reglab/statecodes huggingface dataset:
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 123 - DENTAL/DENTURIST SERVICES › Section 410-123-1160 - Prior Authorization

Current through Register Vol. 63, No. 7, July 1, 2024
(1) Health
			 Services Division (Division) prior authorization (PA) requirements. For
			 fee-for-service (FFS) dental members, the following services require PA:
(a) Crowns (porcelain fused to
			 metal/porcelain ceramic);
(b) Crown
			 repair;
(c) Retreatment of previous
			 root canal therapy - anterior;
(d)
			 Complete dentures;
(e) Immediate
			 dentures;
(f) Partial
			 dentures;
(g) Prefabricated post
			 and core in addition to fixed partial denture retainer;
(h) Fixed partial denture repairs;
(i) Skin graft;
(j) Orthodontics (when covered pursuant to
			 OAR 410-123-1260).
(k) Hospital
			 dentistry always requires PA, regardless of the member's enrollment status.
			 Refer to OAR 410-123-1490  for more information;
(l) Oral surgical services require PA when
			 performed in an ambulatory surgical center (ASC) or an outpatient or inpatient
			 hospital setting and related anesthesia, and the current Medical Surgical
			 Services administrative rule OAR 410-130-0200  for information;
(m) Maxillofacial surgeries may require PA in
			 some instances. Refer to the current Medical Surgical Services OAR
			 410-130-0200, for information.
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 123 - DENTAL/DENTURIST SERVICES › Section 410-123-1200 - Services Not Eligible for Separate Reimbursement

Current through Register Vol. 63, No. 7, July 1, 2024
(1) Services considered incidental, integral
			 to the primary service rendered, part of another service, or included in
			 routine post-op or follow-up care are not eligible for separate reimbursement.
			 Participating providers may not balance bill members for these services.
			 Services that are not to be billed separately may be included in the Current
			 Dental Terminology (CDT) codebook and may not be listed as combined with
			 another procedure.
(2) The
			 following services are not eligible for separate reimbursement:
(a) Alveolectomy/Alveoloplasty in conjunction
			 with extractions;
(b) Cardiac and
			 other monitoring;
(c) Caries risk
			 assessment and Documentation;
(d)
			 Curettage and root planing - per tooth is not eligible for separate
			 reimbursement unless the service is significant and separately
			 identifiable;
(e) Diagnostic
			 casts;
(f) Dietary
			 counseling;
(g) Direct pulp
			 cap;
(h) Discing;
(i) Dressing change;
(j) Electrosurgery;
(k) Equilibration;
(l) Gingival curettage - per tooth;
(m) Gingival irrigation;
(n) Gingivectomy or gingivoplasty to allow
			 for access for restorative procedure, per tooth;
(o) Indirect pulp cap;
(p) Local anesthesia;
(q) Medicated pulp chambers;
(r) Occlusal adjustments;
(s) Occlusal analysis;
(t) Odontoplasty;
(u) Oral hygiene instruction;
(v) Periodontal charting, probing;
(w) Post removal;
(x) Polishing fillings;
(y) Post extraction treatment for
			 alveolaritis (dry socket treatment) if done by the provider of the
			 extraction;
(z) Pulp vitality
			 tests;
(aa) Smooth broken
			 tooth;
(bb) Special infection
			 control procedures;
(cc) Surgical
			 procedure for isolation of tooth with rubber dam;
(dd) Surgical splint;
(ee) Surgical stent; and
(ff) Suture removal.
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 123 - DENTAL/DENTURIST SERVICES › Section 410-123-1220 - Coverage According to the Prioritized List of Health Services

Current through Register Vol. 63, No. 7, July 1, 2024
(1) This rule effective on the date stated in
			 OAR 410-141-3830  incorporates by reference the Oregon Health Evidence Review
			 Commission (HERC) Prioritized List of Health Services (The List), funded
			 through line 469 and including all line items, diagnostic and treatment codes,
			 guideline notes, statements of intent, coding specifications and annotations.
			 All material included therein are incorporated in and made part of this rule by
			 this reference, including interim modifications reported as required under ORS
			 414.690(7) and
			 (8).
(a) The
			 Prioritized List of Health Services includes line items consisting of diagnosis
			 and treatment codes that pair together with specific conditions on the same
			 line. Each line has a description of both a condition(s) and treatment for the
			 condition(s). Services on lines 1-469 are covered for OHP Members, with some
			 dental services subject to exclusion for adults age 21 and over. Coverage of
			 these services is included in the benefit package when providers follow The
			 List's code pairing, Guideline Notes, annotations and statements of intent. The
			 Benefit Package also covers additional services described in this
			 rule;
(b) Diagnostic and Preventive
			 Service codes. Approved CDT codes for preventive dental services are included
			 on the funded portion of The Prioritized List of Health Services, and
			 limitations specified in related Guideline Notes. Dental and Oral Health
			 Providers are subject to utilizing The List for procedure and diagnosis code
			 pairing and funding of preventive and diagnostic services. Preventive services
			 include prophylaxis, sealants, fluoride varnish application, caries arresting
			 medicaments, and vaccinations. Diagnostic services include examinations,
			 imaging, oral evaluations, and testing. All diagnosis and preventive service
			 codes are subject to The List Guidelines Notes and limitations found in this
			 rule;
(c) Ancillary service codes.
			 Covered ancillary codes are subject to applicable Ancillary Guidelines on The
			 List. Approved ancillary codes are listed in this rule at OAR
			 410-123-1620;
(d) The List shall be
			 used in conjunction with applicable OHP provisions found in federal and state
			 laws, the State Plan and Oregon's 1115(a) Waiver for coverage of services such
			 as, but not limited to:
(A) Services on
			 unfunded lines for children ages from birth through 1;
(B) Services provided for a condition
			 appearing in the funded region of The List in conjunction with federal
			 requirements for Early and Periodic Screening, Diagnosis and Treatment (EPSDT)
			 and Oregon's 1115(a) Waiver.
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 123 - DENTAL/DENTURIST SERVICES › Section 410-123-1230 - Buying-Up

