

(3) No additional fees are reimbursed for certain scheduled services (e.g., blood work only, x-rays, lab tests, PFT’s, treadmills) where no preparation time is required.

Stat. Auth.: ORS 410.070
Stats. Implemented: ORS 410.070
Hist.: SPD 9-2011, f. 4-29-11, cert. ef. 5-1-11; APD 1-2014, f. 1-27-14, cert. ef. 2-1-14

411-200-0040

Limitations of Payments

(1) A vendor or consultant who has entered into a price agreement or contract with one part of the Department to provide identified services must provide the same services at the same price to the Department if requested.

(2) The vendor must accept the fees prescribed by these rules as payment in full. If a vendor's usual and customary fee for a service exceeds the fee prescribed by these rules, a client or the client's family may not be liable to the vendor for any portion of a vendor's usual and customary fee unless the client or the client's family agrees in writing to assume the additional charges. Without such explicit agreement, the vendor must accept the Department's payment as payment in full.

(3) No fee is paid to a consultant if DDS cancels an appointment more than 24 hours in advance of the appointed time.

(4) A consultant is not reimbursed for the time to travel to or from an authorized consultative examination.

Stat. Auth.: ORS 410.070
Stats. Implemented: ORS 410.070
Hist.: SDSD 4-2002, f. & cert. ef. 6-12-02; SPD 12-2005, f. & cert. ef. 9-26-05; SPD 12-2006, f. 3-23-06, cert. ef. 4-1-06; SPD 9-2011, f. 4-29-11, cert. ef. 5-1-11; APD 1-2014, f. 1-27-14, cert. ef. 2-1-14

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

© 2013 State of Oregon All Rights Reserved​