justicedao/ipfs_state_laws huggingface dataset:
410-129-0065 Licensing Requirements (1) The Division enrolls only the following types of providers as performing providers under the Speech-Language Pathology, Audiology and Hearing Aid Services program: (a) An individual licensed by the relevant state licensing authority to practice speech-language pathology (SLP); (b) An individual licensed by the relevant state licensing authority to practice audiology; and (c) An individual licensed by the relevant state licensing authority for “dealing in hearing aids” as defined in Oregon Revised Statute 694.015. (2) The Oregon Board of Examiners for SLP and Audiology licenses and the Division recognizes services provided by: (a) Conditional Speech-Language Pathologists; and (b) SLP Assistants. (3) Services of graduate SLP students, furnished under a Conditional SLP License: (a) Shall be provided in compliance with supervision requirements of the state licensing board and the American Speech-Language-Hearing Association; (b) Shall be compliant with applicable record and documentation requirements (see also Oregon Administrative Rules in chapter 335, division 010); and (c) Are reimbursed to the licensed supervising speech-language pathologist. (4) The Division shall not reimburse for services of a licensed speech-language pathologist while the pathologist is teaching or supervising students in SLP. Statutory/Other Authority: ORS 413.042 Statutes/Other Implemented: ORS 414.025 & 414.065 History: DMAP 49-2016, f. 7-26-16, cert. ef. 8-1-16 DMAP 22-2014, f. & cert. ef. 4-2-14 OMAP 59-2003, f. 9-5-03, cert. ef. 10-1-03 OMAP 36-1999, f. & cert. ef. 10-1-99 HR 27-1993, f. & cert. ef. 10-1-93
410-129-0075 Face-to-Face Encounter Requirements for Fee-for-Service Clients (1) For initial ordering of speech generating devices (SGD), an in-person, face-to-face encounter that is related to the primary reason the client requires the medical equipment or supplies must occur no more than six months prior to the start of services: (a) The face-to-face encounter shall be conducted and documented by the treating physician (MD or DO) or an authorized non-physician practitioner (NPP); (b) Authorized NPPs for SGD are nurse practitioners, clinical nurse specialists working in collaboration with a physician, or physician associate under the supervision of a physician; (c) The physician or NPP conducting the face-to-face encounter shall document that the client is evaluated or treated for a condition that supports the need for the SGD ordered within six months prior to completing the written order for the equipment; (d) If the NPP performing the face-to-face encounter does not have prescribing authority, the NPP shall communicate the clinical findings to the ordering physician; (e) The ordering physician shall incorporate the clinical findings into a written or electronic document included in the client’s medical record. (2) If a dually eligible client is evaluated for medical equipment or supplies under Medicare and transitions to Medicaid, the Medicare face-to-face encounter documentation shall meet the Medicaid face-to-face requirement. (3) The durable medical equipment (DME) supplier shall maintain documentation of the qualifying face-to-face encounter and provide the documentation when the item requires PA or at the Division’s request. (4) The table at https://www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/Medicare-FFS-Compliance-Programs/Medical-Review/Downloads/DME_List_of_Specified_Covered_Items_updated_March_26_2015.pdf identifies the DME items subject to these face-to-face requirements. Statutory/Other Authority: ORS 413.042 & ORS 414.065 Statutes/Other Implemented: ORS 414.065 History: DMAP 11-2025, minor correction filed 01/09/2025, effective 01/09/2025 DMAP 15-2020, temporary amend filed 03/26/2020, effective 03/26/2020 through 09/21/2020 DMAP 100-2018, adopt filed 11/06/2018, effective 11/06/2018 DMAP 30-2018, temporary adopt filed 05/17/2018, effective 05/17/2018 through 11/12/2018