Current through Register Vol. 63, No. 7, July 1, 2024
(1) Buying-up as
			 defined in OAR 410-120-0000  is prohibited.
(2) Providers are not permitted to bill and
			 accept payment from the Division or an MCE for a covered service when:
(a) A non-covered service has been provided;
			 and
(b) Additional payment is
			 sought or accepted from the member.
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 123 - DENTAL/DENTURIST SERVICES › Section 410-123-1240

Current through Register Vol. 63, No. 7, July 1, 2024
Stat. Auth.: ORS
				  413.042,
				  414.065
Stats. Implemented: ORS
				  414.065
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 123 - DENTAL/DENTURIST SERVICES › Section 410-123-1245

Current through Register Vol. 63, No. 7, July 1, 2024
Statutory/Other Authority: ORS
				  413.042
Statutes/Other Implemented: ORS
				  414.065
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 123 - DENTAL/DENTURIST SERVICES › Section 410-123-1250 - Dental HbA1c Testing

Current through Register Vol. 63, No. 7, July 1, 2024
(1) Hemoglobin
			 A1c is a measure of the amount of glucose attached to red blood cells and
			 directly relates to average blood glucose levels.
(a) Dental HbA1c testing for at risk members
			 is within the scope of dental practice for Oregon licensed oral health
			 providers. Although not presumed to be a standard of care, testing serves as a
			 resource for dentists which supports identification of those members with HbA1c
			 levels that are above the normal range, and that can affect periodontal status,
			 wound healing, infection control and other conditions of the oral
			 environment;
(b) The Authority and
			 the Oregon Board of Dentistry have determined that licensed oral health
			 providers shall refer members, once identified with HbA1c levels above normal
			 range, to their primary care provider for evaluation, diagnosis and
			 treatment.
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 123 - DENTAL/DENTURIST SERVICES › Section 410-123-1260 - OHP Dental Benefits

Current through Register Vol. 63, No. 7, July 1, 2024
(1) This
			 administrative rule aligns with and reflects changes in relation to the
			 American Dental Association (ADA) diagnosis and treatment pairs that are above
			 the funding line and consistent with treatment guidelines on the Health
			 Evidence Review Commission's (HERC) Prioritized List of Health Services
			 (Prioritized List of Health Services or List) found in OAR 410-141-3830  and not
			 otherwise excluded under OAR 410-141-3825.
(2) Early and Periodic Screening, Diagnostic,
			 and Treatment (EPSDT):
(a) Medicaid-eligible
			 participants from birth up through the day before their twenty-first birthday
			 are eligible for the Early and Periodic Screening, Diagnosis, and Treatment
			 (EPSDT) program. This benefit covers age-appropriate screening visits and
			 medically necessary Medicaid-covered services to treat identified physical,
			 dental, developmental, and mental health conditions;
(b) Oregon's Medicaid and CHIP State Plans
			 lists services covered under the OHP benefit package;
(c) For children over age one, Oregon's
			 Medicaid 1115 Demonstration Waiver covers all EPSDT medically necessary
			 services that are included on the prioritized list;
(d) Dental providers shall deliver EPSDT
			 Dental Health Care screening visits and services at age-appropriate intervals
			 following the "Oregon Health Plan (OHP) - Recommended Dental Periodicity
			 Schedule," dated April 1, 2018, incorporated in rule by reference and posted on
			 the Division website in the Dental Services Provider Guide document at:
https://www.oregon.gov/OHA/HSD/OHP/Pages/Policy-Dental.aspx
;
(e) Dental providers shall establish the
			 delivery of routine preventive care services to children referred from primary
			 care providers who deliver Dental screenings and fluoride varnish services in
			 the medical setting;
(f) Prior
			 Authorization and Referral requirements are imposed on medical and dental
			 service Providers under EPSDT. Such requirements are designed as tools for
			 determining a service, treatment or other measure meets the standards in
			 subsection 2(c) of this section. The Authority determines which treatment to
			 cover based upon the Provider's recommendations, current clinical guidance, and
			 availability of equally effective alternative treatments;
(g) Access and services for EPSDT are
			 governed by federal rules at  42 C.F.R., Part 441, Subpart B which were in
			 effect as of January 01, 1998. EPSDT services shall be medically or dentally
			 necessary, and include, but are not limited to:
(A) Dental preventive screening
			 services;
(B) Dental diagnosis and
			 Dentally Necessary treatment that is indicated by screening at as early an age
			 as necessary, needed for relief of pain and infections, restoration of teeth,
			 and maintenance of dental health.
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 123 - DENTAL/DENTURIST SERVICES › Section 410-123-1262 - Dental Administration of Vaccines

