justicedao/ipfs_state_laws huggingface dataset:
410-145-0000 Definitions As used in this division unless the context requires otherwise: (1) “Board of governors” means the governors of a cooperative program as described in OAR 410-145-0020. (2) “Cooperative program” means a program among two or more health care providers for the purpose of providing heart and kidney transplant services including, but not limited to, the sharing, allocation and referral of physicians, patients, personnel, instructional programs, support services, facilities, medical diagnostic, laboratory or therapeutic services, equipment, devices or supplies, and other services traditionally offered by health care providers. (3) “Director” means the Director of the Department of Human Services. (4) “Health care provider” means a hospital, physician or entity, a significant part of whose activities consist of providing hospital or physician services in this state. For purposes of the immunities provided under ORS 442.700 to 442.760 and 646.740, “health care provider” includes any officer, director, trustee, employee, or agent of, or any entity under common ownership and control with, a health care provider. (5) “Hospital” means a health care facility defined in ORS 442.015(14)(a) to (d) and licensed under 441.015–441.097 and includes community health programs established under 430.610–430.700. In other words, as used in this division the term “hospital” includes health care facilities licensed as hospitals, special inpatient care facilities, skilled and intermediate long-term care facilities, and ambulatory surgical centers. It also includes community mental health and developmental disabilities programs established under ORS 430.610 to 430.700. It does not include establishments furnishing primarily domiciliary care. (6) “Order” means a decision issued by the director under OAR 410-145-0010 either approving or denying an application for a cooperative program and includes modification of an original order under 410-145-0040(3)(b) and orders under 410-145-0060(1) and (4). (7) “Party to a cooperative agreement” or “party” means an entity that enters into the principal agreement to establish a cooperative program and applies for approval under this division and any other entity that, with the approval of the director, becomes a member of the cooperative program. (8) “Physician” means a physician defined in ORS 677. 010(12) and licensed under ORS Chapter 677. (9) “Urban area” means a Metropolitan Statistical Area as defined by the federal Bureau of the Census. Statutory/Other Authority: ORS 413.042, 442.700 & 442.755 Statutes/Other Implemented: ORS 413.042 History: HR 16-1994, f. & cert. ef. 3-31-94
410-145-0020 Board of Governors (1) If the director issues an order approving an application for a cooperative program under OAR 410-145-0010, the director shall establish a board of governors to govern the cooperative program. The board of governors shall not constitute, for any purpose, a governmental agency. (2) The board of governors shall consist of the president or other chief executive officer of each health care provider that is a party to the cooperative program agreement and the director or a designee of the director. The designee shall serve at the pleasure of the director. The designee shall not have any economic or other interest in any of the health care providers associated with the cooperative program. (3) In governing the cooperative program, the board of governors shall develop policy and approve budgets for the implementation of the cooperative program. (4) The director or designee of the director may reject any operating or capital budget of the cooperative program upon a finding by the director that the budget is not consistent with the goals listed in OAR 410-145-0010(2)(E) that the cooperative program is expected to achieve. Statutory/Other Authority: ORS 413.042, 442.720 & 442.755 Statutes/Other Implemented: ORS 413.042 History: HR 16-1994, f. & cert. ef. 3-31-94
