justicedao/ipfs_state_laws huggingface dataset:
410-147-0520 Depreciation Office of Management and Budget (OMB) Circular A-87 and A-122, Section 13 is applicable with the following exception: depreciation and amortization must be calculated on a straight line basis less the estimated salvage value. The clinic must use the American Hospital Association guidelines “Estimated Useful Lives of Depreciable Hospital Assets” for determining asset lives when computing depreciation. For assets not covered by the guidelines and with costs of more than $500 individually and $500 aggregate, the lives established by the clinic are subject to approval by Division of Medical Assistance Programs (Division). Depreciation and amortization schedules must be maintained. Statutory/Other Authority: ORS 413.042 Statutes/Other Implemented: ORS 414.065 History: OMAP 62-2002, f. & cert. ef. 10-1-02, Renumbered from 410-128-0260 OMAP 20-2000, f. 9-28-00, cert. ef. 10-1-00 HR 13-1993, f. & cert. ef. 7-1-93 HR 4-1991, f. 1-15-91, cert. ef. 2-1-91
410-147-0540 Related Party Transactions (1) A “related party” is an individual or organization that is associated or affiliated with, or has control of, or is controlled by the federally qualified health center (FQHC) or rural health clinic (RHC) furnishing the services, facilities, or supplies: (a) “Common ownership” exists if an individual or individuals possess significant ownership or equity in the provider and the institution or organization serving the provider; (b) “Control” exists if an individual or an organization has the power, directly or indirectly, significantly to influence or direct the actions or policies of an organization or institution. (2) Division of Medical Assistance Programs (Division) allows costs applicable to services, facilities, and supplies furnished to the FQHC or RHC by a related party at the lower of cost, excluding profits and markups to the related party, or charge to the clinic. Such costs are allowable in accordance with 42 CFR 413.17, to the extent that they: (a) Relate to Title XIX and Title XXI client care; (b) Are reasonable, ordinary, and necessary; and (c) Are not in excess of those costs incurred by a prudent cost-conscious buyer. (3) The intent is to treat the costs incurred by the related party as if they were incurred by the FQHC/RHC itself. (4) Clinics must disclose a related party who is separately enrolled as a provider with Division and furnish the provider’s National Provider Identifier (NPI) and associated taxonomy code(s). (5) Documentation of costs to related parties shall be made available at the time of an audit or as requested by Division. If documentation is not available, such payments to or for the benefit of the related organization will be non-allowable costs. (6) Division will allow rental expense paid to related individuals or organizations for facilities or equipment to the extent the rental does not exceed the related organization's cost of owning (e.g., depreciation, interest on a mortgage) or leasing the assets, computed in accordance with the provisions of the FQHC and RHC Administrative Rules. (7) If all of these conditions are not met, none of the costs of the related party transaction can be reported as reimbursable costs on the FQHC or RHC’s cost statement report. Statutory/Other Authority: ORS 413.042 Statutes/Other Implemented: ORS 414.065 History: DMAP 34-2008, f. 11-26-08, cert. ef. 12-1-08 OMAP 27-2006, f. 6-14-06, cert. ef. 7-1-06 OMAP 62-2002, f. & cert. ef. 10-1-02, Renumbered from 410-128-0280 OMAP 20-2000, f. 9-28-00, cert. ef. 10-1-00 HR 13-1993, f. & cert. ef. 7-1-93 HR 4-1991, f. 1-15-91, cert. ef. 2-1-91