Current through Register Vol. 63, No. 7, July 1, 2024
(1) Dental administration of vaccines shall
			 be carried out in compliance with Oregon Board of Dentistry OARs 818-012-0006  and 818-012-0007, OHA Medical/Surgical OAR 410-130-0255  and Vaccines for
			 Children (VFC) - OHA Division 46, OARs 333-046-0110  through
			 333-046-0130.
(2) Requirements for
			 vaccine administration:
(a) The dentist shall
			 have completed a course of training approved by the Oregon Board of
			 Dentistry;
(b) Vaccines shall be
			 administered in accordance with the Model Immunization Protocols approved by
			 the Authority; and
(c) The dentist
			 shall not delegate administration of vaccines to another person.
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 123 - DENTAL/DENTURIST SERVICES › Section 410-123-1265 - Teledentistry

Current through Register Vol. 63, No. 7, July 1, 2024
(1) Teledentistry
			 can take multiple forms, both synchronous and asynchronous, including but not
			 limited to:
(a) Live video, a two-way
			 interaction between a member and dentist using audiovisual
			 technology;
(b) Store and forward,
			 an asynchronous transmission of recorded health information such as
			 radiographs, photographs, video, digital impressions, or photomicrographs
			 transmitted through a secure electronic communication system to a dentist, and
			 it is reviewed at a later point in time by a dentist. The dentist at a distant
			 site reviews the information without the member being present in real
			 time;
(c) Remote member monitoring,
			 where personal health and dental information is collected by dental care
			 providers in one location then transmitted electronically to a dentist in a
			 distant site location for use in care; and
(d) Mobile communication devices such as cell
			 phones, tablet computers, or personal digital assistants may support mobile
			 dentistry, health care, public health practices, and education.
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 123 - DENTAL/DENTURIST SERVICES › Section 410-123-1490 - Hospital Dentistry

Current through Register Vol. 63, No. 7, July 1, 2024
(1) The purpose
			 of hospital dentistry is to provide safe, efficient dental care when providing
			 routine (non-emergency) dental services for (Division) members who present
			 special challenges that require the use of general anesthesia or IV conscious
			 sedation services in an Ambulatory Surgical Center (ASC), inpatient or
			 outpatient hospital setting. Refer to OAR 410-123-1060  for
			 definitions.
(2) Division
			 reimbursement for hospital dentistry is limited to covered services and may be
			 prorated if non-covered dental services are performed during the same hospital
			 visit:
(a) See OAR 410-123-1060  for a
			 definition of Division hospital dentistry services;
(b) Refer to OAR 410-123-1220  for a
			 definition of covered services.
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 123 - DENTAL/DENTURIST SERVICES › Section 410-123-1510 - Additional Dental Care Benefits for Pregnant Members

Current through Register Vol. 63, No. 7, July 1, 2024
(1) This rule sets forth the access standards
			 for dental care for pregnant members who receive Oregon Health Plan (OHP)
			 benefits through the fee-for-service (FFS) delivery system.
(2) Pregnant members shall be seen, treated
			 in person or via teledentistry for an OHP-covered service within the following
			 time frames:
(a) For emergency dental care:
			 within 24 hours;
(b) For urgent
			 dental care: within one week.
(c)
			 For routine dental care: within four weeks, unless there is a documented
			 special clinical reason that would make access longer than four weeks
			 appropriate;
(d) For initial dental
			 screening or examination: four weeks.
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 123 - DENTAL/DENTURIST SERVICES › Section 410-123-1540 - Healthier Oregon Dental Benefits

Current through Register Vol. 63, No. 7, July 1, 2024
(1) The CWM and CWM Plus benefit plan ended
			 on June 30, 2023. See OAR 410-134-0005(2)  for benefit coverage and
			 limitations.
(2) CWM and CWM Plus
			 services delivered on or before June 30, 2023 may be billed in accordance with
			 OAR 410-120-1300. See OAR 410-134-0005(3)  for CWM and CWM Plus billing
			 guidance.
(3) As of July 1, 2022,
			 Healthier Oregon members began receiving the same dental benefits that are
			 included in the OHP Plus benefit package as defined in OAR
			 410-123-1220.
Statutory/Other Authority: ORS
				  413.042,
				  414.025, ORS
				  414.231 & 414.065
Statutes/Other Implemented: ORS
				  414.231,
				  414.065 &
				  414.430
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 123 - DENTAL/DENTURIST SERVICES › Section 410-123-1600

Current through Register Vol. 63, No. 7, July 1, 2024
Stat. Auth.: ORS
				  413.042,
				  414.065,
				  414.725
Stats. Implemented: ORS
				  414.725
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 123 - DENTAL/DENTURIST SERVICES › Section 410-123-1620 - Procedure and Diagnosis Codes

