justicedao/ipfs_state_laws huggingface dataset:
410-125-1080 Documentation (1) Federal regulations require Medicaid providers to maintain records that fully support the extent of services for which payment has been requested, and that such records be furnished to the Division upon request (42 CFR 431.107). (2) When requested by the Division or its medical review contractor, hospitals must submit sufficient medical documentation to verify the emergency nature, medical necessity, quality and appropriateness of treatment, and appropriateness of the length of stay for inpatient and outpatient hospital services. The Division may request sufficient information to evaluate the accuracy and appropriateness of ICD-10-CM Coding for the claim. In addition, the Division may request an itemized billing for all services provided. The Division will specify in its request what documentation is required. Statutory/Other Authority: ORS 413.042 Statutes/Other Implemented: ORS 414.065 History: DMAP 51-2015, f. 9-22-15, cert. ef. 10-1-15 HR 21-1990, f. & cert. ef. 7-9-90, Renumbered from 461-015-0680 AFS 72-1989, f. & cert. ef. 12-1-89, Renumbered from 461-015-0040 AFS 49-1989(Temp), f. 8-24-89, cert. ef. 9-1-89 AFS 46-1987, f. & ef. 10-1-87 AFS 60-1982, f. & ef. 7-1-82 AFS 14-1980, f. 3-27-80, ef. 4-1-80
410-125-2000 Access to Records (1) Providers must furnish requested medical and financial documentation within 30 calendar days from the date of request. Failure to comply within 30 calendar days shall result in recovery of payment(s) made by the Division for services being reviewed. (2) The Division conducts post payment review of admissions and claim records. The Division may request records from a hospital or may request access to records while at the hospital. (3) The hospital has 30 days to provide the Division with copies of records. In some cases, there may be a more urgent need to review records. (4) The Medical Payment Recovery Unit (MPRU) conducts recovery activities for the Division involving third party liability resources. MPRU may request records from the hospital. This unit has the same right to medical and financial information as the Division. Statutory/Other Authority: ORS 413.042 Statutes/Other Implemented: ORS 414.065 History: DMAP 32-2010, f. 12-15-10, cert. ef. 1-1-11 OMAP 70-2004, f. 9-15-04, cert. ef. 10-1-04 OMAP 11-2004, f. 3-11-04, cert. ef. 4-1-04 HR 42-1991, f. & cert. ef. 10-1-91 HR 21-1990, f. & cert. ef. 7-9-90, Renumbered from 461-015-0690 AFS 72-1989, f. & cert. ef. 12-1-89, Renumbered from 461-015-0040 AFS 49-1989(Temp), f. 8-24-89, cert. ef. 9-1-89 AFS 46-1987, f. & ef. 10-1-87 AFS 60-1982, f. & ef. 7-1-82 AFS 14-1980, f. 3-27-80, ef. 4-1-80
410-125-2020 Post Payment Review (1) All services provided by a hospital in the inpatient or outpatient setting are subject to post-payment review by the Division. Both emergency and non-emergency services may be reviewed. Claims for services may be reviewed to determine: (a) The medical necessity of the admission or outpatient services provided; (b) The appropriateness of the length of stay; (c) The appropriateness of the plan of care; (d) The accuracy of the ICD-10 coding and DRG assignment; (e) The appropriateness of the setting selected for service delivery; (f) The quality of care of the services provided; (g) The nature of any service coded as emergent; (h) The accuracy of the billing; (i) The care furnished is appropriately documented. (2) If the Division determines that a hospital service was not within Division coverage parameters, the hospital and attending physician shall be notified in writing and will have twenty days to provide additional written documentation to support the medical necessity of the admission and/or procedure(s). (3) If the recommendation for denial is upheld by the Division, the hospital and/or practitioner may request a reconsideration of the denial within 30 days of the receipt of the denial. (4) If the reconsidered decision is to uphold the denial, payment to all providers of service shall be recovered. (5) The hospital and/or practitioner may appeal any final decision through the Division administrative appeals process. (6) No payment shall be made by the Division for inpatient services if the Division or Medicare has determined the service is not medically necessary and/or appropriate. Statutory/Other Authority: ORS 413.042 Statutes/Other Implemented: ORS 414.065 History: DMAP 51-2015, f. 9-22-15, cert. ef. 10-1-15 DMAP 32-2010, f. 12-15-10, cert. ef. 1-1-11 OMAP 70-2004, f. 9-15-04, cert. ef. 10-1-04 OMAP 28-2000, f. 9-29-00, cert. ef. 10-1-00 OMAP 34-1999, f. & cert. ef. 10-1-99 HR 42-1991, f. & cert. ef. 10-1-91 HR 21-1990, f. & cert. ef. 7-9-90, Renumbered from 461-015-0700 AFS 72-1989, f. & cert. ef. 12-1-89, Renumbered from 461-015-0090 AFS 49-1989(Temp), f. 8-24-89, cert. ef. 9-1-89 AFS 46-1987, f. & ef. 10-1-87 AFS 38-1986, f. 4-29-86, ef. 6-1-86 AFS 1-1984, f. & ef. 1-9-84 AFS 14-1980, f. 3-27-80, ef. 4-1-80