410-147-0560 Sanctions (1) Providers are directed to Division of Medical Assistance Programs' General Rules OARs 410-120-1400 Provider Sanctions and 410-120-1460 Type and Conditions of Sanctions and Oregon Health Authority OAR 943-120-0360 Consequences of Non-Compliance and Provider Sanctions. (2) OAR 410-120-1510 and 943-120-0380 govern fraud and abuse. The Authority is authorized to take the actions necessary to investigate and respond to substantiated allegations of fraud and abuse, including but not limited to suspending or terminating the provider from participation in the medical assistance programs Statutory/Other Authority: ORS 414.065 Statutes/Other Implemented: ORS 414.065 History: DMAP 34-2008, f. 11-26-08, cert. ef. 12-1-08 OMAP 62-2002, f. & cert. ef. 10-1-02, Renumbered from 410-128-0395 OMAP 20-2000, f. 9-28-00, cert. ef. 10-1-00 OMAP 35-1999, f. & cert. ef. 10-1-99 HR 13-1993, f. & cert. ef. 71-1-93
410-148-0000 Foreword (1) The Home Enteral/Parenteral Nutrition and IV Services rules are a user's manual designed to assist providers in preparing health claims for medical assistance program clients. The Home Enteral/Parenteral Nutrition and IV Services provider rules are to be used in conjunction with the General Rules for Oregon Medical Assistance Programs, the Oregon Health Plan administrative rules, the Pharmaceutical Services administrative rules, the Early and Periodic Screening, Diagnostic and Treatment administrative rules, and other relevant provider rules and supplemental information. (2) The Home Enteral/Parenteral Nutrition and IV Services provider rules include procedure codes with restrictions, and limitations. The Home EPIV code and fee schedule, which is not a part of these rules, is not an exhaustive list of OHP covered service codes. Please consult the Prioritized List of Health Services for the Oregon Health Plan and the Division’s Maximum Allowable Table. (3) The Division endeavors to furnish medical providers with up-to-date billing, procedural information, and guidelines to keep pace with program changes and governmental requirements. (4) Providers should always follow the Division administrative rules in effect on the date of service. [Publications: Publications referenced are available from the agency.] Statutory/Other Authority: ORS 413.042 Statutes/Other Implemented: ORS 414.065 History: DMAP 116-2024, amend filed 08/09/2024, effective 08/09/2024 OMAP 15-2004, f. 3-11-04, cert. ef. 4-1-04 OMAP 63-2003, f. 9-5-03, cert. ef. 10-1-03 OMAP 46-2001, f. 9-24-01, cert. ef. 10-1-01, Renumbered from 410-121-0600 HR 3-1995, f. & cert. ef. 2-1-95 HR 26-1990, f. 8-31-90, cert. ef. 9-1-90
410-148-0040 Requirements for Home Enteral/Parenteral Nutrition and IV Services (1) Home Enteral/Parenteral Nutrition and IV Services: (a) Home enteral/parenteral nutrition and IV services must include training and/or education of client or support person on nutritional supplement and /or equipment operation; (b) When enteral/parenteral nutrition and IV services are initiated in a hospital setting, reimbursement for training is included in the hospital reimbursement and will not be made separately; (c) Reimbursement for enteral/parenteral and IV services training when done in the home is included in the payment for the nursing visit(s); (d) Per diem reimbursement includes: administrative service, pharmacy professional and cognitive services, including drug admixture, patient assessment, clinical monitoring, and care coordination, and all necessary infusion related supplies and equipment. Enteral/parenteral formula, drugs and nursing visits are not included in per diem rates and must be billed separately. (2) Home enteral nutrition: (a) Home enteral nutrition is considered medically appropriate to maintain body mass and prevent nutritional depletion, which occurs with some illnesses or pathological conditions; (b) Home enteral therapy may be administered orally or by enteral tube feeding, i.e., nasogastric, jejunostomy or gastrostomy delivery systems. (3) Home parenteral nutrition: (a) Is considered medically appropriate for treatment of gastrointestinal dysfunction such as severe short bowel syndrome, chronic radiation enteritis, severe Crohn’s disease, or other conditions where adequate nutrition by the oral and enteral routes is not possible: (b) Initiation of home parenteral nutrition services must include client