Current through Register Vol. 63, No. 7, July 1, 2024
(1)
			 The Division requires providers to use the standardized code sets adopted by
			 the Health Insurance Portability and Accountability Act (HIPAA) and the Centers
			 for Medicare and Medicaid Services (CMS). Unless otherwise directed in rule,
			 providers shall accurately code claims according to the national standards in
			 effect for the date the service(s) was provided.
(2) Procedure codes:
(a) For dental services, and procedures that
			 are directly related to the teeth and the structures supporting the teeth, use
			 Current Dental Terminology (CDT) codes as maintained and distributed by the
			 American Dental Association. Contact the American Dental Association (ADA) to
			 obtain a current copy of the CDT reference manual.
(b) For physician provided oral health
			 services performed due to an underlying medical condition (i.e., procedures on
			 or in preparation for treatment of the jaw, tongue, cheek, roof of mouth), use
			 Health Care Common Procedure Coding System (HCPCS) and Current Procedural
			 Terminology (CPT) codes. Such procedures are covered under the Division's
			 medical surgical program found in Oregon Administrative Rule (OAR)
			 410-130-0000.
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 123 - DENTAL/DENTURIST SERVICES › Section 410-123-1640 - Prescriptions

Current through Register Vol. 63, No. 7, July 1, 2024
(1) Follow criteria
			 outlined in OAR 410-121-0144.
(2)
			 Practitioner-Managed Prescription Drug Plan (PMPDP) -- Follow criteria outlined
			 in PMPDP -- OAR 410-121-0030.
Stat. Auth.: ORS
				  413.042,
				  414.065 & 409.325
Stats. Implemented: ORS
				  414.065
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 123 - DENTAL/DENTURIST SERVICES › Section 410-123-1660 - Meaningful Language Access

Current through Register Vol. 63, No. 7, July 1, 2024
(1)
			 Providers shall take reasonable steps to ensure that persons with Limited
			 English Proficiency (LEP) have meaningful access and an equal opportunity to
			 participate in program services at all dental care visits, including
			 telehealth:
(a) The size or type of provider
			 does not matter. All providers serving OHP members shall tell members that
			 qualified health interpreter services are available free of charge. Interpreter
			 services shall be timely and protect the privacy and independence of the person
			 with LEP;
(b) Bilingual providers
			 and staff may become Certified Health Care Interpreters after completing the
			 requisite interpreter training and receiving a valid certificate from the
			 Authority;
(c) The Authority's
			 Health Care Interpreter Registry lists all qualified or certified Health Care
			 Interpreters available for provider use;
(d) Fee-for-Service (FFS) dental providers
			 may receive a $60 add-on fee, per date of service, for providing interpreter
			 services to OHP members. The addition of this add-on fee for FFS visits does
			 not change CCO requirements related to reimbursement of qualified and certified
			 HCIs for interpretation services.
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 124 - TRANSPLANT SERVICES › Section 410-124-0000 - Transplant Services

Current through Register Vol. 63, No. 7, July 1, 2024
(1) The Health
			 Systems Division (Division) shall make payment for transplant services
			 identified in these rules as covered for eligible Medicaid clients defined in
			 OAR 410-124-0010  that meet the transplant criteria outlined in OAR 410-124-0000  through 410-124-0040  and the Prioritized List of Health Services guideline
			 notes.
(2) The Division shall
			 reimburse for transplants if:
(a) All Division
			 criteria are met; and
(b)
			 Transplants are medically necessary and meet the requirements for physician and
			 hospital services; and
(c) The
			 ICD-10-CM diagnosis code(s) and CPT transplant procedure code(s) are paired on
			 the same currently funded line on the Prioritized List of Health Services
			 adopted under OAR 410-141-3830.
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 124 - TRANSPLANT SERVICES › Section 410-124-0005 - Donor Services

Current through Register Vol. 63, No. 7, July 1, 2024
(1) Living and
			 cadaver donor search and procurement services are covered for medically
			 necessary transplants.
(2) All
			 living or cadaver donor services are payable under the recipient's Medicaid
			 identification number and not under the donor.
(3) For Managed Care Entity(MCE) clients,
			 contact the client's MCE for authorization requirements.
Statutory/Other Authority: ORS
				  413.042
Statutes/Other Implemented: ORS
				  414.065
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 124 - TRANSPLANT SERVICES › Section 410-124-0006 - Transplant Hospital Requirements And Reimbursement