410-125-2030 Recovery of Payments (1) Payments made by the Division of Medical Assistance Programs (Division) shall be recovered for: (a) Services identified by the provider as emergent or urgent, but determined on retrospective review not to have been emergent or urgent. Payment shall also be recovered from the admitting and/or performing physician; (b) Services determined by the Division that the readmission to the same hospital was the result of a premature discharge; (c) Services were billed but not provided; (d) Services provided at an inappropriate level of care, which includes the setting selected for service delivery; (e) The Division non-covered services; (f) Services, which were covered by a third party payer or other resources; or (g) Services denied by a third party payer as not medically necessary. (2) Payment to a physician and other providers of service for inpatient non-urgent or non-emergent services requiring prior authorization is subject to recovery by the Division if recovery is made from the hospital. (3) If review by the Division results in a denial, the hospital may appeal any final decision through the Division Administrative Appeals process. See Administrative Hearings (chapter 410, division 120). (4) As part of the Utilization Review Program, the Division shall develop and maintain a data system profiling the patterns of practice of institutions and practitioners. As a result of these profiles, the Division may initiate focused reviews. Any practitioner or hospital subject to a focused review shall be notified in advance of the review. (5) All providers having a pattern of inappropriate utilization or inappropriate quality of care according to the current standards of the medical community and/or abuse of the Division rules or procedures shall be subject to corrective action. Actions taken shall be those determined appropriate by the Division, or sanctions established under the Oregon Revised Statues (ORS) or Oregon administrative rule and/or referral to a State or Federal authority, licensing body or regulatory agency for appropriate action. Statutory/Other Authority: ORS 413.042 Statutes/Other Implemented: ORS 414.065 History: DMAP 32-2010, f. 12-15-10, cert. ef. 1-1-11 OMAP 70-2004, f. 9-15-04, cert. ef. 10-1-04 OMAP 28-2000, f. 9-29-00, cert. ef. 10-1-00 OMAP 34-1999, f. & cert. ef. 10-1-99 HR 42-1991, f. & cert. ef. 10-1-91
410-125-2040 Provider Appeals — Administrative Review (1) A provider may request an administrative review regarding the decision(s) by the Division that affect the services they provide or have provided. See General Rules (chapter 410 division 120). (2) A requests for an administrative review must be submitted in writing to the Medicaid Administrator, 500 Summer Street NE, E49, Salem, OR 97301-1079. (3) The request must be received within 30 days of the date of notification of the payment decision or notification of change in reimbursement. Statutory/Other Authority: ORS 413.042 Statutes/Other Implemented: ORS 414.065 History: OMAP 70-2004, f. 9-15-04, cert. ef. 10-1-04 HR 42-1991, f. & cert. ef. 10-1-91 HR 21-1990, f. & cert. ef. 7-9-90, Renumbered from 461-015-0710 AFS 72-1989, f. & cert. ef. 12-1-89 AFS 49-1989(Temp), f. 8-24-89, cert. ef. 9-1-89
410-125-2060 Provider Appeals — Hearing Request If the hospital disagrees with the Division calculation of reasonable costs for outpatient services or inpatient services, the outpatient interim rate, Diagnosis-Related Groups based prospective payment for inpatient services, the calculation of the hospital's unit value, or any other hospital reimbursement methodologies or payments, a written request for an appeal may be made to the Division in accordance with the General rules (chapter 410 division 120). A hearing request must be received not later than 30 days following the date of the notice of action. At the time of appeal, the hospital must submit any data the hospital wants the Division to consider in support of the appeal. The appeal will be conducted as described in General rules. Statutory/Other Authority: ORS 413.042 Statutes/Other Implemented: ORS 414.065 History: OMAP 70-2004, f. 9-15-04, cert. ef. 10-1-04 HR 42-1991, f. & cert. ef. 10-1-91 HR 21-1990, f. & cert. ef. 7-9-90, Renumbered from 461-015-0720 AFS 72-1989, f. & cert. ef. 12-1-89, Renumbered from 461-015-0123 AFS 49-1989(Temp), f. 8-24-89, cert. ef. 9-1-89 AFS 52-1985, f. 9-3-85, cert. ef. 10-1-85 AFS 1-1984, f. & cert. ef. 1-9-84 AFS 37-1983(Temp), f. & cert. ef. 7-15-83 AFS 37-1983(Temp), f. & cert. ef. 7-15-83 Renumbered from 461-015-0120(4) AFS 60-1982, f. & cert. ef. 7-1-82 AFS 18-1982(Temp), f. & cert. ef. 3-1-82 AFS 57-1980, f. 8-29-80, cert. ef. 9-1-80 AFS 14-1980, f. 3-27-80, cert. ef. 4-1-80
