justicedao/ipfs_state_laws huggingface dataset:
410-150-0010 Definitions (1) Administrative Examination – A medical or psychological evaluation required by the Department of Human Services (DHS), Oregon Health Authority (OHA), or Oregon Youth Authority (OYA) to assist in determining eligibility and for casework planning for various programs. An evaluation must be written and must contain a diagnosis, prognosis, and supporting objective findings. Functional impairments and expected duration of impairment must be included. (2) Administrative Medical Reports -- Copies of existing records from a specified date. Progress notes, laboratory tests, x-ray reports, special test results and copies of other pertinent records must be included. (3) Good Cause – Circumstances beyond a person’s control, or if a serious illness or death, medical, mental or emotional, learning or language impairment impeded ability to comply with necessary actions timely. 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
410-150-0040 Request Requirements (1) A completed OHP 729 Administrative Medical Examination/Report Authorization is the prior authorization needed to perform an administrative examination, complete supplemental forms, or send copies of records. (a) Only the version of the OHP 729 series that is current as of the date of request is valid. The current OHP 729 series is available online at https://www.oregon.gov/oha/HSD/OHP/Pages/Policy-Admin-Exam.aspx. (b) Only an employee of the Department of Human Services (DHS) or Oregon Youth Authority (OYA), or the Division (OHA) may complete the OHP 729. (c) Providers must keep a copy of the OHP 729 for seven years. (2) There are a series of OHP 729 forms that may or may not be necessary to complete. Always follow the instructions on the OHP 729. (3) Examinations are only to be completed by the provider type listed on the Administrative Exam and Report Codes table found at https://www.oregon.gov/oha/HSD/OHP/Pages/Policy-Admin-Exam.aspx. (4) An administrative medical examination or report requested must be in compliance with the policies outlined in the Division worker guide found at https://www.oregon.gov/oha/HSD/OHP/Pages/Policy-Admin Exam.aspx. (5) Claims may only be submitted by a Division-enrolled provider who: (a) Is contracted with DHS, OYA or the Division to provide Administrative Medical Examinations and Reports; (b) Meets acceptable source criteria for the agency making the request; and (c) Has received a completed OHP 729 form. (6) Providers may only perform the services included on the OHP 729 as requested by a DHS, OYA or Division employee. Providers must: (a) Provide the requested report within 15 days, as noted on the OHP 729, unless there is good cause for a delay. (b) Follow the instructions for all forms received in the OHP 729 series, and (c) Keep a copy of the OHP 729 for seven years. (7) Individuals needing an Administrative Exam who do not have other means of transportation, may use Non-Emergent Medical Transportation (NEMT). Authorizing staff must follow the NEMT Worker Guide, policies and associated rules in Oregon Administrative Rules 410-136. Statutory/Other Authority: ORS 413.042 Statutes/Other Implemented: ORS 414.065 History: DMAP 15-2020, temporary amend filed 03/26/2020, effective 03/26/2020 through 09/21/2020 DMAP 41-2019, amend filed 10/01/2019, effective 12/01/2019 DMAP 65-2018, minor correction filed 05/25/2018, effective 05/25/2018 DMAP 46-2012, f. 10-11-12, cert. ef. 10-15-12 OMAP 22-2003, f. 3-26-03, cert. ef. 4-1-03 OMAP 27-2000, f. 9-28-00, cert. ef. 10-1-00
410-150-0070 Billing Instructions for Administrative Examinations (1) When an examination is needed, administrative examination codes are authorized by the branch office. (2) Medical and ancillary services providers must bill using the Provider Web Portal at https://www.or-medicaid.gov or on a CMS-1500, mailed to the address listed on the OHP 729 at https://www.oregon.gov/oha/HSD/OHP/Pages/Policy-Admin-Exam.aspx. (3) Hospital services must be billed on a UB-04. (4) Record copying fees imposed by a copy service provider must be billed on a CMS – 1500. (5) For Administrative Examination billing, the following are required on the appropriate billing form: (a) The procedure codes specified on the OHP 729; (b) The diagnosis code Z02.89. 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
