justicedao/ipfs_state_laws huggingface dataset:
410-136-3160 Ground and Air Ambulance Transports (1) Transporting a client via ambulance is required when a medical facility or provider states the client’s medical condition requires the presence of a health care professional during the emergency or non-emergency transport. This includes neonatal transports. (2) For non-emergent medical transportation (NEMT) services, the brokerage shall authorize the transport. (3) Brokerages shall provide ambulance or stretcher transports with a medical technician when: (a) A client’s medical condition requires a stretcher; (b) The length of transport would require a personal care attendant; and (c) The client does not have an attendant who can assist with personal care during the ride. (4) Emergency ambulance transportation is required when a client’s medical condition is an emergency pursuant to OAR 410-120-0000, Acronyms and Definitions. The ambulance must transport the client to the nearest appropriate facility able to meet the client's medical needs. Brokerages do not arrange emergency transportation. (5) The following apply to air-ambulance NEMT services: (a) The brokerage shall approve air-ambulance NEMT only when another mode of transportation would further jeopardize or compromise the client's medical condition due to: (A) The length of time required to transport the client by ground-ambulance; (B) Current road conditions preclude the use of ground transportation; or (C) Ground-ambulance is not available. (b) As an exception to section (4) (a) of this rule, the brokerage may grant air-ambulance transportation if it determines the transportation is cost effective. The brokerage shall document how air-ambulance is more cost effective than ground transportation; (c) The brokerage must obtain a written recommendation from the client’s medical provider indicating medical appropriateness before authorizing air-ambulance 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 36-2013, f. 6-27-13, cert. ef. 7-1-13
410-136-3340 Brokerage Service Areas (1) Brokerages enrolled with the Oregon Health Authority (Authority) shall arrange and pay for NEMT services to all eligible clients in the counties shown in Table 136-3340. (2) Oregon Health Plan (OHP) clients and RHAF clients residing in Oregon shall use only the brokerages available in their county of residence unless they have permission from their local brokerage to use another brokerage. (3) Nothing in this rule precludes brokerages from coordinating to provide rides to clients in another brokerage if it would be more cost effective or provide better service for the client. [ED. NOTE: Table referenced is available from the Oregon Health Authority (OHA) and on the Authority’s website.] 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
410-138-0009 Targeted Case Management — Services Not Covered Targeted Case Management (TCM) services do not cover: (1) Direct delivery of an underlying medical, educational, social, or other service to which the eligible client has been referred. (2) Providing transportation to a service to which an eligible client is referred. (3) Escorting an eligible client to a service. (4) Providing child care so that an eligible client may access a service. (5) Contacts with individuals who are not categorically eligible for Medicaid or who are categorically eligible for Medicaid but not included in the eligible target population when those contacts relate directly to the identification and management of the non-eligible or non-targeted individual’s needs and care. (6) Assisting an individual who has not yet been determined eligible for Medicaid to apply for or obtain eligibility. (7) TCM services provided to an individual if the services are case management services funded by Title IV-E or Title XX of the Social Security Act, or federal or state funded parole and probation, or juvenile justice programs. (8) Activities for which third parties are liable to pay. Statutory/Other Authority: ORS 413.042 & 414.065 Statutes/Other Implemented: ORS 414.065 History: DMAP 9-2017, f. 3-31-17, cert. ef. 4-1-17 DMAP 4-2017(Temp), f. 2-2-17, cert. ef. 2-10-17 thru 7-11-17 DMAP 2-2017(Temp), f. & cert. ef. 1-13-17 thru 7-11-17 DMAP 76-2016, f. 12-29-16, cert. ef. 1-1-17 DMAP 23-2014, f. & cert. ef. 4-4-14 DMAP 75-2013(Temp), f. 12-31-13, cert. ef. 1-1-14 thru 6-30-14 DMAP 41-2010, f. 12-28-10, cert. ef. 1-1-11 DMAP 22-2010, f. 6-30-10, cert. ef. 7-1-10 DMAP 43-2009, f. 12-15-09, cert. ef. 1-1-10 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