410-125-2080 Administrative Errors (1) If a hospital has been given incorrect information by the Division of Medical Assistance Programs, or Children, Adults, and Families Programs, or Aging and People with Disabilities/staff, and services were provided on the basis of this information, and payment has been denied as a result, the hospital may submit a request for payment as an administrative error. (2) Include the following: (a) An explanation of the problem; (b) Any documents supporting the request for payment; (c) A copy of any paper remittance advice or electronic 835 printouts received on this claim; (d) A copy of the original claim. (3) Send the request: Division of Medical Assistance Programs, Provider Inquiry, Administrative Errors, 500 Summer Street NE, E-44, Salem, OR 97301-1077. Statutory/Other Authority: ORS 413.042 Statutes/Other Implemented: ORS 414.065 History: OMAP 17-2006, f. 6-12-06, cert. ef. 7-1-06 OMAP 70-2004, f. 9-15-04, cert. ef. 10-1-04 HR 42-1991, f. & cert. ef. 10-1-91 HR 21-1990, f. & cert. ef. 7-9-90, Renumbered from 461-015-0730 AFS 72-1989, f. & cert. ef. 12-1-89 AFS 49-1989(Temp), f. 8-24-89, cert. ef. 9-1-89
410-127-0045 Face-to-Face Encounter Requirements for Home Health Services (1) The Division requires that for the initial ordering of home health services, an in-person face-to-face encounter that is related to the primary reason the client requires the home health services must occur within not more than 90 days before or 30 days after the start of services. (2) The face-to-face encounter shall be conducted by: (a) The certifying physician (MD or DO); or (b) An authorized non-physician practitioner (NPP); or (c) An attending or post-acute physician for clients admitted to home health immediately after an acute or post-acute stay. (3) Authorized NPP’s for home health services are nurse practitioners, a clinical nurse specialist working in collaboration with the physician, or a physician associate under the supervision of a physician. (4) If an authorized NPP performs the face-to-face encounter, they shall communicate the clinical findings to the certifying physician. Those clinical findings must be incorporated into a written or electronic document included in the client’s medical record. (5) The certifying physician shall document that the client was evaluated or treated for a condition that supports the need for the home health services ordered within no more than 90 days before or 30 days after the start of services. The certifying physician shall also document the name of the practitioner who conducted the encounter and the date of the encounter. (6) The documentation of the face-to-face encounter must be a separate and distinct section of or an addendum to the certification and must be clearly titled, dated, and signed by the certifying physician. (7) A face-to-face encounter must occur for certification any time a new start of care assessment is completed to initiate care for the home health services. (8) If a dually eligible client begins home health under Medicare and transitions to Medicaid, the Medicare face-to-face encounter documentation shall meet the Medicaid face-to-face requirement. (9) The home health agency shall maintain documentation of the qualifying face-to-face encounter and provide this documentation to the Division with the prior authorization request for services. Statutory/Other Authority: 411.404 & 414.065 Statutes/Other Implemented: 414.065 History: DMAP 10-2025, minor correction filed 01/09/2025, effective 01/09/2025 DMAP 2-2018, adopt filed 01/10/2018, effective 01/10/2018 DMAP 29-2017(Temp), f. 7-14-17, cert. ef. 7-15-17 thru 1-10-18