410-129-0085 Payment Methodology (1) Speech-Language Pathology and Audiology outpatient services are priced based on RVU (Refer to OAR 410-120-1340(6)) and flat fee rates: (a) Surgical procedures such as cochlear implants may be provided in a hospital or Ambulatory Surgical Center (ASC) (Refer to OAR 410-120-1340 (6) and (8)); (b) The Division reimburses inpatient hospital service under the DRG methodology, unless specified otherwise in the Division’s Hospital Services program administrative rules, chapter 410, division 125. (2) The Division shall reimburse the following codes, using 75 percent of the Manufacturer’s Suggested Retail Price (MSRP). This is verifiable with quote, invoice, or bill from the manufacturer that clearly states the amount indicated is MSRP all require PA: (a) E2599 (Accessory for SGD, not otherwise classified) and reimbursement shall be capped at $6,200; (b) E2512 (SGD accessory, mounting system) and reimbursement shall be capped at $3,300; (c) L8690 (Auditory osseointegrated device, includes all internal and external components) (d) L8691(Auditory osseointegrated device, external sound processor, excludes transducer/actuator, replacement only, each) and reimbursement shall be capped at $1,888.94; (e) L8692 (Auditory osseointegrated device, external sound processor, used without osseointegration, body worn) and reimbursement shall be capped at $2,045.20; (f) L8693 (Auditory osseointegrated device abutment, any length, replacement only); (g) L8694 (Audiory osseointegrated device, transducer/actuator, replacement only, each); (h) V5281 (Assistive Listening Device (Ald) fm/dm system, monaural; (i) V5282 (Ald fm/dm system, binaural); (j) V5283 (Ald neck, loop induction receiver); (k) V5284 (Ald fm/dm ear level receiver); (L) V5285 (Ald fm/dm aud input receiver); (m) V5286 (Ald blu tooth fm/dm receiver); (n) V5287 (Ald fm/dm receiver, nos); (o) V5288 (Ald fm/dm transmitter ald); (p) V5289 (Ald fm/dm adapt/boot coupling device for receiver); and (q) V5290 (Ald transmitter microphone). Statutory/Other Authority: ORS 413.042 & ORS 414.065 Statutes/Other Implemented: ORS 414.065 & ORS 414.025 History: DMAP 93-2023, amend filed 12/21/2023, effective 01/01/2024 DMAP 46-2021, amend filed 10/22/2021, effective 10/22/2021 DMAP 17-2021, temporary amend filed 05/05/2021, effective 05/05/2021 through 10/31/2021 DMAP 100-2018, adopt filed 11/06/2018, effective 11/06/2018 DMAP 30-2018, temporary adopt filed 05/17/2018, effective 05/17/2018 through 11/12/2018
410-129-0100 Medicare/Medicaid Claims (1) When an individual not in managed care has both Medicare and Medicaid coverage, audiologists shall bill audiometry and all diagnostic testings to Medicare first. Medicare will automatically forward these claims to Medicaid. Refer to OAR 410-120-1210 (General Rules) for information on Division or CCO reimbursement. (2) Audiologists shall bill all hearing aids and related services directly to the Division on an OHP 505. Payment authorization is required on most of these services. (3) If Medicare transmits incorrect information to the Division, or if an out-of-state Medicare carrier or intermediary was billed, providers shall bill the Division using an OHP 505 form. If any payment is made by the Division, an adjustment request shall be submitted to correct payment, if necessary. (4) Send all completed OHP 505 forms to the Division. (5) Hearing aid dealers shall bill all services directly to the Division on a CMS-1500. Payment authorization is required on most services. (6) When a client not in managed care has both Medicare and Medicaid coverage, speech-language pathologists shall bill services to Medicare first. Medicare will automatically forward these claims to Medicaid. Refer to OAR 410-120-1210 (General Rules) for information on Division or CCO reimbursement. Statutory/Other Authority: ORS 413.042 Statutes/Other Implemented: ORS 414.025, 414.034, 414.065, 414.329, 414.706 & 414.710 History: DMAP 19-2017, f. & cert. ef. 6-9-17 DMAP 49-2016, f. 7-26-16, cert. ef. 8-1-16 OMAP 57-2004, f. 9-10-04, cert. ef. 10-1-04 OMAP 12-2004, f. 3-11-04, cert. ef. 4-1-04 OMAP 36-1999, f. & cert. ef. 10-1-99 HR 11-1992, f. & cert. ef. 4-1-92 HR 5-1991, f. 1-18-91, cert. ef. 2-1-91