410-138-0040 Targeted Case Management Babies First!, CaCoon, and Nurse-Family Partnership Program Risk Criteria (1) This rule is in effect for services approved by CMS effective for services rendered beginning January 1, 2017, and sets forth the criteria for risk factors for the TCM Babies First!, CaCoon, and Nurse-Family Partnership programs to include perinatal and parental eligibility criteria in Table 1 and risk factors for Babies First!, CaCoon and Nurse Family Partnership TCM infant and children eligibility criteria and diagnosis in Table 2. (2) Table 1 risk criteria for TCM perinatal and parental eligibility and Table 2 risk criteria for TCM infant and children eligibility and diagnosis criteria become effective January 1, 2017, and may be obtained by clicking on the PDF copy. [ED. NOTE: To view attachments referenced in rule text, click here to view rule.] Statutory/Other Authority: ORS 413.042 & 414.065 Statutes/Other Implemented: ORS 414.065 History: DMAP 58-2022, amend filed 06/21/2022, effective 06/22/2022 DMAP 51-2021, temporary amend filed 12/28/2021, effective 01/01/2022 through 06/29/2022 DMAP 13-2020, amend filed 03/24/2020, effective 03/27/2020 DMAP 48-2017, amend filed 11/07/2017, effective 11/07/2017 DMAP 9-2017, f. 3-31-17, cert. ef. 4-1-17 DMAP 4-2017(Temp), f. 2-2-17, cert. ef. 2-10-17 thru 7-11-17 DMAP 2-2017(Temp), f. & cert. ef. 1-13-17 thru 7-11-17 DMAP 76-2016, f. 12-29-16, cert. ef. 1-1-17 DMAP 41-2010, f. 12-28-10, cert. ef. 1-1-11 DMAP 22-2010, f. 6-30-10, cert. ef. 7-1-10 OMAP 50-2004, f. 9-9-04, cert. ef. 10-1-04 HR 37-1994, f. 12-30-94, cert. ef. 1-1-95 HR 20-1992, f. & cert. ef. 7-1-92
410-138-0080 Targeted Case Management Program Billing Policy (1) Reimbursement is based on cost-based rate methodology and subject to all rules and laws pertaining to federal financial participation. The Authority’s acceptance of cost data provided by provider organizations for the purpose of establishing rates paid for TCM services does not imply or validate the accuracy of the cost data provided. (2) The cost-based rate shall be derived by considering the following expenditures directly attributable to TCM staff: (a) TCM staff salaries and other personnel expenses; (b) Supervisory salaries and other personnel expenses; (c) Administrative support salaries and other personnel expenses; (d) Services and supply expenses; (e) Various overhead expenditures, if not already considered in the indirect rate. (3) The Division shall accept a claim up to 12 months from the date of service. See provider rule OAR 410-120-1300 (Timely Submission of Claims). (4) Providers shall only bill for allowable activities in the TCM programs that assist individuals eligible under the Medicaid State Plan to gain access to needed medical, social, educational, housing, environmental, and other services. (5) The Division may not allow duplicate payments to other public agencies or private entities under other program authorities for TCM services under the eligible client’s care plan. Medical services shall be provided and billed separately from case management services. The Authority shall recover duplicate payments. (6) The Division may not reimburse for TCM services if the services are case management services funded by Title IV-E or Title XX of the Social Security Act. These services shall be billed separately. (7) Any place of service is valid. (8) Prior authorization is not required. Statutory/Other Authority: ORS 413.042 & 414.065 Statutes/Other Implemented: ORS 414.065 History: DMAP 98-2025, amend filed 12/29/2025, effective 01/01/2026 DMAP 9-2017, f. 3-31-17, cert. ef. 4-1-17 DMAP 4-2017(Temp), f. 2-2-17, cert. ef. 2-10-17 thru 7-11-17 DMAP 2-2017(Temp), f. & cert. ef. 1-13-17 thru 7-11-17 DMAP 76-2016, f. 12-29-16, cert. ef. 1-1-17 DMAP 41-2010, f. 12-28-10, cert. ef. 1-1-11 DMAP 22-2010, f. 6-30-10, cert. ef. 7-1-10 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 61-2004, f. 9-10-04, cert. ef. 10-1-04 HR 37-1994, f. 12-30-94, cert. ef. 1-1-95 HR 20-1992, f. & cert. ef. 7-1-92
410-138-0390 Targeted Case Management Retroactive Payments (1) Providers may submit claims retroactively for services provided to the targeted populations described in OAR 410-138-0020(2) if the claims meet the following criteria: (a) Services were provided less than 12 months prior to the date of first claim submission and were provided on or after the date indicated in the rule listed above and were allowable services in accordance with OAR 410-138-0007; (b) The maximum number of units billed does not exceed the maximum allowed under each TCM program. (c) The case manager was appropriately licensed or certified and met all current requirements for case managers at the time the service was provided, as described in the