Current through Register Vol. 63, No. 7, July 1, 2024
Transplant services shall be reimbursed only when provided in a
				transplant hospital that meets the Division requirements.
(1) Medicare certified transplant
			 facility.
(2) Must be an enrolled
			 provider with Oregon Health Authority, Health Systems Division outlined in OAR
			 410-120-1260.
(3) Selection of
			 transplant hospitals by geographic location: If the services are available in
			 the state of Oregon, reimbursement shall not be made to out-of-state transplant
			 hospitals.
(4) Out-of-state
			 transplant hospitals shall be considered only if:
(a) The type of transplant required is not
			 available in Oregon and/or the type of transplant (for example, liver
			 transplant) is available in Oregon but the Oregon transplant hospital does not
			 provide that type of transplant for all clients or all covered diagnoses,
			 (e.g., pediatric transplants); and
(b) An in-state transplant hospital requests
			 the out-of-state transplant referral; and
(c) Be cost effective as determined by the
			 Division. For example, if the transplant service is covered by the client's
			 benefit package and the client's primary insurer (i.e., Medicare) requires the
			 use of an out-of-state transplant hospital; or
(d) It is a contiguous, out-of-state
			 transplant hospital that has a contract or special agreement for reimbursement
			 with the Division.
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 124 - TRANSPLANT SERVICES › Section 410-124-0010 - Eligibility for Transplant Services

Current through Register Vol. 63, No. 7, July 1, 2024
(1) To be eligible
			 for transplant services the client must be enrolled under the following Benefit
			 Packages at the time the transplant services are provided:
(a) Oregon Health Plan Plus benefit package
			 (BMH) described in OAR 410-120-1210 (4)(a);
(b) State funded Healthier Oregon Population
			 (HOP) described in OAR 410-134-0003(2)(a)(C) (xiii) as of July 1,
			 2022.
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 124 - TRANSPLANT SERVICES › Section 410-124-0020

Current through Register Vol. 63, No. 7, July 1, 2024
Statutory/Other Authority: ORS
				  413.042
Statutes/Other Implemented: ORS
				  414.065
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 124 - TRANSPLANT SERVICES › Section 410-124-0040 - Emergency Transplants

Current through Register Vol. 63, No. 7, July 1, 2024
(1) An
			 Emergency Transplant is one in which medical appropriateness requires that a
			 transplant be performed less than five days after determination of the need for
			 a transplant.
(2) Emergency
			 transplants are subject to post transplant review of the client's medical
			 records by the Health Systems Division (Division) or Managed Care Entity (MCE),
			 to determine if the client and the transplant hospital met the criteria in
			 these rules at the time of the transplant. Related charges, including
			 transportation, physician's services, and donor charges shall be covered if
			 payment is approved. The Division shall make payment as described in OAR
			 410-124-0006  for covered transplants. MCE shall make payment as described in
			 their contract.
Statutory/Other Authority: ORS
				  413.042
Statutes/Other Implemented: ORS
				  414.065
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 125 - HOSPITAL SERVICES › Section 410-125-0000 - Determining When the Patient Has Medical Assistance

Current through Register Vol. 63, No. 7, July 1, 2024
(1) The Medical Card gives the client's name
			 as listed with the Oregon Health Plan (OHP) and their alpha-numeric prime
			 number.
(2) Eligibility may change
			 on a monthly basis. In some instances, eligibility will change during the
			 month. Eligibility should be verified each time services are provided in order
			 to assure that the client is eligible for date(s) of service. For ways to
			 verify client eligibility see General Rules OAR 410-120-1140.
Stat. Auth.: ORS
				  413.042
Stats. Implemented: ORS
				  413.042
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 125 - HOSPITAL SERVICES › Section 410-125-0020 - Retroactive Eligibility

Current through Register Vol. 63, No. 7, July 1, 2024
(1) The
			 Division of Medical Assistance Programs (Division) may pay for services
			 provided to an individual who does not have Medicaid coverage at the time
			 services are provided if the individual is made retroactively eligible for
			 medical assistance and eligibility is extended back to the date services were
			 provided. Contact the local branch concerning possible retroactive eligibility.
			 In some cases, the date of branch contact may be considered the date of
			 application for eligibility.
(2)
			 Authorization for payment may be given after the service is provided under
			 limited circumstances. For prior authorization information see OAR 410-125-0124  (Hospital Services Program).
Stat. Auth.: ORS
				  413.042
Stats. Implemented: ORS
				  414.065
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 125 - HOSPITAL SERVICES › Section 410-125-0030 - Hospital Hold

Current through Register Vol. 63, No. 7, July 1, 2024
(1) A hospital hold
			 is a process which allows an in-state general hospital or an out-of-state
			 contiguous general hospital to assist an individual who is admitted to the
			 hospital for an inpatient hospital stay to secure a date of request when the
			 individual is unable to apply for the Oregon Health Plan due to inpatient
			 hospitalization.
(2) The Division
			 of Medical Assistance Programs (Division) will accept hospital holds for
			 inpatient stays. Hospitals must either submit a DMAP 3261 or a hospital
			 generated form to the Division within 24 hours of the admission time or the
			 next working day. If a hospital uses its own form, the form must contain all
			 the information found on the DMAP 3261.
Forms referenced are available from the
				  agency.
Stat. Auth.: ORS
				  413.042
Stats. Implemented: ORS
				  414.065
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 125 - HOSPITAL SERVICES › Section 410-125-0040 - Title XIX/Title XXI Clients