410-129-0180 Procedure Codes (1) Procedure codes listed in the Speech-Language Pathology, Audiology and Hearing Aid Services Program rules are intended for use by licensed speech-language pathologists, licensed audiologists, and certified hearing aid dealers. (2) Physicians and nurse practitioners are subject to the administrative rules contained in the Division Medical-Surgical Services Program rules and shall bill the Division using the processes and procedure codes identified in those rules. [Publications: Publications referenced are available from the agency.] Statutory/Other Authority: ORS 413.042 Statutes/Other Implemented: ORS 414.025 & 414.065 History: DMAP 49-2016, f. 7-26-16, cert. ef. 8-1-16 HR 27-1993, f. & cert. ef. 10-1-93 HR 5-1991, f. 1-18-91, cert. ef. 2-1-91
410-129-0220 Augmentative Communications System or Device (1) Augmentative Communications System or Device and the necessary attachment equipment to bed or wheelchair are a covered benefit of the Division. (2) The requested system or device shall be approved, registered, or listed as a medical device with the Food and Drug Administration. (3) Criteria for coverage: Providers shall meet each of the following components and submit documentation to the Division with claims subject to PPR and with PA request for review: (a) A physician’s statement of diagnosis and medical prognosis (not a prescription for an augmentative device) documenting the inability to use speech for effective communication as a result of the diagnosis; (b) Reliable cognitive ability and a consistent motor response to communicate that can be measured by standardized or observational tools: (A) Object permanence – ability to remember objects and realize they exist when they are not seen; and (B) Means end – ability to anticipate events independent of those currently in progress – the ability to associate certain behaviors with actions that will follow. (c) The client shall be assessed by a SLP and when appropriate an occupational therapist or physical therapist. The evaluation report shall include: (A) A completed OHA 3047 form: Augmentative Communication Device Selection Report Summary (page 1) and required elements of the Formal Augmentative/Alternative Communication Evaluation (page 2). Attach additional pages required to complete information requested; (B) An explanation of why this device is best suited for this client and why the device is the lowest level that will meet basic functional communication needs; (C) Evidence of a documented trial of the selected device and a report on the client’s success in using this device; and (D) A therapy treatment plan with the identification of the individual responsible to program the device and monitor and reevaluate on a periodic basis. (d) Providers send requests for augmentative communications systems or devices to the Division; and (e) The manufacturer’s MSRP and the vendor’s acquisition cost quotations for the device shall accompany each request including where the device is to be shipped. (4) The Division shall reimburse for the lowest level of service that meets the medical need. Statutory/Other Authority: ORS 413.042 Statutes/Other Implemented: ORS 413.042 & 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 49-2016, f. 7-26-16, cert. ef. 8-1-16 DMAP 3-2011, f. 3-23-11, cert. ef. 3-25-11 DMAP 26-2010(Temp), f. 9-24-10, cert. ef. 10-1-10 thru 3-25-11 OMAP 59-2003, f. 9-5-03, cert. ef. 10-1-03 OMAP 38-2000, f. 9-29-00, cert. ef. 10-1-00 OMAP 36-1999, f. & cert. ef. 10-1-99 HR 36-1994, f. 12-30-94, cert. ef. 1-1-95 HR 11-1992, f. & cert. ef. 4-1-92 HR 5-1991, f. 1-18-91, cert. ef. 2-1-91 HR 40-1990(Temp), f. & cert. ef. 11-15-90