or support person education on catheter care, infusion technique, solution preparation, sterilization technique, and equipment operation; (c) Parenteral nutrition is appropriate only when oral or enteral feeding is inadequate or contraindicated. (4) Home intravenous (IV) services: (a) Home intravenous (IV) services are covered by the Division for the administration of antibiotics, analgesics, chemotherapy, hydrational fluids or other intravenous medications in a client’s residence, (i.e., home or nursing facility) or an Ambulatory Infusion Suite (AIS). (b) In addition, the provision of all goods and services needed for maintaining venous or arterial access and required monitoring is covered. Statutory/Other Authority: ORS 413.042 Statutes/Other Implemented: ORS 414.065 History: DMAP 11-2007, f. 6-14-07, cert. ef. 7-1-07 OMAP 22-2003, f. 3-26-03, cert. ef. 4-1-03 OMAP 46-2001, f. 9-24-01, cert. ef. 10-1-01, Renumbered from 410-121-0660 OMAP 29-2000, f. 9-29-00, cert. ef. 10-1-00 HR 3-1995, f. & cert. ef. 2-1-95 HR 11-1994, f. 2-25-94, cert. ef. 2-27-94 HR 34-1993(Temp), f. & cert. ef. 12-1-93 HR 22-1993(Temp), f. & cert. ef. 9-1-93 HR 9-1992, f. & cert. ef. 4-1-92 HR 26-1990, f. 8-31-90, cert. ef. 9-1-90
410-148-0080 Equipment Rental/Purchase/Repair (1) The following equipment shall be covered, if medically appropriate and when cost effective, on a rental basis only: (a) IV/Parenteral nutrition infusion pumps; (b) Enteral nutrition infusion pumps; (2) The equipment provider is responsible for providing working rental equipment including replacement if repairs are necessary. (3) Rental payment for the enteral nutrition infusion pumps and the parenteral nutrition infusion pumps shall not be made beyond the purchase price or beyond fifteen (15) consecutive months (whichever is least costly).; (a) Consecutive months are defined as "any period of continuous use where no more than a 60-day break occurs". (b) Having met the purchase price, as described in this rule, the pump becomes the property of the client; (A) The Division may allow for medically necessary repairs on equipment the patient owns when the repairs are not covered under any manufacturer/supplier warranty. (B) The provider may bill the Division for maintenance and servicing of the pump (as long as the maintenance and servicing is not covered under any manufacturer/supplier warranty) when a period of at least six (6) months has elapsed since the final month of pump rental. (C) Payment for the maintenance and servicing shall only be made one (1) time during every six (6) month period and only for actual incidents of maintenance and servicing. (D) For a purchased pump, a rental pump may be covered for up to one (1) month during equipment repair for a client requiring medically necessary, continuous service. Use HCPCS code K0462 when billing for the temporary rental pump while the patient-owned pump is being repaired; (4) Reasonable useful lifetime of an enteral nutrition infusion pump and parenteral nutrition infusion pump is no less than eight (8) years. Computation of the useful lifetime is based on the date the pump was dispensed to the client, not the age of the pump. (5) All other equipment for home enteral/parenteral nutrition and IV services shall be covered as either purchase or based on length of need and medical appropriateness. (6) All rental or purchase of equipment, full services warranty, pickup, delivery, set-up, fitting, and adjustments are included in the reimbursement. Individual consideration may be given in specific circumstances upon written request to the Division. (7) Repair of rental equipment is the responsibility of the provider. (8) The Division shall not make payment for rental of pumps that are supplied by any manufacturer at no cost to the provider. Statutory/Other Authority: ORS 413.042 Statutes/Other Implemented: ORS 414.065 History: DMAP 116-2024, amend filed 08/09/2024, effective 08/09/2024 OMAP 64-2004, f. 9-10-04, cert. ef. 10-1-04 OMAP 15-2004, f. 3-11-04, cert. ef. 4-1-04 OMAP 46-2001, f. 9-24-01, cert. ef. 10-1-01, Renumbered from 410-121-0700 OMAP 29-2000, f. 9-29-00, cert. ef. 10-1-00 OMAP 7-1998, f. 2-27-98, cert. ef. 3-1-98 HR 3-1995, f. & cert. ef. 2-1-95 HR 20-1991, f. & cert. ef. 4-16-91 HR 26-1990, f. 8-31-90, cert. ef. 9-1-90
