justicedao/ipfs_state_laws huggingface dataset:
410-133-0220 Billing (1) The enrolled school medical provider must: (a) Bill the Authority in compliance with OARs 410-120-1280 and 943-120-0330; (b) Bill services using a professional claim format (i.e., paper CMS-1500 or electronic equivalent to the CMS-1500 form). (c) Include a procedure code, a diagnosis code, a modifier, and a referring provider ID (Medicaid ID or NPI) for each service billed. (d) Submit timely claims. The Authority shall accept a claim up to 12 months from the date of service. Once a service has been submitted on a claim within the 12-month timely filing limit, the school medical provider has an additional six months to resubmit the denied claim or adjust the paid claim. (2) Duplicate billing: (a) Occurs when a claim is submitted for a specific service when the same service is provided and billed for on the same date of service. (b) Reimbursement made because of duplicate billing shall be recovered. (c) The billing provider is subject to OARs 410-120-1400 and 410-120-1510. Statutory/Other Authority: ORS 413.042 & 414.065 Statutes/Other Implemented: ORS 414.065 History: DMAP 65-2025, amend filed 08/29/2025, effective 08/29/2025 DMAP 121-2024, amend filed 09/06/2024, effective 09/06/2024 DMAP 56-2020, amend filed 10/02/2020, effective 10/05/2020 DMAP 19-2020, temporary amend filed 04/09/2020, effective 04/09/2020 through 10/05/2020 DMAP 19-2009, f. 6-12-09, cert. ef. 7-1-09 DMAP 43-2008, f. 12-17-08, cert. ef. 12-28-08 DMAP 32-2008(Temp), f. & cert. ef. 10-2-08 thru 3-27-09 DMAP 28-2008(Temp), f. 6-30-08, cert. ef. 7-1-08 thru 12-28-08 OMAP 53-2005, f. 9-30-05, cert. ef. 10-1-05 OMAP 24-2005(Temp), f. & cert. ef. 4-5-05 thru 10-1-05 OMAP 53-2003, f. 8-13-03 cert. ef. 9-1-03 OMAP 31-2003, f. & cert. ef. 4-1-03 HR 39-1991, f. & cert. ef. 9-16-91
410-133-0245 Cost-Based Rates and Payment (1) The Authority shall determine cost-based rates based upon annual costs submitted by education agencies. (2) Cost-based rates for each education agency shall: (a) Be based upon the prior year's annual audited costs and the Oregon Department of Education’s (ODE) approved current year indirect rate. (b) Establish an hourly rate and a per-minute increment rate for the current calendar year for each covered service discipline (e.g., physical therapy and nursing, as separate disciplines, shall each have a separate rate). (3) An education agency shall not bill for more than the cost-based rate prescribed by the Authority. (4) Cost data shall be submitted in a format prescribed by the Authority and in accordance with Oregon's Medicaid State Plan approved by the Centers for Medicare and Medicaid Services (CMS). (5) Costs for telehealth technologies used to provide school-based health services are included in the cost for each service discipline and are not billed separately. Statutory/Other Authority: ORS 413.042 Statutes/Other Implemented: ORS 414.065 History: DMAP 65-2025, amend filed 08/29/2025, effective 08/29/2025 DMAP 121-2024, amend filed 09/06/2024, effective 09/06/2024 DMAP 56-2020, amend filed 10/02/2020, effective 10/05/2020 DMAP 19-2020, temporary amend filed 04/09/2020, effective 04/09/2020 through 10/05/2020 DMAP 19-2009, f. 6-12-09, cert. ef. 7-1-09 OMAP 53-2005, f. 9-30-05, cert. ef. 10-1-05 OMAP 24-2005(Temp), f. & cert. ef. 4-5-05 thru 10-1-05
410-133-0320 Documentation and Recordkeeping (1) The school medical provider is responsible for recordkeeping and documentation in adherence to federal, state, and local laws and regulations including OAR 410-120-1360. (2) Documentation for school-based health services: (a) Is a combination of education requirements, service documentation by SBHS-recognized providers, and the IPOC, when applicable. (b) Planned services require an IPOC and service documentation, in adherence to federal, state, and local laws and regulations including OAR 410-120-1360 and OAR 410-133-0320. (c) Unplanned services require service documentation, in adherence to federal, state, and local laws and regulations including OAR 410-120-1360 and OAR 410-133-0320. (d) Must include: (A) Date of service; (B) Medicaid-enrolled child or young adult’s: (i) Full name; (ii) Medicaid ID; and (iii) Diagnosis code(s); (C) Name of the school medical provider; (D) Name of the rendering provider performing the service; (E) Name of the healthcare provider supervising the service (when applicable); (F) Medically necessary and appropriate need for the service; (G) Location and duration of the service; and (H) Nature, extent, or units of service. (3) Service documentation must be documented within the rendering provider’s respective scope of practice and in compliance with their respective board rules and requirements, OAR 410-133-0120, and OAR 