410-129-0260 Hearing Aids and Hearing Aid Technical Service and Repair (1) The provider shall bill the Division for hearing aids at the provider’s acquisition cost and shall be reimbursed at that rate. For purposes of this rule, acquisition cost is defined as the actual dollar amount paid by the provider to purchase the item directly from the manufacturer or supplier plus any shipping or postage. (2) The provider shall submit history of hearing aid use and an audiogram when requesting Prior Authorization (PA) for hearing aids. (3) Procedure codes are the following: (a) 92594 – Electroacoustic evaluation for hearing aid, monaural; (b) 92595 – Electroacoustic evaluation for hearing aid, binaural; (c) 92596 – Ear protector eval, measurement of adequacy of hearing protection device; (d) V5014 – Repair/modification of hearing aid, requires PA; (e) V5266 – Hearing aid batteries, limited to 60 individual batteries per calendar year; (f) V5264 – Ear mold/insert, not disposable, any type, requires PA; (g) V5274 – Assistive listening device, not otherwise specified, requires PA; (h) V5030 – Hearing aid, monaural, body worn, air conduction, requires PA; (i) V5040 – Hearing aid, monaural, body worn, bone conduction, requires PA; (j) V5050 – Hearing aid, monaural, in the ear, requires PA; (k) V5060 – Hearing aid, monaural, behind the ear, requires PA; (L) V5130 – Hearing aid, binaural, in the ear, requires PA; (m) V5140 – Hearing aid, binaural, behind the ear, requires PA; (n) V5171 – Hearing aid, contralateral routing device, monaural, ITE, requires PA; (o) V5180 – Hearing aid, contralateral routing device, monaural, BTE, requires PA; (p) V5211 – Hearing aid, contralateral routing system, binaural, ITE- requires PA; (q) V5221 – Hearing aid, contralateral routing system, binaural, BTE- requires PA; (r) V5246 – Hearing aid, digitally programmable analog, monaural, ITE, requires PA; (s) V5247 – Hearing aid, digitally programmable analog, monaural, (BTE) requires PA; (t) V5252 – Hearing aid, digital programmable, binaural, ITE, requires PA; (u) V5253 – Hearing aid, digital programmable, binaural, BTE, requires PA; (v) V5256 – Hearing aid, digital, monaural, ITE, requires PA; (w) V5257 – Hearing aid, digital, monaural, BTE, requires PA. Statutory/Other Authority: ORS 413.042 Statutes/Other Implemented: ORS 414.025 & ORS 414.065 History: DMAP 93-2023, amend filed 12/21/2023, effective 01/01/2024 DMAP 44-2019, amend filed 11/06/2019, effective 11/14/2019 DMAP 102-2018, amend filed 12/13/2018, effective 12/13/2018 DMAP 100-2018, amend filed 11/06/2018, effective 11/06/2018 DMAP 49-2016, f. 7-26-16, cert. ef. 8-1-16 OMAP 18-2006, f. 6-12-06, cert. ef. 7-1-06 OMAP 12-2004, f. 3-11-04, cert. ef. 4-1-04 OMAP 22-2003, f. 3-26-03, cert. ef. 4-1-03 OMAP 1-2003, f. 1-31-03, cert. ef. 2-1-03 OMAP 10-2002, f. & cert. ef. 4-1-02 OMAP 39-2001, f. 9-24-01, cert.e f. 10-1-01 OMAP 20-2001, f. 3-30-01, cert. ef. 4-1-01 OMAP 38-2000, f. 9-29-00, cert. ef. 10-1-00 OMAP 36-1999, f. & cert. ef. 10-1-99 HR 27-1993, f. & cert. ef. 10-1-93 HR 11-1992, f. & cert. ef. 4-1-92 HR 5-1991, f. 1-18-91, cert. ef. 2-1-91
410-130-0000 Foreword (1) The Division Medical-Surgical Services rules are designed to assist medical-surgical providers to deliver medical services and prepare health claims for clients with Medical Assistance Program coverage. Providers must follow the Division rules in effect on the date of service. (2) The Division enrolls only the following types of providers as performing providers under the Medical-Surgical program: (a) Doctors of medicine, osteopathy and naturopathy; (b) Podiatrists; (c) Acupuncturists; (d) Licensed Physician associates; (e) Nurse practitioners; (f) Laboratories; (g) Family planning clinics; (h) Social workers (for specified services