410-145-0030 Annual Report Not later than 60 days following each anniversary date of the director’s approval of a cooperative program, the board of governors of the cooperative program shall deliver four copies of an annual report to the director, accompanied by a review fee of $16,000. The report shall specifically describe: (1) How heart and kidney transplant services and related services of the cooperative program are being provided in accordance with the order; (2) Which of the goals identified in the order are being achieved and to what extent; and (3) Any substantial changes in the cooperative program. (4) If the cooperative program does not include both heart and kidney transplant services, the annual report will describe any efforts that have been made by the parties over the previous year to provide for inclusion of both heart and kidney transplants in the cooperative program, and will describe what the parties will do to work towards inclusion of such services in the future. The annual report must describe the ongoing efforts being made and any planned efforts for including both heart and kidney transplant services in the cooperative program. Statutory/Other Authority: ORS 413.042, 442.725 & 442.755 Statutes/Other Implemented: ORS 413.042 History: HR 16-1994, f. & cert. ef. 3-31-94
410-145-0040 Review and Evaluation of Annual Report (1) The director shall review and evaluate the annual report delivered under OAR 410-145-0030. The director shall: (a) Determine the extent to which the cooperative program is achieving the goals identified in the order; (b) Review the activities being conducted to achieve the goals; and (c) Determine whether each of the activities is still necessary and appropriate to achieve the goals. (2) If the director determines that additional information is needed for the review described in section (1) of this rule, the director may order the board of governors to provide the information within a specified time. Such an order shall be issued no later than 14 days after receipt of the cooperative program’s annual report. (3) Within 60 days after receiving the annual report or any additional information ordered under section (2) of this rule, the director shall: (a) Approve the report if the director determines that the cooperative program is operating in accordance with the order and that the goals identified in the order are being adequately achieved by the cooperative program; (b) Modify the order as appropriate to adjust to changes in the cooperative program approved by the director and approve the report as provided in subsection (a) of this section; (c) Order the board of governors to make remedial changes in anticompetitive activities not in compliance with the order and request the board of governors to report on progress not later than a deadline specified by the director; (d) Revoke approval of the cooperative program; or (e) Take any of the action set forth in OAR 410-145-0060. Statutory/Other Authority: ORS 413.042, 442.730 & 442.755 Statutes/Other Implemented: ORS 413.042 History: HR 16-1994, f. & cert. ef. 3-31-94
410-145-0050 Complaint Procedure (1) Any person may file a complaint with the director requesting that a specific decision or action of a cooperative program supervised by the director be reversed or modified, or that approval for all or part of the activities permitted by the order be suspended or terminated. The complaint shall allege the reasons for the requested action and shall include any evidence relating to the complaint. (2) The director on the director’s own initiative may at any time request information from the board to governors concerning the activities of the cooperative program to determine whether the cooperative program is in compliance with the order. Statutory/Other Authority: ORS 413.042, 442.735 & 442.755 Statutes/Other Implemented: ORS 413.042 History: HR 16-1994, f. & cert. ef. 3-31-94
410-145-0060 Action on Complaints (1) During the review of the annual report described in OAR 410-145-0040, after receiving a complaint under 410-145-0050, or on the director’s own in initiative, the director may take one or more of the following actions: (a) If the director determines that a particular decision or action is not in accordance with the order, or that the parties are engaging in anticompetitive activity not permitted by the order, the director may direct the board of governors to identify and implement corrective action to insure compliance with the order or may modify the order. (b) If the director determines that the coopera-tive program is engaging in unlawful activity not permitted by the order or is not complying with the directive given under subsection (a) of this section, the director may serve on the cooperative program a proposed order directing the cooperative program to: (A) Conform with the directive under sub-section (a) of this section; or (B) Cease and desist from engaging in the activity. (2) The cooperative program shall have up to 30 days to comply with a proposed order under