Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 172 - MEDICAID PAYMENT FOR BEHAVIORAL HEALTH SERVICES › Section 410-172-0640 - Behavioral Health Services Fee Schedule

Current through Register Vol. 63, No. 7, July 1, 2024
(1) The Division shall pay providers based on
			 the Behavioral Health Services Fee Schedule (fee-for-service (FFS) payment
			 rates for behavioral health services) posted on the Authority web
			 site.
(2) Payment shall be made at
			 each provider's usual and customary charge or the Division's published
			 reimbursement upper payment limit, whichever is less, minus payments received
			 or due from other payers. Payments to other specified providers shall be made
			 according to other approved schedules.
(3) The Division's maximum allowable
			 rate-setting process uses a methodology that is based on the existing Medicaid
			 fee schedule with adjustments for legislative changes and payment
			 levels.
(4) Limitations contained
			 in the Behavioral Health Services Fee Schedule, such as the maximum rate and
			 the amount, duration, and scope of services provided, are subject to change at
			 the discretion of the Division. Updates and changes are posted on the
			 Behavioral Health Services Fee Schedule website at
www.oregon.gov/OHA/HSD/OHP/Pages/Fee-Schedule.aspx
.
(5) Payment shall be made for services listed
			 in the Medicaid Behavioral Health Procedure Fee Schedule that are rendered to
			 Medicaid-eligible individuals by a qualified provider during the period in
			 which the provider is enrolled with the Division.
(6) For cost-reimbursed services, the
			 provider shall maintain adequate records to thoroughly explain how the amounts
			 reported on the cost statement were determined. The records shall be accurate
			 and in sufficient detail to substantiate the data reported. Providers whose
			 rates are paid based on a collective bargaining agreement are not exempt from
			 this requirement.
(7) In accordance
			 with
			 42
			 CFR §
									405.506, a charge that exceeds the
			 customary charge of the physician or other person who rendered the medical or
			 other health service, or the prevailing charge in the locality, or an
			 applicable lowest charge level may be found to be reasonable, but only where
			 there are unusual circumstances, or medical complications requiring additional
			 time, effort, or expense that support an additional charge, and only if it is
			 acceptable medical or medical service practice in the locality to make an extra
			 charge in such cases. The mere fact that the physician's or other person's
			 customary charge is higher than prevailing would not justify a determination
			 that it is reasonable.
(8) Payment
			 by the Division does not limit the Authority or any state or federal oversight
			 entity from reviewing or auditing a claim before or after the payment. Payment
			 may be denied or subject to recovery if medical review, audit, or other
			 post-payment review determines that payment for the service was not provided in
			 accordance with applicable Oregon Administrative Rules or the service does not
			 meet the criteria for quality or medical appropriateness of the care.
Statutory/Other Authority: ORS
				  413.042 & 430.640
Statutes/Other Implemented: ORS
				  413.042,
				  414.025,
				  414.065,
				  430.640,
				  430.705  & 430.715