410-127-0046 Electronic Visit Verification (EVV) (1) The Home Health Care Agencies must comply with Section 12006(a) of the 21st Century Cures Act by electronically verifying Home Health services. Oregon Medicaid has selected the Provider Choice Model for EVV. Home Health Care agencies must provide a method to capture EVV information that meets the requirements of the 21st Century Cures Act. (2) The submission of EVV data to the Authority by the Home Health Care agency provider is certification that the foregoing information is true, accurate, and complete. (a) Provider specific EVV solutions that do not capture the start time and end time to the minute are not EVV compliant; (b) Provider specific EVV solutions that do not capture geo location coordinates at the start time and again at the end time of service provided are not EVV compliant; (c) Provider alteration of one or more data points in a provider specific EVV solution record, prior to sending that record to the Department or Authority for payment is prohibited; (d) Home health services that are not EVV compliant are not eligible for payment and payments may be denied or recovered from the Home Health Care agency provider; (e) The Authority does not grant exceptions to Home Health Care agency providers for provider specific EVV solutions. A provider who is enrolled by the Authority shall comply with department guidance to determine whether a limited exception for an individual or a rendering provider employed by the provider may be permitted by the Authority. See administrative rule chapter 411; (f) The requirement to use EVV does not apply to individuals enrolled and living in a residential service setting, including 24-hour group homes, foster care homes, supported living, or receiving On the Job Attendant Care, or Day Support Activities. EVV does not include any employment or community transportation services. (3) The following data elements are required to be reported to Oregon Health Authority monthly: (a) Provider number of Agency; (b) Individual name of provider rendering the service; (c) Client prime number; (d) Service Date; (e) Start and end time (to the minute); (f) Location (geo location) of service delivery; (g) Type of service performed; (4) Home Health Agencies must use the reporting template and submit reports each month to HH.EVVData@oha.oregon.gov. (5) Payment by the Authority or Department does not restrict or limit the Authority or any state or federal oversight entity’s right to review or audit a claim before or after the payment. Payment may be denied or subject to recovery if the review or audit determines the care, service or item was not provided in accordance with this EVV rule or does not meet the criteria for quality or medical appropriateness of the care, service or item or payment. Statutory/Other Authority: ORS 413.042 Statutes/Other Implemented: ORS 414.065 History: DMAP 91-2023, adopt filed 12/21/2023, effective 01/01/2024
410-127-0065 Signature Requirements (1) Physicians shall sign for services they order. This signature shall be handwritten or electronic, and it must be in the client's medical record. (2) The ordering physician shall ensure the authenticity of the signature. Statutory/Other Authority: ORS 413.042 Statutes/Other Implemented: ORS 414.065 History: DMAP 2-2018, amend filed 01/10/2018, effective 01/10/2018 DMAP 29-2017(Temp), f. 7-14-17, cert. ef. 7-15-17 thru 1-10-18 DMAP 33-2010, f. 12-15-10, cert. ef. 1-1-11 OMAP 38-2006, f. 12-15-06, cert. ef. 1-1-07
410-127-0080 Prior Authorization (1) Home health providers must obtain prior authorization (PA) for services as specified in rule. (2) Providers must request PA as follows (see the Home Health Supplemental Information booklet for contact information) and include the documentation requirements from the supplemental (e.g., face-to-face encounter, plan of care, primary diagnosis, initial assessment, evaluation, etc.): (a) For clients enrolled in a Coordinated Care Organization (CCO) or a Prepaid Health Plan (PHP), from the CCO or the PHP; (b) For all other clients, from the Division. (3) For services requiring authorization, providers must contact the responsible unit for authorization within five working days following initiation or continuation of services. The FAX or postmark date on the request shall be honored as the request date. The provider shall obtain payment authorization. Authorization shall be given based on medical appropriateness and appropriate level of care, cost, and effectiveness as supported by submitted documentation. The plan of care submitted must include the client’s condition, the rationale for the care plan including justification for the required skill level of care, and the summary of care for additional certification periods. (4) Payment authorization does not guarantee reimbursement (e.g., eligibility changes, incorrect identification number, provider contract ends). (5) For rules related to authorization of payment including retroactive eligibility, see General Rules OAR 410-120-1320. Statutory/Other