subsection (1)(b) of this rule, counted from the order’s date of issuance, unless the board of governors demonstrates to the director’s satisfaction that additional time is need for compliance. (3) If the director determines that the participants in the cooperative program are in substantial noncompliance with the cease and desist directive, the director may seek an appropriate injunction in the circuit courts of Marion or Multnomah Counties. (4) If the director determines that a sufficient number of goals set forth in OAR 410-145-0010(2)(e) are not being achieved or that the cooperative program is engaging in activity not permitted by the order, the director may suspend or terminate approval for all or part of the activities approved and permitted by the order. (5) A proposed order to be entered under subsection (1)(b) or section (4) of this rule may be served upon the cooperative program without prior notice. The cooperative program may contest the proposed order by filing a written request for a contested case hearing with the director not later than 20 days following the date of the proposed order. The proposed order shall become final if no request for a hearing is received. Unless inconsis-tent with this section, the provisions of ORS 183.310–183.550, as applicable, shall govern the hearing procedure and any judicial review. (6) The only effect of an order suspending or terminating approval under ORS 442.700–442.760 shall be to withdraw the immunities granted under 442.715(3) for anticompetitive activity permitted by the order and taken after the effective date of the order. Statutory/Other Authority: ORS 442.740 & 442.755 Statutes/Other Implemented: ORS 413.042 History: HR 16-1994, f. & cert. ef. 3-31-94
410-145-0070 Confidentiality of Information (1) If parties to a cooperative program agreement provide the director with written or oral information that is confidential or otherwise protected from disclosure under Oregon law, the disclosures shall not be considered a waiver of any right to protect the information from disclosure in other proceedings. (2) The parties to a cooperative agreement shall specifically identify to the director any information that meets the requirements of section (1) of this rule, and the director shall considered only information that has been so identified by the parties to be confidential. The director will make the decision as to whether such information is in fact protected from disclosure under Oregon law. The director shall inform the party who submitted the information of any decisions regarding its confidentiality. Information which has been found to be subject to disclosure under Oregon law may be released by the director to any requesting persons subject to the provisions of ORS 192.410–192.505. Statutory/Other Authority: ORS 413.042, 442.750 & 442.755 Statutes/Other Implemented: ORS 413.042 History: HR 16-1994, f. & cert. ef. 3-31-94
410-145-0080 Reconsideration and Judicial Review (1) Orders, modifications of orders, findings and directives issued under OAR 410-145-0010, 410-145-0040(3), or 410-145-0060(1)(a) are subject to reconsideration and stay under the procedures provided in 137-003-0080 through 137-003-0092. (2) Notwithstanding the provisions of ORS 183.310(6) and 183.480, only a party to a cooperative program agreement or the director shall be entitled to a contested case hearing, reconsideration, or judicial review of an order issued pursuant to 442.700 to 442.760. (3) The director may recover any expenses incurred in the conduct of any hearing under this rule, including hearing officer and court reporter fees and the director’s legal expenses, through an assessment on other parties to the hearing. Statutory/Other Authority: ORS 413.042, 442.710, 442.730, 442.740 & 442.755 Statutes/Other Implemented: ORS 413.042 History: HR 16-1994, f. & cert. ef. 3-31-94