410-120-1360. (4) Recordkeeping for school-based health services provided by SBHS-recognized providers must: (a) Include information necessary to support each health service billed by the school medical provider including: (A) If applicable, the child or young adult’s IPOC including any addendum to the IPOC that correlates with the covered health services provided and reimbursed; (B) If applicable, the Section 504 Accommodation Plan associated with the IPOC; and (C) Service documentation recorded by the SBHS-recognized provider. (b) Be retained by the school medical provider in compliance with OAR 410-120-1360. Statutory/Other Authority: ORS 413.042 Statutes/Other Implemented: ORS 414.065 History: DMAP 65-2025, amend filed 08/29/2025, effective 08/29/2025 DMAP 121-2024, amend filed 09/06/2024, effective 09/06/2024 DMAP 33-2016, f. 6-29-16, cert. ef. 7-1-16 DMAP 19-2009, f. 6-12-09, cert. ef. 7-1-09 OMAP 53-2005, f. 9-30-05, cert. ef. 10-1-05 OMAP 24-2005(Temp), f. & cert. ef. 4-5-05 thru 10-1-05 OMAP 53-2003, f. 8-13-03 cert. ef. 9-1-03 OMAP 31-2003, f. & cert. ef. 4-1-03 HR 22-1995, f. & cert. ef. 12-1-95 HR 39-1991, f. & cert. ef. 9-16-91
410-133-0340 Client Rights and Record Confidentiality (1) School medical providers must provide access to records and documentation that support claims submitted to the Authority for school-based health services provided to Medicaid-enrolled children and young adults when requested by the Authority, Oregon Department of Justice, Medicaid Fraud Unit, Oregon Secretary of State, or the United States Department of Health and Human Services, or their authorized representatives. (2) Client rights of confidentiality for Medicaid-enrolled children and young adults must be respected in accordance with the provisions of 42 CFR Part 431, Subpart F and ORS 411.320. (3) School medical providers are subject to the confidentiality laws applicable to student records, including student medical records maintained as part of the education record. Statutory/Other Authority: ORS 413.042 Statutes/Other Implemented: ORS 192.410–192.505 History: DMAP 65-2025, amend filed 08/29/2025, effective 08/29/2025 DMAP 121-2024, amend filed 09/06/2024, effective 09/06/2024 OMAP 53-2005, f. 9-30-05, cert. ef. 10-1-05 OMAP 24-2005(Temp), f. & cert. ef. 4-5-05 thru 10-1-05 OMAP 15-2000, f. 9-28-00, cert. ef 10-1-00 HR 39-1991, f. & cert. ef. 9-16-91
410-134-0000 Purpose (1) The purpose of this OAR Chapter 410, division 134 is to set forth the rules that are specific to the Healthier Oregon program. (2) The Healthier Oregon program is a medical assistance benefit package equal to OHP Plus defined and described in OAR 410-120-1210. (3) The Healthier Oregon program is funded with state and federal dollars as described in OAR 410-134-0004. Statutory/Other Authority: ORS 413.042 Statutes/Other Implemented: ORS 413.042, 414.025, 414.065, 414.231 & 414.706 History: DMAP 89-2023, amend filed 12/19/2023, effective 12/20/2023 DMAP 55-2023, temporary amend filed 06/30/2023, effective 07/01/2023 through 12/27/2023 DMAP 65-2022, adopt filed 06/30/2022, effective 07/01/2022
410-134-0001 Acronyms and Definitions (1) The following acronyms and definitions within this rule specifically apply to the Healthier Oregon program in its entirety. (a) The Authority incorporates acronyms and definitions in OAR 410-141-3500, OAR 410-120-0000 and OAR 410-200-0015; (b) The acronyms and definitions adopted by the Department of Human Services (Department) in chapters 411, 413, and 461; (c) Public Health Division chapter 333 division 4 definitions; (d) Behavioral Health Division chapter 309 division 19 definitions. (2) “Citizenship Waived Medical Benefit Package” (CWM) as defined in OAR 410-120-0000. (3) “Citizenship Waived Medical Plus Benefit Package” (CWX or CWM Plus) as defined in OAR 410-120-0000. (4) “Emergency Medical Condition” is defined in OAR 410-120-0000. (5) “Emergency Health Benefit Funding: is defined in OAR 410-120-0000 and in OAR 410-134-0004 of this rule. (6) “Healthier Oregon Cover All Kids (CAK)” means Cover All Kids as defined in OAR 410-200-0015: (a) Before July 1, 2022, CAK recipients received state-funded coverage equal to OHP Plus as defined in OAR 410-120-1210. (b) As of July 1, 2022, recipients are included in Healthier Oregon; (i) Medical assistance benefit package and coverage is equal to OHP Plus as defined in OAR 410-120-1210; and (ii) Funding is defined in OAR 410-134-0004. (7) “Reproductive Health Equity Act (RHEA)” means Reproductive Health Equity Act (ORS 414.432) funding, which provides access to reproductive health and abortion services to Oregonians who are able to get pregnant and who would be eligible for federally funded medical assistance if not for 8 U.S.C. 1611 or 1612. (8) “Supplemental Health Benefit State Funding” as defined in OAR 410-120-0000 and in OAR 410-134-0004 of this rule. Statutory/Other Authority: ORS 413.042 & 414.065 Statutes/Other Implemented: ORS 413.042, 414.065, ORS 414.025, 414.231, 414.432 & 414.706 History: DMAP 89-2023, amend filed 12/19/2023, effective 12/20/2023 DMAP 55-2023, temporary amend filed 06/30/2023, effective 07/01/2023 through 12/27/2023 DMAP 65-2022, adopt filed 06/30/2022, effective 07/01/2022