provider requirements rule OAR 410-138-0060 appropriate for the TCM program; (d) Documentation regarding provider qualifications and the services that the provider retroactively claims shall have been available at the time the services were performed. (2) The Division may not allow duplicate payments to be made to the same or different providers for the same service for the same client, nor will payment be allowed for services for which third parties are liable to pay (see also OAR 410-138-0005). (3) Reimbursement is subject to all rules and laws pertaining to federal financial participation. Statutory/Other Authority: ORS 413.042 & 414.065 Statutes/Other Implemented: ORS 414.065 History: DMAP 98-2025, amend filed 12/29/2025, effective 01/01/2026 DMAP 9-2017, f. 3-31-17, cert. ef. 4-1-17 DMAP 4-2017(Temp), f. 2-2-17, cert. ef. 2-10-17 thru 7-11-17 DMAP 76-2016, f. 12-29-16, cert. ef. 1-1-17 DMAP 21-2013, f. & cert. ef. 4-26-13 DMAP 48-2012(Temp), f. & cert. ef. 10-31-12 thru 4-28-13 DMAP 41-2010, f. 12-28-10, cert. ef. 1-1-11 DMAP 22-2010, f. 6-30-10, cert. ef. 7-1-10 DMAP 43-2009, f. 12-15-09, cert. ef. 1-1-10 DMAP 34-2009(Temp), f. & cert. ef. 11-16-09 thru 5-1-10
410-140-0415 Codes (1) Providers shall use an International Classification of Diseases, 10th revision, Clinical Modification (ICD-10-CM) diagnosis code on all claims. (2) Providers shall provide the member's diagnosis to ancillary service providers (e.g., SWEEP Optical Laboratories) when prescribing services, equipment, and supplies. (3) Providers shall use the standardized code sets required by the Health Insurance Portability and Accountability Act (HIPAA) and adopted by the Centers for Medicare and Medicaid Services (CMS). Providers shall accurately code claims using the combination of Health Care Common Procedure Coding System (HCPCS) and Current Procedural Terminology (CPT) codes in effect for the date the service was provided: (a) Providers may not bill CPT or HCPCS procedure codes for separate procedures when a single CPT or HCPCS code includes all services provided. Providers shall comply with published coding guidelines; (b) Intermediate and comprehensive ophthalmological services as described under the ophthalmology section of the CPT codebook shall be billed using codes included under this section and not those included under the Evaluation and Management section; (c) When there is no appropriate descriptive procedure code to bill the Division, the provider shall use the code for “unlisted services.” (4) The Division recognizes HIPAA compliant modifiers in coding. (5) Provider Error: Neither the contractor nor the Division shall be responsible for costs, expenses or for any required rework due to errors by any provider. Statutory/Other Authority: ORS 413.042 Statutes/Other Implemented: 414.025, 414.065, 414.591 & 414.631 History: DMAP 127-2024, adopt filed 10/08/2024, effective 10/08/2024
410-140-0425 Meaningful Language Access (1) Providers shall take reasonable steps to ensure that persons with Limited English Proficiency (LEP) have meaningful access and an equal opportunity to participate in program services at all visual service care visits: (a) The size or type of provider does not matter. All providers serving OHP members shall tell members that qualified health interpreter services are available free of charge. Interpreter services shall be timely and protect the privacy and independence of the person with LEP; (b) Bilingual providers and staff may become Certified Health Care Interpreters after completing the requisite interpreter training and receiving a valid certificate from the Authority; (c) The Authority’s Health Care Interpreter Registry lists all qualified or certified Health Care Interpreters available for provider use; (d) Fee-for-Service (FFS) vision providers may receive a $60 add-on fee, per date of service, for providing interpreter services to OHP members. The addition of this add-on fee for FFS visits does not change CCO requirements related to reimbursement of qualified and certified HCIs for interpretation services. (2) FFS vision providers who furnish Certified Health Care Interpreter (HCI) services to OHP members are eligible to receive a $60 add-on fee per date of service. The Authority shall cover this fee only when: (a) The fee is billed in conjunction with a covered OHP service or medically necessary follow-up visit related to the initial Covered Service; (b) The fee is not billed in conjunction with bundled rate services that incorporate administrative costs (e.g., inpatient hospital stays, home health or hospice visits, services provided by long-term care facilities, or services billed at an