410-148-0120 Reimbursement Limitations for Clients in a Nursing Facility (1) The Division of Medical Assistance Programs (Division) will not reimburse for the following services/supplies for clients residing in a nursing facility: (a) Nursing service visits (including assessment visit). Refer to Aging and People with Disabilities (APD) administrative rule covering all-inclusive rate; (b) Supplies and items covered in the nursing facility All-inclusive rate. Refer to the Supplemental Information section of the Home Enteral/Parenteral Nutrition and IV Services provider website (http://www.oregon.gov/OHA/HSD/OHP/Pages/Policy-Home-EPIV.aspx) for a listing of those supplies and items; (c) Oral nutritional supplements that are in addition to consumption of food items or meals. (2) The Division will reimburse for the following: (a) Oral nutritional supplements are covered by the Division for nursing facility clients when medically appropriate, i.e., the client cannot consume food items or meals; (b) Tube fed enteral nutrition formula, when medically appropriate; (c) Patient controlled pump for pain control medication (CADD). [Publications: Publications referenced are available from the agency.] Statutory/Other Authority: ORS 413.042 Statutes/Other Implemented: ORS 414.065 History: DMAP 64-2018, minor correction filed 05/25/2018, effective 05/25/2018 OMAP 15-2004, f. 3-11-04, cert. ef. 4-1-04 OMAP 63-2003, f. 9-5-03, cert. ef. 10-1-03 OMAP 46-2001, f. 9-24-01, cert. ef. 10-1-01, Renumbered from 410-121-0730 HR 11-1994, f. 2-25-94, cert. ef. 2-27-94 HR 34-1993(Temp), f. & cert. ef. 12-1-93 HR 26-1993, f. & cert. ef. 10-1-93
410-148-0140 Billing Information (1) For medications: (a) Pharmacies billing electronically bill through the Division of Medical Assistance Program (Division) pharmacy benefit manager, point of sale. For more information on point of sale, contact the Division’s pharmacy benefit manager’s help desk; (b) Only those pharmacies and Home Enteral/Parenteral Nutrition and IV (EPIV) providers billing manually for medications and home IV drug ingredients that are not billed through point of sale may use the CMS 1500 claim form or the 837P electronic claim form (instructions in home enteral/parenteral and IV services supplemental guide; (c) Providers who bill by paper are required to complete a CMS 1500 claim form. (2) For home enteral/parenteral and IV services other than medications: (a) Providers must use the CMS 1500 form to bill for home enteral/parenteral nutrition and IV services identified with a five-digit Healthcare Common Procedure Coding System (HCPCS) or Current Procedural Terminology (CPT). Use the billing instructions found in the Home Enteral/Parenteral Nutrition and IV Services supplemental materials; (b) See OAR 410-148-0160 for billing clients with Medicare coverage. [Publications: Publications referenced are available from the agency.] Statutory/Other Authority: ORS 413.042 Statutes/Other Implemented: ORS 414.065 History: DMAP 23-2009, f. 6-12-09, cert. ef. 7-1-09 DMAP 26-2008, f. 6-13-08, cert. ef. 7-1-08 OMAP 63-2003, f. 9-5-03, cert. ef. 10-1-03 OMAP 46-2001, f. 9-24-01, cert. ef. 10-1-01, Renumbered from 410-121-0740 OMAP 7-1998, f. 2-27-98, cert. ef. 3-1-98 HR 9-1992, f. & cert. ef. 4-1-92 HR 26-1990, f. 8-31-90, cert. ef. 9-1-90