410-134-0003 Healthier Oregon and Healthier Oregon Cover All Kids Coverage (1) The Healthier Oregon and Healthier Oregon Cover All Kids benefit package description, benefits package identifier, eligibility criteria, and coverage is described in this Rule. (2) Healthier Oregon and Healthier Oregon Cover All Kids benefit package descriptions: (a) Benefit Package identifiers: (A) BMH: for non-pregnant adults 21 and over and Cover All Kids; or (B) BMP: for pregnant adults or individuals within their post-partum period, who are age 21 and over; (b) Eligibility criteria: Eligible recipients are individuals who meet the financial and non-financial eligibility requirements for an Health Systems Division (HSD) or Oregon Supplemental Income Program Medical (OSIPM) Program, except they do not meet the citizenship or non-citizen status requirements pursuant to OAR 410-200-0215; (c) Coverage and limitations: (A) Oregon Health Plan services defined in OAR 410-120-1210; (B) Oregon Health Plan limitations defined in OAR 410-120-1210. Statutory/Other Authority: ORS 413.042, 414.065 & 414.231 Statutes/Other Implemented: ORS 413.042, 414.065, 414.231, ORS 414.025, 414.312, 414.430, 414.432, 414.706 & 414.710 History: DMAP 89-2023, amend filed 12/19/2023, effective 12/20/2023 DMAP 55-2023, temporary amend filed 06/30/2023, effective 07/01/2023 through 12/27/2023 DMAP 65-2022, adopt filed 06/30/2022, effective 07/01/2022
410-134-0005 Coverage and Billing for Citizenship Waived Medical and Citizenship Waived Medical Plus (1) The Citizenship Waived Medical (CWM) and Citizenship Waived Medical Plus (CWM Plus) benefit package ended on June 30, 2023. Prior to July 1, 2023, CWM Plus was referred to as “CWX”. (2) Benefit and coverage limitations for members who were eligible for, or retroactively determined to be eligible for, the CWM and CWM Plus can be found under DMAP 65-2022, adopt filed 06/30/2022, effective 07/01/2022. (3) Citizenship Waived Medical (CWM) and CWM Plus (previously referred to as “CWX”) services delivered on or before June 30, 2023, may be billed if claims are timely submitted in accordance with OAR 410-120-1300. CWM and CWM Plus billing guidance can be found under DMAP 13-2023, minor correction filed 03/30/2023, effective 03/30/2023. Statutory/Other Authority: ORS 413.042 & 414.065 Statutes/Other Implemented: ORS 413.042, 414.065, ORS 414.312, 414.430, 414.432 & 414.706 History: DMAP 89-2023, adopt filed 12/19/2023, effective 12/20/2023
410-136-3010 Coordinated Care Organizations (1) The Authority contracts with Coordinated Care Organizations (CCOs) to provide medical services for clients receiving Title XIX and Title XXI services for the purpose of providing integrated and coordinated care services across physical health, dental health, and non-emergent medical transportation (NEMT). OAR chapter 410, division 120 including OAR 410-120-1210 describes services through CCOs and division 141 including OAR 410-141-3920 through OAR 410-141-3965 describes NEMT requirements through CCOs. (2) For clients enrolled in a CCO, NEMT services are included in the budget provided to a CCO by the Authority. The CCO shall provide NEMT services to its enrolled members. (3) For clients enrolled in a CCO, all transportation services must be coordinated through the member’s CCO or the CCO’s designated transportation provider prior to receiving services. Statutory/Other Authority: ORS 413.042 & ORS 414.625 Statutes/Other Implemented: ORS 414.625 History: DMAP 95-2023, amend filed 12/22/2023, effective 01/01/2024 DMAP 39-2014, f. & cert. ef. 7-1-14
410-136-3080 Out-of-State Transportation (1) “Out-of-state transportation” means transportation to or from any location outside Oregon, with the exception of contiguous areas up to 75 miles outside the Oregon border. (2) The brokerage shall arrange rides and pay for out-of-state transportation, as defined in section (1) of this rule, to and from an out-of-state OHP or RHAF covered medical service when: (a) The brokerage confirms that the Authority authorized the OHP client’s out-of-state OHP covered medical service per OAR 410-120-1180, Medical Assistance Benefits: Out-of-State Services or the CCO authorized per OAR 410-141-3930 Transportation: Out-of-Service Area and Out-of-State Transportation; and (b) The client is eligible for transportation services per OAR 