encounter rate by rural health clinics, federally qualified health centers and tribal health centers); and (c) The language assistance service is provided by a qualified or Certified Health Care Interpreter as described in Oregon Revised Statute (ORS) Chapter 413. (3) Billing: Providers shall verify that the interpreter is registered with the Authority’s Health Care Interpreter Registry. If the interpreter is registered, providers pay the interpreter directly for services provided. After payment is made to the interpreter, bill the Authority for the add-on fee on the claim form: (a) Add the appropriate code to a new line on the claim form; (b) Keep Documentation in the member’s medical record that indicates use of the qualified or certified Health Care Interpreter for any potential audit of services billed. Statutory/Other Authority: ORS 414.572 & 413.550 Statutes/Other Implemented: ORS 414.572 & 413.550 History: DMAP 127-2024, adopt filed 10/08/2024, effective 10/08/2024
410-140-0430 Limitations and Exclusions (1) Buying up, as defined in OAR 410-120-1350 is prohibited. (2) Vision therapy is not covered except under EPSDT when medically necessary and medically appropriate (Refer to Chapter 410, Division 151). (3) The following ophthalmic materials are not covered and include, but are not limited to: (a) Glasses with a prescription that is equal to or less than +/-.25 diopters in both eyes; (b) Two (2) pair of glasses instead of bifocals or trifocals in a single frame; (c) Hand-held, low vision aids; (d) Non-spectacle mounted aids; (e) Single lens spectacle mounted low vision aids; (f) Telescopic and other compound lens systems, including distance vision telescopic, near vision telescopes, and compound microscopic lens systems; (g) Extra or spare pairs of glasses; (h) Anti-reflective lens coating; (i) U-V lens; (j) Progressive and blended lenses; (k) Bifocals and trifocals segments over 28mm including executive; (L) Aniseikonic lenses; (m) Sunglasses; and (n) Frame styles outside of the contract between the Division and contractor based on member preference and are not medically necessary. (4) Post-operative care includes all related follow-up visits and examinations provided within: (a) Ninety (90) days following the date of major surgery; or (b) Ten (10) days following the date of minor surgery; and (c) Claims for evaluation and management services and ophthalmological examinations billed within the follow-up period shall be denied. (5) Provider Error: Neither the contractor nor the Division shall be responsible for costs, expenses or for any required rework due to errors by any provider. Statutory/Other Authority: ORS 413.042 Statutes/Other Implemented: 414.025, 414.065, 414.591 & 414.631 History: DMAP 127-2024, adopt filed 10/08/2024, effective 10/08/2024
410-141-3501 Administration of Oregon Integrated and Coordinated Health Care Delivery System Regulation; Rule Precedence (1) The Authority may adopt reasonable and lawful policies, procedures, rules and interpretations to promote the orderly and efficient administration of the Oregon Integrated and Coordinated Health Care Delivery System and medical assistance programs. This includes the Oregon Health Plan (OHP) pursuant to ORS Chapter 414, subject to the rulemaking requirements of Oregon Revised Statutes and Oregon Administrative Rule (OAR) procedures. (2) To the extent possible, the Authority’s policies, procedures, rules, and MCE contracts shall be interpreted to avoid a conflict among themselves or with governing state or federal law. In the event of an irreconcilable conflict, the following order of precedence shall govern: (a) Medicaid Plan and waivers or other directives from CMS; (b) Federal Statutes; (c) Federal Regulations; (d) Oregon Revised Statutes; (e) Oregon Administrative Rules using the following order of precedence: (A) This OAR chapter 410 division 141 (“Oregon Health Plan”); (B) OAR chapter 410 division 120 (“Medical Assistance Programs”); (C) Any applicable Provider rules in OAR 410 based on the category of health service; (D) OAR Chapter 943, Division 120; (E) OAR Chapter 309; (F) All other applicable OARs; (f) The MCE Contract, including any internal order of precedence established therein. Statutory/Other Authority: ORS 413.042, 414.615, 414.625, 414.635 & 414.651 Statutes/Other Implemented: ORS 414.610 - 414.685 History: DMAP 55-2019, adopt filed 12/17/2019, effective 01/01/2020