only); (i) Licensed Direct entry midwives; (j) Portable x-ray providers; (k) Ambulatory surgical centers; (l) Chiropractors; (m) Licensed Dieticians (for specified service only); (n) Registered Nurse First Assistants; (o) Certified Nurse Anesthetists; (p) Clinical Pharmacists; (q) Birthing Centers; (r) Licensed Genetic Counselor. (3) For clients enrolled in a managed care plan, contact the client's plan for coverage and billing information. (4) The Medical-Surgical Services rules contain information on policy, special programs, prior authorization, and criteria for some procedures. All Division rules are intended to be used in conjunction with the General Rules for Oregon Medical Assistance Programs (OAR 410 division 120) and the Oregon Health Plan (OHP) Administrative Rules (OAR 410 division 141). (5) The Health Services Commission's Prioritized List of Health Services is found on their website at: www.oregon.gov/OHA/HPA/CSI-Herc/Pages/Prioritized-List.aspx. Statutory/Other Authority: ORS 413.042 & 676.730 Statutes/Other Implemented: ORS 414.025 & 414.065 History: DMAP 12-2025, minor correction filed 01/09/2025, effective 01/09/2025 DMAP 51-2023, amend filed 06/30/2023, effective 06/30/2023 DMAP 47-2018, minor correction filed 05/25/2018, effective 05/25/2018 DMAP 43-2011, f. 12-21-11, cert. ef. 1-1-12 DMAP 19-2008, f. 6-13-08, cert. ef. 7-1-08 OMAP 13-2004, f. 3-11-04, cert. ef. 4-1-04 OMAP 40-2001, f. 9-24-01, cert. ef. 10-1-01 OMAP 31-2000, f. 9-29-00, cert. ef. 10-1-00 HR 23-1997, f. & cert. ef. 10-1-97 HR 6-1994, f. & cert. ef. 2-1-94 HR 10-1990, f. 3-30-90, cert. ef. 4-1-90, Renumbered from 461-014-0500 AFS 48-1989, f. & cert. ef. 8-24-89, Renumbered from 461-014-0001 AFS 5-1989(Temp), f. 2-9-89, cert. ef. 3-1-89 AFS 50-1986, f. 6-30-86, cert. ef. 8-1-86 AFS 27-1982, f. 4-22-82 & AFS 51-1982, f. 5-28-82, cert. ef. 5-1-82 for providers located in the geographical areas covered by the AFS branch offices located in North Salem, South Salem, Dallas, Woodburn, McMinnville, Lebanon, Albany and Corvallis, cert. ef. 6-30-82 for remaining AFS Branch offices AFS 36-1981, f. 6-29-81, cert. ef. 7-1-81 PWC 868, f. 12-30-77, cert. ef. 2-1-78
410-130-0225 Teaching Physicians (1) Supervising faculty physicians in a teaching hospital may not bill the Division of Medical Assistance Programs (Division) on a CMS-1500 or 837P when serving as an employee of the hospital during the time the service was provided or when the hospital reports the service as a direct medical education cost on the Medicare and Division cost report. (2) For requirements for the provision of services, including documentation requirements, follow Medicare guidelines for Teaching Physician Services. Statutory/Other Authority: ORS 413.042 Statutes/Other Implemented: ORS 414.025 & 414.065 History: OMAP 26-2006, f. 6-14-06, cert. ef. 7-1-06 OMAP 69-2003, f. 9-12-03, cert. ef. 10-1-03, Renumbered from 410-130-0370 OMAP 31-2000, f. 9-29-00, cert. ef. 10-1-00 OMAP 3-1998, f. 1-30-98, cert. ef. 2-1-98 HR 6-1994, f. & cert. ef. 2-1-94 HR 40-1992, f. 12-31-92, cert. ef. 2-1-93
410-130-0230 Administrative Medical Examinations and Reports (1) This rule does not apply to Managed Health Care plans. (2) These services are covered only when requested by an CAF, APD, AMH, OYA, Child Welfare branch office or approved by the Division of Medical Assistance Programs (Division). The branch office may request an administrative medical examination or a medical report (DMAP 729) to establish client eligibility for an assistance program or casework planning. (3) See the Administrative Examination and Report Billing rule for complete billing instructions. [Publications: Publications referenced are available from the agency.] Statutory/Other Authority: ORS 413.042 Statutes/Other Implemented: ORS 414.025 & 414.065 History: HR 4-1997, f. 1-31-97, cert. ef. 2-1-97 HR 10-1996, f. 5-31-96, cert. ef. 6-1-96 HR 6-1994, f. & cert. ef. 2-1-94 HR 36-1992, f. & cert. ef. 12-1-92