410-150-0090 Billing Instructions - Licensed Polygraphist (1) Billing for licensed polygrapher services must be submitted using the Provider Web Portal at https://www.or-medicaid.gov or on a CMS-1500, mailed to the address listed on the OHP 729. (2) A polygraph does not qualify as a health care service, therefore it is not subject to Health Insurance Portability and Accountability Act (HIPAA) regulations. 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
410-151-0000 Early and Periodic Screening, Diagnostic and Treatment Program (1) The Early and Periodic Screening, Diagnostic and Treatment (EPSDT) program offers comprehensive and preventive health care services to EPSDT Beneficiaries in accordance with 42 CFR § 441 Subpart B . EPSDT provides EPSDT Medically Necessary and EPSDT Medically Appropriate Medicaid-covered services to treat any physical, dental, vision, developmental, nutritional, and mental and behavioral health conditions. Coverage for EPSDT Beneficiaries includes all services coverable under the Oregon Health Plan (OHP), when EPSDT Medically Necessary and EPSDT Medically Appropriate for the EPSDT Beneficiary. (2) The EPSDT rules in this division relating specifically to the provision of OHP services for EPSDT Beneficiaries take precedence over any and all general rules relating to the provision of OHP services to the general OHP population set forth in Oregon Administrative Rules Chapters 410 and 309. (3) Physicians or other practitioners of the healing arts as defined in OAR 410-120-0000 within the scope of their practice under State law may provide OHP services to EPSDT Beneficiaries. Statutory/Other Authority: ORS 413.042 Statutes/Other Implemented: ORS 414.025, 414.065 & 414.150 History: DMAP 97-2023, adopt filed 12/27/2023, effective 01/01/2024
410-151-0002 Coverage Requirements (1) The coverage requirements for services to EPSDT Beneficiaries set forth in this Rule supersede any other coverage standards or requirements set forth in any other Medical Assistance rules that are applicable to non-EPSDT Beneficiaries, regardless of whether the other standards or requirements conflict or are otherwise inconsistent with the EPSDT coverage requirements in this Rule. (2) The Oregon Health Authority (the Authority) and Managed Care Entities (MCEs) must cover services that are EPSDT Medically Necessary and EPSDT Medically Appropriate (or EPSDT Dentally Appropriate) for EPSDT Beneficiaries, even if: (a) The services are not included or paired on the Prioritized List of Health Services (defined in OAR 410-120-0000); or (b) The service is below the funding line on the Prioritized List of Health Services. (3) The Authority and MCEs may not deny coverage of services for EPSDT Beneficiaries without a case-by-case review for EPSDT Medical Necessity and EPSDT Medical Appropriateness (or EPSDT Dental Appropriateness). It is allowable for services to be denied for EPSDT Beneficiaries after a case-by-case review in which it is determined by the Authority or the MCE that the service is not EPSDT Medically Necessary and EPSDT Medically Appropriate (or EPSDT Dentally Appropriate) for that specific EPSDT Beneficiary. Specific circumstances in which the Authority and MCEs may deny coverage of services for an EPSDT Beneficiary are outlined in a guidance document, effective January 1, 2023, available at https://www.oregon.gov/oha/hsd/ohp/pages/epsdt.aspx. (4) The Authority and MCEs must cover Durable Medical Equipment for EPSDT Beneficiaries in accordance with sections (1) through (3) of this rule and OAR 410-122-0010 through OAR 410-122-0720. (5) Providers must not refuse to render or refer for EPSDT Medically Necessary and EPSDT Medically Appropriate (or EPSDT Dentally Appropriate) care. Coverage decisions must be made by the Authority or the MCE in accordance with the requirements in sections (1) through (4) of this rule and any denial of coverage must be provided in writing by the Authority or the MCE in accordance with the requirements in OAR 410-151-0007. Statutory/Other Authority: ORS 413.042 Statutes/Other Implemented: ORS 414.025, 414.065 & 414.150 History: DMAP 100-2025, minor correction filed 12/29/2025, effective 12/29/2025 DMAP 97-2023, adopt filed 12/27/2023, effective 01/01/2024