410-146-0000 Foreword (1) The Health Systems Division (Division) American Indian/Alaska Native (AI/AN) Oregon Administrative Rules are designed to assist the following providers to prepare claims for services provided to clients with Medical Assistance Program coverage: (a) Indian Health Service (IHS) facilities; and (b) Tribal 638 facilities, defined as Tribally-operated health care clinics owned or operated by a Tribe or Tribal organization with funding authorized by Title I or Title V of the Indian Self-Determination and Education Assistance Act (Public Law 93-638, as amended), and recognized by the Centers for Medicare and Medicaid Services (CMS) under the 1996 Memorandum of Agreement (MOA); (2) Indian Health Care Providers (IHCP) not designated an IHS or Tribal 638 facility should refer to Oregon Health Plan (OHP) General Rules (OAR 410 division 120) and other applicable program-specific rules to enroll and operate as any other provider type recognized under the state plan. (3) CMS does not recognize Urban Indian Health Program (UIHP) clinics as eligible for reimbursement of services under the MOA. UIHP Clinics should refer to: (a) Federally Qualified Health Centers (FQHC) and Rural Health Clinics administrative Rules (OAR 410 division 147) to enroll as a FQHC if the clinic is an urban Indian organization under the Indian Health Care Improvement Act, Public Law 94-437; or (b) OHP General Rules (OAR 410 division 120) and other applicable program-specific rules to enroll and operate as any other provider type recognized under the state plan. (4) The AI/AN administrative rules include important information about general program policy, provider enrollment, maintenance of financial records, special programs, and billing. Unless specifically directed by the AI/AN rules, do not use other Division administrative rules to determine appropriate action. (5) OHP-enrolled IHCP must use the OHP General Rules (OAR 410 division 120) and the OHP Administrative Rules (OAR 410 Division 141) as directed in the AI/AN rules and in conjunction with applicable program-specific rules including the AI/AN administrative rules. (6) The Health Evidence Review Commission's Prioritized List of Health Services defines the Division’s Medicaid-covered services. For more information, refer to the OHP Administrative Rules (OAR 410-141-0520). Statutory/Other Authority: ORS 414.065 Statutes/Other Implemented: ORS 414.065 History: DMAP 42-2017, amend filed 10/03/2017, effective 10/03/2017 DMAP 19-2007, f. 12-5-07, cert. ef. 1-1-08 OMAP 62-2004, f. 9-10-04, cert. ef. 10-1-04 OMAP 59-2002, f. & cert. ef. 10-1-02 OMAP 45-2001, f. 9-24-01, cert. ef. 10-1-01 OMAP 2-1999, f. & cert. ef. 2-1-99
410-146-0040 ICD-10-CM Diagnosis Codes and CPT/HCPCs Procedure Codes (1) The Division requires diagnosis codes on all claims including those submitted by independent laboratories and portable radiology and including nuclear medicine and diagnostic ultrasound providers. A clinic must always provide the client's diagnosis to ancillary service providers when prescribing services, equipment, and supplies. (2) The appropriate ICD-10-CM code must be used to identify: (a) Diagnoses; (b) Symptoms; (c) Conditions; (d) Problems; (e) Complaints; or (f) Other reasons for the encounter/visit. (3) Clinics must list the principal diagnosis in the first position on the claim. Clinics must use the principal diagnosis code for the diagnosis, condition, problem, or other reason for an encounter/visit shown in the medical record to be chiefly responsible for the services provided. Clinics may list up to three additional diagnosis codes on the claim for documented conditions that coexist at the time of the encounter/visit and require or affect client care, treatment, or management. (4) Clinics must list the diagnosis codes using the highest degree of specificity available in the ICD-10-CM. The Division considers a diagnosis code invalid if it has not been coded to its highest specificity. (5) The Division requires providers to use the standardized code sets required by the Health Insurance Portability and Accountability Act (HIPAA) and adopted by CMS. Unless otherwise directed in rule, providers must accurately code claims according to the national standards in effect for the date the service was provided: (a) For dental services, use codes that are in effect for the date the services was provided that are found in Dental Procedures and Nomenclature as maintained and distributed by the American Dental Association; (b) For health care services, use the combination of Health Care Common Procedure Coding System (HCPCS) and Current Procedural Terminology (CPT) codes in effect for the date the services was provided. These services include, but are not limited to, the following: (A) Physician services; (B) Physical and occupational therapy services; (C) Radiology procedures; (D) Clinical laboratory tests; (E) Other medical diagnostic procedures; (F) Hearing and vision services. (6) The Division maintains unique coding and claim submission requirements for Administrative Exams and Death with Dignity services. Refer to OAR 410 division 150, Administrative Examination and Billing Services, and OAR 410-130-0670, Death with Dignity Services for specific requirements. Statutory/Other Authority: ORS 413.042 & ORS 414.065 Statutes/Other Implemented: ORS 414.065 History: DMAP 42-2017, amend filed 10/03/2017, effective 10/03/2017 DMAP 51-2015, f. 9-22-15, cert. ef. 10-1-15 DMAP 41-2008, f. 12-11-08, cert. ef. 1-1-09 DMAP 19-2007, f. 12-5-07, cert. ef. 1-1-08 OMAP 62-2004, f. 9-10-04, cert. ef. 10-1-04 OMAP 68-2003, f. 9-12-03, cert. ef. 10-1-03 OMAP 59-2002, f. & cert. ef. 10-1-02 OMAP 45-2001, f. 9-24-01, cert. ef. 10-1-01 OMAP 6-2001, f. 3-30-01, cert. ef. 4-1-01 OMAP 25-2000, f. 9-28-00, cert. ef. 10-1-00 OMAP 2-1999, f. & cert. ef. 2-1-99