Authority: ORS 413.042 Statutes/Other Implemented: ORS 414.065 History: DMAP 2-2018, amend filed 01/10/2018, effective 01/10/2018 DMAP 29-2017(Temp), f. 7-14-17, cert. ef. 7-15-17 thru 1-10-18 DMAP 29-2013, f. & cert. ef. 6-27-13 DMAP 33-2010, f. 12-15-10, cert. ef. 1-1-11 DMAP 34-2008, f. 11-26-08, cert. ef. 12-1-08 OMAP 91-2003, f. 12-30-03, cert. ef. 1-1-04 OMAP 1-2003, f. 1-31-03, cert. ef. 2-1-03 OMAP 19-2000, f. 9-28-00, cert. ef. 10-1-00 OMAP 15-1999, f. & cert. ef. 4-1-99 HR 15-1995, f. & cert. ef. 8-1-95 HR 2-1993, f. 2-19-93, cert. ef. 2-20-93 HR 30-1992(Temp), f. & cert. ef. 9-25-92 HR 12-1991, f. & cert. ef. 3-1-91 HR 28-1990, f. 8-31-90, cert. ef. 9-1-90, Renumbered from 411-075-0005 SSD 10-1990, f. 3-30-90, cert. ef. 4-1-90 SSD 6-1986, f. & ef. 4-24-86 SSD 4-1983, f. 5-4-83, ef. 5-5-83 Renumbered from 461-019-0410, AFS 69-1981, f. 9-30-81, ef. 10-1-81 AFS 8-1979, f. 3-30-79, ef. 4-1-79 PWC 798, f. & ef. 6-1-76 PWC 682, f. 7-19-74, ef. 8-11-74
410-127-0200 Home Health Revenue Center Codes Payment authorization is required for those services indicated by the Code PA. Following are the procedure codes to be used for billing: (1) Medical/surgical supplies and devices: (a) 270 -- General classification; (b) 271 – Non-sterile supply; (c) 272 -- Sterile supply. (2) Physical Therapy: (a) 421 -- Visit charge -- PA; (b) 424 -- Evaluation (includes OASIS assessment) or re-evaluation. (3) Occupational Therapy: (a) 431 -- Visit charge -- PA; (b) 434 -- Evaluation or re-evaluation. (4) Speech-language pathology: (a) 441 -- Visit charge -- PA; (b) 444 -- Evaluation (includes OASIS assessment) or re-evaluation. (5) Skilled nursing: (a) 551 -- Visit charge -- PA; (b) 559 -- Other skilled nursing -- evaluation (includes OASIS assessment). (6) Home health aide -- 571 -- Visit charge -- PA. (7) Total charge -- 001 -- Total Charge. Statutory/Other Authority: ORS 413.042 Statutes/Other Implemented: ORS 414.065 History: DMAP 4-2020, amend filed 02/24/2020, effective 02/25/2020 DMAP 32-2019, temporary amend filed 08/13/2019, effective 08/19/2019 through 02/14/2020 DMAP 2-2018, amend filed 01/10/2018, effective 01/10/2018 DMAP 29-2017(Temp), f. 7-14-17, cert. ef. 7-15-17 thru 1-10-18 OMAP 19-2000, f. 9-28-00, cert. ef. 10-1-00 HR 15-1995, f. & cert. ef. 8-1-95 HR 14-1992, f. & cert. ef. 6-1-92 HR 12-1991, f. & cert. ef. 3-1-91 HR 28-1990, f. 8-31-90, cert. ef. 9-1-90
410-129-0060 Prescription Required (1) The prescription is the written order by the prescribing practitioner pursuant to state law governing SLP, audiology, and hearing aid services. Prescription shall specify the ICD diagnosis code for all SLP, audiology, and hearing aid services that require payment/prior authorization. (2) The provision of speech therapy services shall be supported by a written order and a therapy treatment plan signed by the prescribing practitioner. A practitioner means an individual licensed pursuant to state law to engage in the provision of health care services within the scope of the practitioner’s license or certification. (3) A written order: (a) Is required for the initial evaluation; (b) For therapy, shall specify the ICD diagnosis code, service, amount, and duration required. (4) Written orders shall be submitted with claims that are subject to PPR or that require PA request, and a copy shall be on file in the provider’s therapy record. The written order and the treatment plan shall be reviewed and signed by the prescribing practitioner every six months. (5) Authorization of payment to an audiologist or hearing aid dealer for a hearing aid will be considered only after examination for ear pathology and written prescription for a hearing aid by an ear, nose, and throat specialist (ENT) or general practitioner who has training to examine the ear and performs within the scope of his practice, i.e., primary care physician (not appropriate for an orthopedic specialist, chiropractor, gynecologist, etc.). Statutory/Other Authority: ORS 413.042 Statutes/Other Implemented: ORS 414.025 & ORS 414.065 History: DMAP 44-2019, amend filed 11/06/2019, effective 11/14/2019 DMAP 18-2019, temporary amend filed 06/18/2019, effective 07/01/2019 through 12/27/2019 DMAP 56-2017, amend filed 12/26/2017, effective 01/01/2018 DMAP 49-2016, f. 7-26-16, cert. ef. 8-1-16 DMAP 51-2015, f. 9-22-15, cert. ef. 10-1-15 DMAP 6-2007, f. 6-14-07, cert. ef. 7-1-07 OMAP 36-1999, f. & cert. ef. 10-1-99 HR 36-1994, f. 12-30-94, cert. ef. 1-1-95 HR 27-1993, f. & cert. ef. 10-1-93 HR 5-1991, f. 1-18-91, cert. ef. 2-1-91, Renumbered from 461-021-0301 AFS 67-1985, f. 11-19-85, ef. 12-1-85