Current through Register Vol. 63, No. 7, July 1, 2024
(1) Title XIX /Title XXI clients are eligible
			 for medical assistance through programs established by the Federal government
			 and for which the State receives federal assistance. Most Title XIX/Title XXI
			 clients are eligible for the Plus or Standard Benefit packages. See the General
			 rules (chapter 410 division 120) for more information on eligibility, benefit
			 package, and covered services. Most Title XIX/Title XXI clients are enrolled in
			 a FCHP, a MHO and a DCO. Some Title XIX clients are Medicare
			 Beneficiaries.
(2) The Division of
			 Medical Assistance Programs (Division) contracts with Prepaid Health Plans
			 (PHPs): Fully-Capitated Health Plans (FCHPs), Mental Health Organizations
			 (MHOs), and Dental Care Organizations (DCOs), to provide certain medical,
			 mental health and dental services on a prepaid basis.
(a) FCHPs provide a comprehensive package of
			 health care benefits including hospital, physician, laboratory, X-ray and other
			 diagnostic imaging, Medicheck (EPSDT), pharmacy, physical therapy,
			 speech-language therapy, occupational therapy, case management, and other
			 services;
(b) MHOs provide mental
			 health services. They can be fully-capitated health plans, community mental
			 health programs, private behavioral organizations or a combination
			 thereof;
(c) DCOs provide dental
			 care;
(d) If the client is enrolled
			 in a Prepaid Health Plan, the name, address and phone number of the plan will
			 appear on the Medical Care Identification. Always check with the plan listed if
			 there is a question about coverage;
(e) PHP clients receive most of their primary
			 care services through the PHP or upon referral from the PHP. In emergency
			 situations, all services may be provided without prior authorization or
			 referral. However, all claims for emergency services must be sent to the
			 prepaid health plan. The hospital must work with the client's prepaid health
			 plan to arrange for billing and payment for emergency and non-emergency
			 services;
(f) The Division will not
			 reimburse for services that can be provided by the client's PHP and are
			 included in the PHP's contract as covered services. Reimbursement is between
			 the service provider and the PHP.
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 125 - HOSPITAL SERVICES › Section 410-125-0041 - Non-Title XIX/XXI Clients

Current through Register Vol. 63, No. 7, July 1, 2024
(1)
			 State-funded clients are clients who have not qualified for medical assistance
			 through a federal program but have access to medical benefits through state
			 funded programs. There are two categories of clients who are in State-funded
			 programs.
(2) Program General
			 Assistance (GA) clients: Program GA clients are children in foster care, in
			 Services to Children and Families (SCF) custody, who are not eligible for Title
			 XIX/Title XXI programs. They have access to the full range of Medicaid covered
			 services, but payment for services provided may be different from that for
			 Title XIX/Title XXI clients. For additional reimbursement information see the
			 Hospital Services Supplemental Information on the Division of Medical
			 Assistance Programs (Division) web site.
(3) Program SF clients: Program SF clients
			 are individuals who are receiving treatment in a state facility, such as Oregon
			 State Hospital, or the Eastern Oregon Training Center. These clients may need
			 to receive hospital care outside the state facility. They are entitled to the
			 full range of Medicaid covered hospital services. These individuals will be
			 referred by the state facility for services. They do not have Medical Care
			 Identification cards. They are not enrolled in a Fully Capitated Health Plan.
			 The state facility from which the client is transferred will contact the
			 hospital regarding billing instructions for these clients.
Stat. Auth.: ORS
				  413.042
Stats. Implemented: ORS
				  414.065
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 125 - HOSPITAL SERVICES › Section 410-125-0045 - Coverage and Limitations

Current through Register Vol. 63, No. 7, July 1, 2024
In general, most medically appropriate services are covered.
				There are, however, some restrictions and limitations. Please refer to the
				Division of Medical Assistance Programs' (Division) General Rules Program for
				information on general scope of coverage and limitations. Some of the
				limitations and restrictions that apply to hospital services are:
(1) Prior authorization (PA): Some services
			 require PA for the Oregon Health Plan (OHP) Plus Benefit Package check OAR
			 410-125-0080.
(2) Non-covered
			 services:
(a) Services that are not medically
			 appropriate, unproven medical efficacy or services that are the responsibility
			 of another Department of Human Services (Department) or Oregon Health Authority
			 (Authority) Division are not covered by the Division of Medical Assistance
			 Programs;
(b) Service coverage is
			 based on the Health Evidence Review Commission's (HERC) Prioritized List of
			 Services and the client's benefit package;
(c) See the General Rules Program (chapter
			 410, division 120) and other program divisions in chapter 410 for a list of not
			 covered services. Further information on covered and non-covered services is
			 found in the Revenue Code section in the Hospital Services Supplemental
			 Information.
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 125 - HOSPITAL SERVICES › Section 410-125-0050 - Client Copayments

Current through Register Vol. 63, No. 7, July 1, 2024
Copayments may be required for certain services and/or benefit
				package(s). See OAR 410-120-1230  for specific details.
Stat. Auth.: ORS
				  413.042
Stats. Implemented: ORS
				  414.065
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 125 - HOSPITAL SERVICES › Section 410-125-0080 - Inpatient Services