410-146-0060 Prior Authorization (1) Some covered services or items require prior authorization (PA) by the Division before the service may be provided or before payment will be made. Refer to Oregon Administrative Rule (OAR) 410-120-1320 Authorization of Payment. (2) Most Oregon Health Plan (OHP) clients have prepaid health services contracted by the Oregon Health Authority (Authority) through enrollment in a PHP. Refer to OAR 410-120-1140 Verification of Eligibility. (3) An OHP client who is an American Indian or Alaska Native (AI/AN) with proof of Indian heritage is exempt from mandatory enrollment in a PHP and can request disenrollment from a PHP if automatically enrolled. An AI/AN OHP client may choose to remain in the Medicaid fee-for-service (FFS) delivery system for physical, dental, and behavioral health care, including SUD health care and receive services from an Indian Health Service facility, tribal health clinic or program or urban clinic. Refer to OAR 410-141-0060. (4) If a client is enrolled in a PHP there may be PA requirements for some services that are provided through the PHP. The IHCP shall contact the PHP prior to providing services to any: (a) Non-AI/AN OHP clients enrolled in a PHP and with whom the IHCP has a contract to comply with the PHP’s PA requirements or other policies necessary for reimbursement from the PHP. The IHCP must contact the client's PHP for specific instructions; (b) AI/AN OHP client enrolled in a PHP with whom the IHCP does not have a contract to comply with PA requirements in these rules, the General Rules, and applicable Division program rules. (5) If a client receives services on a FFS basis or is an AI/AN PHP-enrolled client with whom the IHCP does not have a contract and plans to bill the Division directly on an FFS basis, a PA may be required from the Division for certain services. An IHCP assumes full financial risk in providing services to a client prior to receiving authorization or in providing services that are not in compliance with Oregon Administrative Rules. (6) If the service or item is subject to PA, the IHCP must follow and comply with PA requirements in these rules, the General Rules, and applicable program rules, including but not limited to: (a) The service is adequately documented (see OAR 410-120-1360, Requirements for Financial, Clinical and Other Records). Providers must maintain documentation in the provider's files to adequately determine the type, medical appropriateness, or quantity of services provided; (b) The services provided are consistent with the information submitted when authorization was requested; (c) The services billed are consistent with the services provided; and (d) The services are provided within the timeframe specified on the authorization of payment document. Statutory/Other Authority: ORS 413.042 & ORS 414.065 Statutes/Other Implemented: ORS 414.065 History: DMAP 42-2017, amend filed 10/03/2017, effective 10/03/2017 DMAP 34-2008, f. 11-26-08, cert. ef. 12-1-08 DMAP 19-2007, f. 12-5-07, cert. ef. 1-1-08 OMAP 68-2003, f. 9-12-03, cert. ef. 10-1-03 OMAP 45-2001, f. 9-24-01, cert. ef. 10-1-01 OMAP 2-1999, f. & cert. ef. 2-1-99
410-146-0075 Client Copayments (1) AI/AN clients who are members of a federally recognized Indian Tribe or Tribal Organization and receive Medicaid-covered services rendered through an IHCP are exempt from copayments. Refer to OAR 410-120-1230 Client Copayment. (2) IHCPs may not charge copayments to eligible non-AI/AN Division clients receiving care at their facility. Statutory/Other Authority: ORS 413.042 & ORS 414.065 Statutes/Other Implemented: ORS 414.065 History: DMAP 42-2017, amend filed 10/03/2017, effective 10/03/2017 DMAP 19-2007, f. 12-5-07, cert. ef. 1-1-08 OMAP 68-2003, f. 9-12-03, cert. ef. 10-1-03 OMAP 3-2003, f. 1-31-03, cert. ef. 2-1-03 OMAP 89-2002, f. 12-24-02, cert. ef. 1-1-03