410-136-3020, General Requirements for NEMT. (3) The brokerage shall arrange for and pay for the most appropriate mode of transportation, and necessary travel to and from an airport or other departure location within Oregon, for out-of-state travel approved by the Authority. (4) The brokerage may utilize any procurement method and criteria to purchase airline tickets, and any necessary travel to and from an airport or other departure location within Oregon, subject only to least expensive mode of transportation that meets the non-emergent medical needs of the client. (5) Brokerages shall not arrange or pay for: (a) A client’s return from any foreign country to any location within the United States for the client to obtain medical care because the care is not available in the foreign country; (b) A client’s return to Oregon from another state when the client was not in the other state to obtain authorized medical services or treatments, unless the client is enrolled in RHAF, lives outside of Oregon, and is seeking RHAF covered services within Oregon. (6) Brokerages may arrange emergency medical transportation services if authorized by the Authority, for a client traveling outside Oregon for a OHP covered medical service who experience an emergency medical condition needing emergency medical transportation as defined in OAR 410-120-0000. Statutory/Other Authority: ORS 413.042 Statutes/Other Implemented: ORS 414.065 History: DMAP 152-2024, amend filed 12/30/2024, effective 01/01/2025 DMAP 95-2023, amend filed 12/22/2023, effective 01/01/2024 DMAP 36-2013, f. 6-27-13, cert. ef. 7-1-13
410-136-3100 Attendants for Child Transports (1) This rule applies to non-emergent medical transportation (NEMT) for children twelve (12) years of age and under who are eligible for NEMT services to and from Oregon Health Plan (OHP) and RHAF covered medical services. The rule also applies to children and young adults with special physical or developmental needs, regardless of age, hereafter referred to as “child” or “children.” (2) Parents or legal guardians must provide an attendant to accompany the children while traveling to and from medical appointments except when: (a) The driver is a DHS volunteer, DHS employee or an Authority employee; (b) The child requires secured transport per OAR 410-136-3120, Secured Transports; (c) An ambulance subcontractor transports the child for NEMT services, and the brokerage reimburses the ambulance subcontractor at the ambulance transport rate; or (d) The child is enrolled in RHAF and seeking RHAF covered services. (3) Attendants are required for NEMT ambulance transports when the brokerage uses an ambulance to provide wheelchair or stretcher car or van rides. (4) ODHS shall establish and administer written guidelines for children in the department’s custody, including written guidelines for volunteer drivers. If ODHS’s requirements or administrative rules differ from this rule, ODHS’s requirements or administrative rules take precedence. (5) An attendant may be the mother, father, stepmother, stepfather, grandparent or legal guardian of the child. The attendant also may be any adult that the parent or legal guardian authorizes to be an attendant. An attendant also may be a brother, sister, stepbrother or stepsister of the child, as long as the attendant is at least eighteen (18) years of age, and the parent or legal guardian authorizes it. An attendant also may be a behavioral health personal care attendant allowed to accompany the client in accordance with OAR 410-172-0780. (6) Brokerages or their subcontractors may require the child’s parent or legal guardian to provide written authorization for an attendant other than themselves to accompany the child. (7) Brokerages or their subcontractors shall not bill additional charges for a child’s attendant. (8) The attendant must accompany the child from the pick-up location to the destination and on the return trip. The attendant must also remain with the child during their appointment. Another person shall not accompany the attendant unless the parent or legal guardian authorizes it or unless the other person is an eligible child traveling to the same location for a medical appointment. (9) The parent, guardian or adult caregiver for the child shall provide and install child safety seats as required by state law. The subcontractor shall not transport a child if a parent or legal guardian fails to provide a child safety seat that complies with state law. Statutory/Other Authority: ORS 413.042 Statutes/Other Implemented: ORS 414.065 History: DMAP 152-2024, amend filed 12/30/2024, effective 01/01/2025 DMAP 95-2023, amend filed 12/22/2023, effective 01/01/2024 DMAP 36-2013, f. 6-27-13, cert. ef. 7-1-13