410-130-0368 Anesthesia Services (1) Anesthesia is not covered for procedures that are below the funding line on the Health Services Commission’s Prioritized List of Health Services (see OAR 410-141-0520). (2) Effective January 1, 2012 all anesthesia claims submitted must be billed in minutes only. This includes; (a) Claims for services provided prior to 1/1/12 that are submitted for the first time in 2012; (b) Resubmitted unpaid claims for services provided prior to 1/1/12; and (c) Adjustments made to claims for services performed prior to 1/1/12. Units must be converted by the provider from units to minutes. (3) Qualifier MJ (indicating minutes) must be added to all claims; (a) Claims with qualifier UN (indicating units) will be denied; and (b) Claims without a qualifier will be denied. (4) Reimbursement is based on the base units assigned to each anesthesia code listed in the current American Society of Anesthesiology Relative Value Guide plus one unit per each 15 minutes of anesthesia time, except for anesthesia for neuraxial labor analgesia/anesthesia/anesthesia (code 01967). See (5) below for reimbursement of neuraxial labor analgesia/anesthesia. (a) The Division of Medical Assistance Programs (Division) will automatically calculate payment by adding the base units of the billed anesthesia code plus a unit per each 15 minutes of anesthesia time; (b) Reimbursement will be made at a fraction of a unit for the last 1-14 minutes of anesthesia time; (c) Do not add base units in addition to minutes. (5) Anesthesia for neuraxial labor analgesia/anesthesia (code 01967) will be paid at a flat rate regardless of the units billed. (6) Reimbursement for qualifying circumstances codes 99100-99140 and modifiers P1-P6 is bundled in the payment for codes 00100-01999. Do not add charges for 99100-99140 and modifiers P1-P6 in charges for 00100-01999. (7) A valid consent form is required for all hysterectomies and sterilizations. (8) If prior authorization (PA) was not obtained for a procedure that requires PA, then the anesthesia services may not be paid. Refer to OAR 410-130-0200 PA Table 130-0200-1. (9) Anesthesia services are not payable to the provider performing the surgical procedure except for moderate (conscious) sedation. (10) Moderate (conscious) sedation must be billed with codes 99143-99150. [ED. NOTE: Tables referenced are available from the agency.] Statutory/Other Authority: ORS 413.042 Statutes/Other Implemented: ORS 414.025 & 414.065 History: DMAP 43-2011, f. 12-21-11, cert. ef. 1-1-12 DMAP 5-2007, f. 6-14-07, cert. ef. 7-1-07 OMAP 8-2005, f. 3-9-05, cert. ef. 4-1-05
410-130-0562 Abortion For medically induced abortions by oral ingestion of medication use S0199 for all visits, counseling, lab tests, ultrasounds, and supplies. S0199 is a global package except for medication: (1) Bill medications with codes S0190-S0191 and appropriate HCPCS codes. (2) For surgical abortions use CPT codes 59840 through 59857: (3) For services related to surgical abortion such as lab, ultrasound and pathology bill separately. Add modifier U4 (a Division of Medical Assistance Programs (Division) modifier) for surgical abortion related services. (4) Use the most appropriate ICD-10 diagnosis code. Statutory/Other Authority: ORS 413.042 Statutes/Other Implemented: ORS 414.025 & 414.065 History: DMAP 51-2015, f. 9-22-15, cert. ef. 10-1-15 OMAP 69-2003, f. 9-12-03, cert. ef. 10-1-03 OMAP 23-2003, f. 3-26-03, cert. ef. 4-1-03 OMAP 2-2002, f. 2-15-02, cert. ef. 4-1-02 OMAP 31-2000, f. 9-29-00, cert. ef. 10-1-00 OMAP 3-1998, f. 1-30-98, cert. ef. 2-1-98 HR 4-1997, f. 1-31-97, cert. ef. 2-1-97 HR 10-1996, f. 5-31-96, cert. ef. 6-1-96 HR 42-1994, f. 12-30-94, cert. ef. 1-1-95 HR 6-1994, f. & cert. ef. 2-1-94 HR 23-1992, f. 7-31-92, cert. ef. 8-1-92 HR 8-1992, f. 2-28-92, cert. ef. 3-1-92 HR 43-1991, f. & cert. ef. 10-1-91 HR 19-1991, f. 4-12-91, cert. ef. 5-1-91