410-151-0003 Utilization Management Requirements (1) The Oregon Health Authority (Authority) and Managed Care Entities (MCEs) do not have the right to pre-establish limits or caps on the amount of services or number of visits covered for EPSDT Beneficiaries. Instead, coverage decisions must be made in accordance with OAR 410-151-0002. However, it is acceptable to establish limits (for example, 10 physical therapy visits) subject to prior authorization for coverage of additional services. (2) The Authority and MCEs do not have the right to require prior authorization for any EPSDT screening services. (3) The Authority and MCEs shall promptly complete prior authorization procedures in accordance with OAR 410-141-3835 and OAR 410-130-0200 and the individual program chapter 410 and 309 OARs as applicable. (4) The Authority and MCEs shall ensure prompt delivery of EPSDT Medically Necessary and EPSDT Medically Appropriate (or EPSDT Dentally Appropriate) services to EPSDT Beneficiaries. Statutory/Other Authority: ORS 413.042 Statutes/Other Implemented: ORS 414.025, 414.065 & 414.150 History: DMAP 97-2023, adopt filed 12/27/2023, effective 01/01/2024
410-151-0004 Temporary rule language in effect until 08/09/2026. Screening Exams (1) Periodic EPSDT screening exams shall be provided in accordance with the Bright Futures Periodicity Schedule (https://downloads.aap.org/AAP/PDF/periodicity_schedule.pdf) and must include: (a) A comprehensive health and developmental history including assessment of both behavioral health and physical health development; (b) Assessment of nutritional status; (c) Comprehensive unclothed physical exam including inspection of teeth and gums; (d) Appropriate immunizations; (e) Lead testing as required by OAR 410-151-0040; (f) Other appropriate laboratory tests (including but not limited to anemia test and sickle cell test) based on age and EPSDT Beneficiary risk; (g) Health education including anticipatory guidance; (h) Appropriate hearing and vision screening; and (i) Dental screening exams for preventative dental care, which must be performed in keeping with section (2) below of this rule. (2) Periodic EPSDT screening exams for preventive dental care shall be provided in accordance with the OHP Dental Periodicity Schedule, found at https://www.oregon.gov/oha/hsd/ohp/pages/policy-dental.aspx. (3) EPSDT providers may bill for both lab and non-lab services using the appropriate Current Procedural Terminology (CPT) and Healthcare Common Procedure Coding System (HCPCS) codes. Immunizations must be billed according to the guidelines listed in OAR 410-130-0255; (4) Inter-periodic EPSDT screening exams are any EPSDT Medically Necessary and EPSDT Medically Appropriate (or EPSDT Dentally Appropriate) encounters with a physician or other licensed practitioner of the healing arts within their scope of practice under State law. Inter-periodic EPSDT exams may occur at any time and may be warranted when the EPSDT Beneficiary has been ill or has experienced a change in health or development. Statutory/Other Authority: ORS 413.042 Statutes/Other Implemented: ORS 414.025, 414.065 & 414.150 History: DMAP 5-2026, temporary amend filed 02/11/2026, effective 02/11/2026 through 08/09/2026 DMAP 114-2024, minor correction filed 07/19/2024, effective 07/19/2024 DMAP 97-2023, adopt filed 12/27/2023, effective 01/01/2024
410-151-0005 Referrals (1) When a medical, behavioral health, nutritional, or dental condition is discovered during the EPSDT screening process, the EPSDT Beneficiary shall be referred to an appropriate provider for further diagnosis and, when EPSDT Medically Necessary and EPSDT Medically Appropriate (or EPSDT Dentally Appropriate), receive treatment. (2) The screening provider shall explain the need for the referral to the EPSDT Beneficiary, and, when applicable, the EPSDT Beneficiary’s parent or guardian. (3) If the EPSDT Beneficiary, EPSDT Beneficiary’s parent, guardian, or legal authority agrees to the referral, the referring provider shall offer assistance in finding an appropriate referral provider and making an appointment. (4) The EPSDT Beneficiary’s MCE or the Authority shall also make available care coordination as needed. Statutory/Other Authority: ORS 413.042 Statutes/Other Implemented: ORS 414.025, 414.065 & 414.150 History: DMAP 97-2023, adopt filed 12/27/2023, effective 01/01/2024
410-151-0006 Transportation and scheduling assistance In accordance with the responsibilities in OAR 410-136-3000 Medical Transportation Services, the Authority or the MCE must offer and provide, when requested by the EPSDT Beneficiary or their parent or guardian: (1) Transportation assistance to covered services; (2) Scheduling assistance for appointments for covered services. Statutory/Other Authority: ORS 413.042 Statutes/Other Implemented: ORS 414.025, 414.065 & 414.150 History: DMAP 97-2023, adopt filed 12/27/2023, effective 01/01/2024