Current through Register Vol. 63, No. 7, July 1, 2024
(1) Elective
			 (not urgent or emergent) hospital admission:
(a) Coordinated Care Organization (CCO) and
			 Mental Health Organization (MHO) clients: Contact the client's CCO, or MHO. The
			 health plan may have different prior authorization (PA) requirements than the
			 Division;
(b) Medicare clients: The
			 Division does not require PA for inpatient services provided to clients with
			 Medicare Part A or B coverage;
(c)
			 Division clients: Oregon Health Plan (OHP) clients covered by the OHP Plus
			 Benefit Package:
(A) For a list of medical
			 and surgical procedures that require PA, see the Division's Medical-Surgical
			 Services Program, rules OAR chapter 410, division 130, specifically OAR
			 410-130-0200, table 130-0200-1, unless they are urgent or emergent defined in
			 OAR 410-125-0401;
(B) For PA,
			 contact the Division unless otherwise indicated in the Medical-Surgical Service
			 program rules, specifically OAR 410-130-0200, Table 130-0200-1.
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 125 - HOSPITAL SERVICES › Section 410-125-0085 - Outpatient Services

Current through Register Vol. 63, No. 7, July 1, 2024
(1) Outpatient
			 services that may require prior authorization (PA) include (see the individual
			 program in the Authority's Health Systems Division (Division)) Oregon
			 Administrative Rules:
(a) Physical Therapy
			 (chapter 410, division 131);
(b)
			 Occupational Therapy (chapter 410, division 131);
(c) Speech Therapy (chapter 410, division
			 129);
(d) Audiology (chapter 410,
			 division 129);
(e) Hearing Aids
			 (chapter 410, division 129);
(f)
			 Dental Procedures (chapter 410, division 123);
(g) Drugs (chapter 410, division 121);
(h) Apnea monitors, services, and
			 supplies (chapter 410, division 122);
(i) Home Parenteral/Enteral Therapy (chapter
			 410, division 148);
(j) Durable
			 Medical Equipment and Medical supplies (chapter 410, division 122);
(k) Certain hospital services.
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 125 - HOSPITAL SERVICES › Section 410-125-0086 - Prior Authorization for FCHP/MHO Clients

Current through Register Vol. 63, No. 7, July 1, 2024
Most non-emergent inpatient and outpatient services require
				prior authorization by a Fully Capitated Health Plan (FCHP) or a Mental Health
				Organization (MHO). Emergency hospital services must be covered by an FCHP or
				MHO without regard to prior authorization or the emergency care provider's
				contractual relationship with the FCHP or MHO. Emergency hospital services are
				defined as covered inpatient and outpatient services that are needed to
				evaluate or stabilize an emergency medical condition. Once a client's condition
				is considered stabilized, or a medical screening examination has determined
				that the client's medical condition is not emergent, an FCHP or MHO may require
				prior authorization for hospital admission, follow-up care, or further
				treatment. Failure to obtain prior authorization from the FCHP or MHO may
				result in a denial of payment for services. Contact the client's FCHP or MHO
				for further information on prior authorization.
Stat. Auth.: ORS
				  413.042
Stats. Implemented: ORS
				  414.065
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 125 - HOSPITAL SERVICES › Section 410-125-0090 - Inpatient Rate Calculations - Type A, Type B, and Critical Access Oregon Hospitals

Current through Register Vol. 63, No. 7, July 1, 2024
(1) The
			 Office of Rural Health designates Type A, Type B, and Critical Access Oregon
			 Hospitals.
(2) Reimbursement to
			 Type A, Type B, and Critical Access Oregon Hospitals for covered inpatient
			 services is as follows:
(a) Interim
			 reimbursement for inpatient covered services is the hospital specific cost to
			 charge percentage from the last finalized cost settlement, except Laboratory
			 and Radiology services are based on the Division of Medical Assistance Programs
			 (DMAP) fee schedule;
(b)
			 Retrospective cost-based reimbursement is made during the annual cost
			 settlement period for all covered inpatient services, except for the hospitals
			 that have payment contracts with managed care plans;
(c) Cost-based reimbursement is derived from
			 the most recent audited Medicare Cost Report and adjusted to reflect the
			 Medicaid mix of services.
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 125 - HOSPITAL SERVICES › Section 410-125-0095 - Hospitals Providing Specialized Inpatient Services

Current through Register Vol. 63, No. 7, July 1, 2024
(1) Some hospitals provide specific highly
			 specialized inpatient services by arrangement with the Division of Medical
			 Assistance Programs (Division).
(2)
			 Reimbursement is made according to the terms of a contract between the Division
			 and the hospital.
Stat. Auth.: ORS
				  413.042
Stats. Implemented: ORS
				  414.065
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 125 - HOSPITAL SERVICES › Section 410-125-0101 - Hospital-Based Nursing Facilities and Medicaid Swing Beds

Current through Register Vol. 63, No. 7, July 1, 2024
To be eligible to receive reimbursement for hospital-based
				long-term care nursing facility services or Medicaid swing beds, the hospital
				must:
(1) Have approval from the
			 Centers for Medicare and Medicaid Services (CMS) to furnish skilled nursing
			 facility services as a Medicare hospital swing bed unit,
(2) Be enrolled and have a current signed HSD
			 provider agreement,
(3) Services
			 must be provided, billed, separate from other hospital services.
Statutory/Other Authority: ORS
				  413.042
Statutes/Other Implemented: ORS
				  414.065
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 125 - HOSPITAL SERVICES › Section 410-125-0102 - Medically Needy Clients