410-148-0160 Billing for Clients Who Have Both Medicare and Basic Health Care Coverage (1) The Division of Medical Assistance Programs (Division) may be billed directly for services provided to a client when the provider has established and clearly documented in the client's record that the service provided does not qualify for Medicare reimbursement. (2) When the service qualifies for Medicare reimbursement, bill as follows: (a) When billing for home enteral/parenteral nutrition services: (A) Bill in the usual manner to the local or designated Medicare Intermediary; (B) After Medicare makes a payment determination, bill the Division on the DMAP 505 form following the billing instructions and using the procedure codes listed for the Home Enteral/Parenteral Nutrition and IV Services in the fee schedule and supplemental materials; (b) When billing for Home EPIV services: (A) Bill the local Medicare Intermediary in the usual manner; (B) After Medicare makes payment determination, bill the Division following the billing instructions and using the procedure codes listed for the Home EPIV Services fee schedule and supplemental materials. [Publications: Publications referenced are available from the agency.] Statutory/Other Authority: ORS 413.042 Statutes/Other Implemented: ORS 414.065 History: OMAP 63-2003, f. 9-5-03, cert. ef. 10-1-03 OMAP 46-2001, f. 9-24-01, cert. ef. 10-1-01, Renumbered from 410-121-0750 OMAP 7-1998, f. 2-27-98, cert. ef. 3-1-98 HR 3-1995, f. & cert. ef. 2-1-95 HR 26-1993, f. & cert. ef. 10-1-93 HR 9-1992, f. & cert. ef. 4-1-92
410-148-0280 Home Parenteral Nutrition (1) Codes that have "PA" indicated require prior authorization. Codes with "BR" indicated are covered by report. (2) Standard Total Parenteral Nutrition (TPN): (a) Bill using Healthcare Common Procedure Coding System (HCPCS) codes S9365 through S9368; (b) Home infusion for stand TPN includes the following drugs and products in the per diem rate: (A) Non-specialty amino acids (e.g., aminosyn, freeamine, travasol) (B) Concentrated dextrose (e.g., D10, D20, D40, D50, D60, D70) (C) Sterile water; (D) Electrolytes (e.g., CaC12, KCL, KPO4, MgSo4, NaAc, NaCl, NaPO4); (E) Standard multi-trace elements (e.g., MTE4, MTE5, MTE7); (F) Standard multi-vitamin solutions (e.g., MVI-13). (c) The following items are not included in the per diem and should be billed separately: (A) Specialty amino acids for renal failure, hepatic failure or for high stress conditions (e.g., aminess, aminosyn-RF, nephramine, RenAmin, HepatAmine, Aminosyn-HBC, BranchAmin, FreeAmine HBC, Trophamine); (B) Specialty amino acids with concentrations of 15% and above when medically necessary for fluid restricted patients (e.g., Aminosyn 15%, Novamine 15%, Clinisol 15%); (C) Lipids (D) Added trace elements, vitamins not from standard multitrace element or multivitamin solution; (E) Products serving non-nutritional purposes (e.g., heparin, insulin, iron dextran). (2) Parenteral Nutrition Solutions: (a) Bill using HCPCS codes B4164 through B5200. See HCPCS book for description. (b) Note: Reimbursement for compounding, admixture and administrative fees is included in the unit price. (3) Parenteral Supply Kits/Supplies — Procedure Codes (4) Parenteral Nutrition Equipment — Procedure Codes — Table 0280-1. (5) Not Otherwise Classified (NOC) — B9999, NOC For Parenteral Supplies — PA/BR. [ED. NOTE: Tables referenced are available from the agency.] Statutory/Other Authority: ORS 413.042 Statutes/Other Implemented: ORS 414.065 History: OMAP 15-2004, f. 3-11-04, cert. ef. 4-1-04 OMAP 22-2003, f. 3-26-03, cert. ef. 4-1-03 OMAP 46-2001, f. 9-24-01, cert. ef. 10-1-01, Renumbered from 410-121-0860 OMAP 29-2000, f. 9-29-00, cert. ef. 10-1-00 OMAP 7-1998, f. 2-27-98, cert. ef. 3-1-98 HR 3-1995, f. & cert. ef. 2-1-95 HR 26-1993, f. & cert. ef. 10-1-93 HR 26-1990, f. 8-31-90, cert. ef. 9-1-90
410-148-0300 Other Home IV and Enteral/Parenteral Administration Services (1) Codes that have "PA" indicated require prior authorization. Codes with "BR" indicated are covered by report. (2) Catheter Care Kits. All catheter care kit allowable amounts are determined on a per diem basis (1 day = 1 unit): (a) When performed as a stand alone therapy, or during days not covered under per diem by another therapy, bill using catheter care codes S5497 through S5521; (b) The following supplies for non-routine catheter procedures may be billed separately from per diem reimbursement: (A) S5517 Catheter declotting supply