410-141-3540 Member Protections (1) In the event of a finding of MCE impairment by the Authority, or of a termination of the MCE contract, members of the MCE shall be offered disenrollment from the MCE and enrollment in accordance with the Authority’s rules. (2) For the purpose of this section only, and only in the event of a finding of MCE impairment by the Authority or of a termination of the MCE contract, any covered health care service furnished within the state by a provider to a member of the impaired or terminated MCE shall be considered to have been furnished pursuant to a contract between the provider and the MCE with whom the member was enrolled when the services were furnished. (3) Each contract between an MCE and a provider of health services shall provide that if the MCE fails to pay for covered health services as set forth in the contract, the member is not liable to the provider for any amounts owed by the MCE. (4) If the contract between the contracting provider and the MCE has not been reduced to writing or fails to contain the provisions required by this rule, the member is not liable to the contracting provider for any amounts owed by the MCE. (5) No contracting provider or agent, trustee or assignee of the contracting provider shall bill a member, send a member’s bill to a Collection Agency, or maintain a civil action against a member to collect any amounts owed by the MCE for which the member is not liable to the contracting provider in this rule and under 410-120-1280. (6) Nothing in this section impairs the right of a provider to charge, collect from, and attempt to collect from or maintain a civil action against a member for any of the following: (a) Health services not covered by the MCE, if a valid OHP Client Agreement to Pay for Health Services form OHP 3165, or facsimile, signed by the client, has been completed as described in OAR 410-120-1280; or (b) Health services rendered after the termination of the contract between the MCE and the provider, unless the health services were rendered during the confinement in an inpatient facility and the confinement began prior to the date of termination or unless the provider has assumed post-termination treatment obligations under the contract. Before providing a non-covered service, the provider must complete an OHP 3165, or facsimile, as described in OAR 410-120-1280. Statutory/Other Authority: ORS 413.042, 414.615, 414.625, 414.635 & 414.651 Statutes/Other Implemented: ORS 414.610 - 414.685 History: DMAP 55-2019, adopt filed 12/17/2019, effective 01/01/2020
410-141-3545 Coordinated Care Organization Behavioral Health Provider, Treatment and Facility Certification and Licensure Behavioral health treatment services are covered for eligible OHP clients when provided by a CCO under the following circumstances: (1) Provider Organizations (as defined under OAR 410-120-0000) of outpatient behavioral health services shall: (a) Be certified by the Authority as described in OAR 309-008-0250 for the scope of services provided; and (b) Comply with applicable rules, including but not limited to, those defined in OAR chapter 309 and any requirements in the CCO contract. (2) A certificate may not be required for certain types of providers, regardless of whether public funds are received, as outlined in OAR 309-008-0250(4); (3) Provider organizations (as defined under OAR 410-120-0000) of residential treatment services shall: (a) Meet the definition of a residential treatment facility under ORS 430.010, 430.306 and 443.400; (b) Be licensed by the Authority as described in ORS 443.725 and OAR chapter 415 divisions 12 and 50 for the scope of service provided; and (c) Comply with applicable rules including, but not limited to, those defined in OAR chapter 415 and chapter 309 and any requirements in the CCO contract. Statutory/Other Authority: ORS 413.042, 414.065, 430.010, 430.306, 443.400 & 443.725 Statutes/Other Implemented: ORS 413.042, 414.065, 430.010, 430.306 & 443.400 History: DMAP 55-2019, adopt filed 12/17/2019, effective 01/01/2020
410-141-3600 MCE Assessment: Definitions The following definitions apply for purposes of OAR 410-141-3600 through 3655: (1) "Deficiency" means the amount by which the assessment as correctly computed exceeds the assessment, if any, reported by the managed care entities (MCEs). (2) "Delinquency" means the MCE failed to file a report when due or to pay the assessment as correctly computed when the assessment was due. (3) “MCE Assessment” means the managed care assessment defined under OAR 410-141-3610. (4) “Recoupment” means an accounts receivable system that collects money owed by the provider to the Authority by withholding all or a portion of a provider's future payments. Statutory/Other Authority: ORS 413.042 & 414.025 Statutes/Other Implemented: ORS 414.065 & 2017 HB 2391 History: DMAP 55-2019, adopt filed 12/17/2019, effective 01/01/2020