410-151-0007 Notice and hearing requirements. If the Authority or an MCE takes action to deny, suspend, reduce or terminate services for an EPSDT Beneficiary, it must provide the EPSDT Beneficiary, and, as applicable, the EPSDT Beneficiary’s parent or guardian, with a written notice that complies with the requirements in OAR 410-141-3885 and OAR 410-120-1865, which require, without limitation: (1) A statement of the intended action and effective date; (2) The specific reasons and legal support for the action; (3) An explanation of the EPSDT Beneficiary’s appeal and hearing rights; (4) The EPSDT Beneficiary’s rights to representation. Statutory/Other Authority: ORS 413.042 Statutes/Other Implemented: ORS 414.025, 414.065 & 414.150 History: DMAP 97-2023, adopt filed 12/27/2023, effective 01/01/2024
410-151-0008 EPSDT Beneficiary communication requirements The Authority and MCEs must notify EPSDT Beneficiaries and, as applicable, the EPSDT Beneficiary’s parent or guardian, about services covered under EPSDT and how to access them, in accordance with a guidance document which became effective January 1, 2023 and is available at https://www.oregon.gov/oha/hsd/ohp/pages/epsdt.aspx. The notice must comply with the criteria for written materials set forth in OAR 410-141-3585 and be sent to EPSDT Beneficiaries and, as applicable, the EPSDT Beneficiary’s parent or guardian in accordance with the following timelines: (1) Within sixty (60) days of an EPSDT Beneficiary enrolling in Oregon Health Plan (OHP) coverage; (2) Immediately following birth for newborn infants; and (3) Annually for any EPSDT Beneficiary who has not undergone an EPSDT screening or used other OHP services. Statutory/Other Authority: ORS 413.042 Statutes/Other Implemented: ORS 414.025, 414.065 & 414.150 History: DMAP 99-2025, minor correction filed 12/29/2025, effective 12/29/2025 DMAP 97-2023, adopt filed 12/27/2023, effective 01/01/2024
410-151-0040 Lead Screening (1) All children enrolled in the Oregon Health Plan, including Fee-for-Service and MCEs, must have blood lead screening tests. Children with Medical Assistance Program coverage must have blood lead screening tests at age 12 months and 24 months. Any child between ages 24 and 72 months with no record of a previous blood lead screening test must receive one. Completion of a risk assessment questionnaire does not meet the lead screening requirement for children under Medicaid. (2) Method of Blood Collection: A single venous or capillary blood draw is acceptable for the blood lead screening test. A capillary blood lead level greater than or equal to 3.5 micrograms per deciliter must be confirmed with either a venous draw or a second capillary draw within 12 weeks. (3) Blood lead levels greater than or equal to 3.5 micrograms per deciliter from a venous draw or two capillary blood lead tests greater than or equal to 3.5 micrograms per deciliter drawn within 12 weeks of each other in children under 18 years of age and pregnant or lactating women are defined as cases and initiate case management by the local public health authority. See the definition of “Blood lead level at or above the blood lead reference value” in OAR 333-017-0000. (4) Billing of laboratory services is covered in: OAR 410-130-0680. (a) For the collection of blood, use CPT 36415 for a venipuncture sample or CPT 36416 for capillary puncture samples. (b) To bill for venipuncture or capillary blood lead screening, use Current Procedural Terminology (CPT) code 83655. (5) Health care providers shall report all cases or suspected cases when blood lead levels are at or above the blood lead reference value to local public health authority within one working day and within seven days when any blood lead level tests are performed including the result. See OAR 333-018-0015(3)(c)(A); OAR 333-018-0015(3)(d) (6) All children, pregnant and lactating women with lead poisoning are eligible to receive follow up case management services. See OAR 333-019-0000 and Oregon Health Authority Public Health Division’s Oregon Lead Poisoning Investigative Guidelines at: https://www.oregon.gov/oha/PH/HealthyEnvironments/HealthyNeighborhoods/LeadPoisoning/CountyHealthDepartments/Documents/Diseaseguidelines.pdf . (7) The local public health authorities are eligible for investigation reimbursements. To bill for comprehensive lead investigation, use HCPCS code T1029. Payment for code T1029 includes the home investigation and any follow-up case management services provided after the home investigation is completed. The Authority limits reimbursement of T1029 to one time per dwelling. For clients enrolled in Fee-for-Service, the service is payable by the Authority for dates of service through September 30, 2020. Effective October 1, 2020 for members enrolled in managed care plans, the service is payable by the managed care plan. Statutory/Other Authority: ORS 413.042 Statutes/Other Implemented: ORS 414.025, 414.065 & 414.150 History: DMAP 112-2024, adopt filed 07/11/2024, effective 07/11/2024