Current through Register Vol. 63, No. 7, July 1, 2024
(1) The
			 QIO can give prior authorization for non-emergency inpatient services for
			 clients who are in the Medically Needy Program but have not yet met their
			 spend-down. Only Medically Needy Program clients under age 21 and pregnant
			 women have coverage for inpatient services if enrolled in the Medically Needy
			 Program.
(2) Prior authorization
			 cannot be granted for outpatient services, which require prior authorization.
			 However, you may contact the Division of Medical Assistance Programs (Division)
			 Medical/ Dental Group once the client has been made eligible and request
			 retroactive authorization.
Stat. Auth.: ORS
				  413.042
Stats. Implemented: ORS
				  414.065
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 125 - HOSPITAL SERVICES › Section 410-125-0103 - Medicare Clients

Current through Register Vol. 63, No. 7, July 1, 2024
When Medicare is the primary payer, services provided in the
				inpatient or out-patient setting do not require prior authorization. However,
				if the Division of Medical Assistance Programs (Division) is the primary payer
				because the service is not covered by Medicare; the prior authorization
				requirements listed in chapter 410 division 125 would apply.
Stat. Auth.: ORS
				  413.042
Stats. Implemented: ORS
				  414.065
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 125 - HOSPITAL SERVICES › Section 410-125-0115 - Non-Contiguous Area Out-of-State Hospitals - Effective for services rendered on or after October 1, 2003

Current through Register Vol. 63, No. 7, July 1, 2024
Non-contiguous area hospitals are out-of-state hospitals
				located more than 75 miles outside the Oregon border. Unless such hospitals
				have an agreement or contract with Division of Medical Assistance Programs
				(Division) for specialized services, non-contiguous area out-of-state hospitals
				will receive DRG reimbursement or billed charges whichever is less. The unit
				value for non-contiguous out-of-state hospitals will be set at the final unit
				value for the 50th percentile of Oregon hospitals (see Inpatient Rate
				Calculations from Other Hospitals, DRG Rate Methodology, OAR 410-125-0141  for
				the methodology used to calculate the unit value at the 50th percentile). No
				cost outlier, capital or medical education payments will be made. The hospital
				will receive a disproportionate share reimbursement if eligible (see OAR
				410-125-0150).
Stat. Auth.: ORS
				  413.042
Stats. Implemented: ORS
				  414.065
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 125 - HOSPITAL SERVICES › Section 410-125-0120 - Transportation To and From Medical Services

Current through Register Vol. 63, No. 7, July 1, 2024
(1) Transportation to and from medical
			 services, including hospital services, is a covered service. However, all
			 non-emergency transports require prior authorization in order for the
			 transportation provider to be paid.
(2) The transportation must be the least
			 expensive obtainable under existing conditions and appropriate to the client's
			 needs.
(3) Contact the
			 Division-contracted regional Transportation Brokerage (Brokerage) for prior
			 authorization for the transport or instruct the transportation provider to
			 contact the Brokerage. Brokerage map and contact information is available at
			 http://www.oregon.gov/OHA/HSD/Pages/Policy-Medical-Transportation.aspx [File
			 Link Not Available].
(4) Hospitals
			 must follow the after hours procedures for the Brokerages and contact the
			 appropriate after hours providers for non-emergent transportation for hospital
			 discharges.
(5) No prior
			 authorization is required when the client's condition requires emergency
			 transport.
(6) When a hospital
			 sends a patient to another facility or provider during the course of an
			 inpatient stay and the client is returned to the admitting hospital within 24
			 hours, the hospital must arrange for and pay for the transportation. See
			 billing instructions contained in the Hospital Supplemental Information on the
			 Division website for additional information.
Statutory/Other Authority: ORS
				  413.042
Statutes/Other Implemented: ORS
				  414.065
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 125 - HOSPITAL SERVICES › Section 410-125-0121 - Contiguous Area Out-of-State Hospitals - Effective for services rendered on or after October 1, 2003

Current through Register Vol. 63, No. 7, July 1, 2024
Contiguous area hospitals are out-of-state hospitals located
				less than 75 miles outside the Oregon border. Unless such hospitals have an
				agreement or contract with Division of Medical Assistance Programs (Division)
				for specialized services, contiguous area out-of-state hospitals will receive
				DRG reimbursement or billed charges whichever is less. The unit value for
				contiguous out-of-state hospitals will be set at the final unit value for the
				50th percentile of Oregon hospitals (see Inpatient Rate Calculations for Other
				Hospitals, DRG Rate Methodology OAR 410-125-0141  for the methodology).
				Contiguous area out-of-state hospitals are also eligible for cost outlier
				payments. No capital or medical education payments will be made. The hospital
				will receive a disproportionate share reimbursement if eligible (see OAR
				410-125-0150).
Stat. Auth.: ORS
				  413.042
Stats. Implemented: ORS
				  414.065