410-136-3120 Secured Transports (1) Secured transport NEMT services are for the involuntary transport of clients who are in danger of harming themselves or other individuals. Secured transports are allowable when: (a) The brokerage verified that the subcontractor has met the requirements of the secured transport protocol pursuant to OAR 309-033-0200 through 309-033-0970, and, therefore, the subcontractor is able to transport the client who is in crisis or at immediate risk of harming themselves or others due to mental or emotional problems or substance abuse; and (b) The transport is to a Medicaid enrolled facility that the Authority recognizes as being able to treat the immediate medical or behavioral health care needs of the client in crisis. (2) One additional attendant may accompany the client at no additional charge when medically appropriate, such as to administer medications, etc. in-route, or to satisfy legal requirements, including, but not limited to when a parent, legal guardian or escort is required during transport. (3) The brokerage shall authorize transports to and from OHP covered medical services for an eligible client when the court orders the medical service with the following exceptions: (a) The client is in the custody of or under the legal jurisdiction of any law enforcement agency; (b) The client is an inmate of a public institution as defined in OAR 461-135-0950, Eligibility for Inmates; or (c) The Authority has suspended the client’s OHP eligibility pursuant to ORS 414.420 or 414.424. (4) The brokerage shall assume that a client returning to their place of residence is no longer in crisis or at immediate risk of harming themselves or others, and is, therefore, able to use non-secured transportation. In the event that a secured transport is medically appropriate to return a client to their place of residence, the brokerage shall obtain written documentation, signed by the treating medical professional, stating the circumstances that required secured transport. The brokerage shall retain the documentation and a copy of the order in their record for the Authority to review. (5) The brokerage shall not approve or pay for secured medical transport provided to a person going to or from a court hearing or to or from a commitment hearing. (6) The Authority is not a law enforcement agency as defined in OAR 461-135-0950 in accordance with ORS 131.930, and as stated in OAR 461-135-0950(2)(a)(A) for an inmate living in a public institution awaiting trial or an individual serving a sentence for a criminal offense. If an NEMT eligible client is not in criminal custody as an inmate under the jurisdiction of a law enforcement agency, then transport from a penal or detention facility to a Medicaid enrolled facility for an OHP covered service is authorized. Statutory/Other Authority: ORS 413.042 Statutes/Other Implemented: ORS 414.065 History: DMAP 95-2023, amend filed 12/22/2023, effective 01/01/2024 DMAP 36-2013, f. 6-27-13, cert. ef. 7-1-13
410-136-3140 Transports of Clients Changing Hospitals or Other Facilities (1) Brokerages shall arrange and pay for transporting an eligible client who has had a change in condition, noted in the client’s Oregon Department of Human Services (ODHS) care plan, resulting in a need for a new service setting with a lower or higher level of care. This includes clients who are changing levels of care between their community-based care settings or between institutional and community-based settings. The client’s ODHS worker must request the ride. (2) Brokerages shall not arrange or pay for: (a) The transport or return of an inpatient client from an admitting hospital to another hospital (or facility) for diagnostic or other short-term services when the patient will return to the admitting hospital within the first 24-hours of admission. The subcontractor shall bill the admitting hospital directly for these transports; (b) The transport of a client receiving long-term care service in their home or residing in a long-term care facility for the sole purpose of shopping for another long-term care facility, even if the client is looking for a new facility to receive a lower or higher level of care; (c) The transport of a client moving from one type of facility to a facility of the same type, such as from an adult foster home to another adult foster home; and (d) The transport of a client who is relocating to another state, unless the transport is to receive an OHP covered medical service pursuant to OAR 410-136-3080, Out-of-State Transportation. Statutory/Other Authority: ORS 413.042 Statutes/Other Implemented: ORS 414.065 History: DMAP 95-2023, amend filed 12/22/2023, effective 01/01/2024 DMAP 29-2014, f. & cert. ef. 5-20-14 DMAP 69-2013(Temp), f. 12-24-13, cert. ef. 1-1-14 thru 6-30-14 DMAP 36-2013, f. 6-27-13, cert. ef. 7-1-13