410-152-0000 Purpose (1) Community Violence Prevention services are evidence-based, trauma-informed, supportive, and non-psychotherapeutic services provided by a certified Violence Prevention Professional. (2) Services are provided within or outside of a clinical setting for the purpose of promoting improved health outcomes and positive behavioral change, preventing injury, recidivism and reducing the likelihood that individuals who are victims of community violence may commit or promote violence themselves. Statutory/Other Authority: Oregon Medicaid State Plan Amendment, 42 C.F.R 440.130 (c), House Bill 4045 & 2022 Legislative Session Statutes/Other Implemented: ORS 413.032, 413.042 & 414.065 History: DMAP 89-2024, adopt filed 05/01/2024, effective 05/01/2024
410-152-0005 Violence Prevention Professional Certification Requirements. To be certified as a Violence Prevention Professional, an individual shall: (1) Be employed by a community-based organization who is enrolled with the Oregon Health Authority as a Medicaid billing provider. The community-based organization must also be affiliated with a licensed hospital in Oregon that authorizes the program to provide community violence prevention services to individuals in the hospital. (2) Complete thirty-five (35) hours of initial training on trauma informed care, de-escalation, conflict mediation, retaliation prevention, case management, victim advocacy and patient privacy with an Oregon Health Authority approved training and certification program for violence prevention professionals in Oregon. (3) Six (6) hours of Oregon Health Authority approved continuing education every two (2) years that must include effects of trauma and violence, trauma-informed care, case management and advocacy, community violence prevention strategies and patient privacy (HIPAA, 45 CFR parts 160 & 164) (4) Have lived experience, either as a victim of a violent injury as a result of community violence or as someone closely impacted by community violence. Statutory/Other Authority: Oregon Medicaid State Plan Amendment, 42 C.F.R 440.130 (c), House Bill 4045 & 2022 Legislative Session Statutes/Other Implemented: ORS 413.032, 413.042 & 414.065 History: DMAP 89-2024, adopt filed 05/01/2024, effective 05/01/2024
410-152-0015 Community Violence Prevention Services. (1) All Community Violence Prevention services provided by a community violence prevention program shall be performed by a certified Violence Prevention Professional. (2) Community Violence Prevention services performed by a certified Violence Prevention Professional, shall be determined to be medically appropriate, medically necessary and appropriate for the individual’s age. Community Violence Prevention services may include based on the individualized plan of care: (a) Conflict mediation; (b) Crisis intervention; (c) Mentorship; (d) Peer support and counseling; (e) Case management; (f) Referrals to certified or licensed health care professionals or social service providers; or (g) Screening services to victims’ community violence. (3) Community Violence Prevention services shall be ordered or referred by a physician or other qualified licensed practitioner of the healing arts and shall be detailed in the individualized plan of care. (4) The type, frequency, and quantity of units of Community Violence Prevention services authorized in the plan of care shall be appropriate for the individual’s age and designed to prevent further impacts of community violence, prevent future community violence, prolong life, and promote the physical and mental health and efficiency, of the individual. (5) Providers are required to provide health care language interpreter services for Medicaid members with Limited English Proficiency (LEP) and communication services for people who are deaf and hard of hearing pursuant to Title VI of the Civil Rights Act, The Americans with Disabilities Act (ADA), ORS 413.550 to 413.558, and subject to the requirements in OAR Chapter 950 Division 50. These services must be provided at no cost to the member. Statutory/Other Authority: Oregon Medicaid State Plan Amendment, 42 C.F.R 440.130 (c), House Bill 4045 & 2022 Legislative Session Statutes/Other Implemented: ORS 413.032, 413.042 & 414.065 History: DMAP 89-2024, adopt filed 05/01/2024, effective 05/01/2024