kit, 1 day = 1 unit; (B) S5518 Catheter repair supply kit, 1 day = 1 unit; (C) S5520 PICC insertion supply kit, 1 day = 1 unit; (D) S5521 Midline insertion supply kit, 1 day = 1 unit. (E) E0776 IV Pole — Purchase. (F) E0776 with modifier RR IV Pole — Rental, 1 day = 1 unit (3) Home Nursing Visits: (a) When enteral/parenteral services are performed in the home, only a single provider of skilled home health nursing services may obtain authorization and/or bill for such services for the same dates of service; (b) Requests made by providers for any intravenous or enteral/parenteral related skilled nursing services, either solely or in combination with any other skilled nursing services in the home are to be reviewed for prior authorization by the Division of Medical Assistance Programs (Division) Medical Unit; (c) Procedure Codes: (A) 99601, Home infusion/specialty drug administration, per visit (up to 2 hours). Modifier SS is used to indicate — Home infusion services provided in the infusion suite of the IV therapy provider — 1 visit = 1 unit — PA; (B) 99602, each additional hour. List separately in addition to code for primary procedure). Modifier SS is used to indicate — Home infusion services provided in the infusion suite of the IV therapy provider. Use 99602 in conjunction with 99601 — PA; (C) T1001, Home Nursing Visit for Assessment — 1 visit = 1 Unit. (4) Not Otherwise Classified (NOC) — S9379, NOC for Home IV Supplies — PA/BR. Statutory/Other Authority: ORS 413.042 Statutes/Other Implemented: ORS 414.065 History: DMAP 11-2007, f. 6-14-07, cert. ef. 7-1-07 OMAP 15-2004, f. 3-11-04, cert. ef. 4-1-04 OMAP 63-2003, f. 9-5-03, cert. ef. 10-1-03 OMAP 22-2003, f. 3-26-03, cert. ef. 4-1-03 OMAP 46-2001, f. 9-24-01, cert. ef. 10-1-01, Renumbered from 410-121-0880 OMAP 29-2000, f. 9-29-00, cert. ef. 10-1-00 OMAP 7-1998, f. 2-27-98, cert. ef. 3-1-98 HR 26-1993, f. & cert. ef. 10-1-93 HR 46-1990, f. & cert. ef. 12-28-90 HR 26-1990, f. 8-31-90, cert. ef. 9-1-90
410-148-0320 Billing Quantities, Metric Quantities and Package Sizes (1) Use the following metric conversions when billing; (a) Fluid Ounce — 30 ml; (b) Pint — 480 ml; (c) Quart — 960 ml; (d) Gallon — 3,840 ml; (e) Ounce (solids) — 30 gm; (f) Pound (solids) — 454 gm. (2) Use the following units when billing products: (a) Solid substances (e.g., powders, creams, ointments, etc.), bill per gram; (b) Solid substances that are reconstituted with a liquid (e.g., dry powder ampules and vials) such as antibiotic vials or piggybacks must be billed in metric quantity of one each; (c) Tablets, capsules, suppositories, lozenges, packets bill per each unit. Oral contraceptives are to be billed per each table; (d) Diagnostic supplies (e.g., chemstrips, clinitest tabs), bill per each unit; (e) Injectables that are prepackaged syringe (e.g., tubex, carpujects), bill per ml; (f) Medical Supplies (e.g., Testape, Cordran tape) bill in metric quantity of one each; (g) Prepackaged medications and unit doses must be billed per unit (tablet or capsule). Unit dose liquids are to be billed by ml; (h) Fractional ml liquid doses (e.g., flu vaccine, pneumovax, etc.) use unique codes and bill per each dose; (i) Fractional units: If no unique codes are available, round quantity up to the next whole unit (e.g., 3.5 gm to 4.0 gm; 7.2 ml up to 8 ml). Statutory/Other Authority: ORS 413.042 Statutes/Other Implemented: ORS 414.065 History: OMAP 46-2001, f. 9-24-01, cert. ef. 10-1-01, Renumbered from 410-121-0900 HR 26-1990, f. 8-31-90, cert. ef. 9-1-90
410-150-0005 Purpose The Administrative Examination and Report rules are provided for use in conjunction with the General Rules of the Division of Medical Assistance Programs (DMAP) to assist providers in completing examinations requested and in preparing claims for administrative evaluations and reports. Division 150 rules do not apply to managed care plans. Statutory/Other Authority: ORS 413.042 Statutes/Other Implemented: ORS 414.065 History: DMAP 41-2019, adopt filed 10/01/2019, effective 12/01/2019