reglab/statecodes huggingface dataset:
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 125 - HOSPITAL SERVICES › Section 410-125-0124 - Retroactive Authorization

Current through Register Vol. 63, No. 7, July 1, 2024
Retroactive authorization for payment can be granted after the
				service is provided only in the following circumstances:
(1) The person was not yet eligible for
			 Medicaid/CHIP at the time the services were provided. Payment can be made if
			 the services are covered Medicaid/CHIP services and the client's eligibility is
			 extended back to the date the hospital provided services. See: the Hospital
			 Services Supplemental Information on the Division of Medical Assistance
			 Programs (Division) website for additional billing information.
(2) If another insurer denied the claim
			 because the service is not covered by that insurer, and the hospital did not
			 seek prior authorization because it had good reason to believe the service was
			 covered by the insurer. Payment can be made by the Division if the services are
			 covered by Medicaid. See: the Hospital Services Supplemental Information on the
			 Division website for additional billing information.
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 410-125-0125 - Free-Standing Inpatient Psychiatric Facilities

Current through Register Vol. 63, No. 7, July 1, 2024
Free-standing inpatient psychiatric facilities (institutions
				for mental diseases), including Oregon's state-operated psychiatric and
				training facilities, are reimbursed according to the terms of an agreement
				between the Addictions and Mental Health, Aging and People with Disabilities,
				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 410-125-0140 - Prior Authorization Does Not Guarantee Payment

Current through Register Vol. 63, No. 7, July 1, 2024
(1) Prior authorization (PA) is valid for the
			 date range approved only as long as the client remains eligible for services.
			 For example, a client may become ineligible after the PA has been granted but
			 before the actual date of service, or a client's hospital benefit days may be
			 used prior to the time the claim for the prior authorized service is submitted
			 to the Division of Medical Assistance Programs (Division) for
			 payment.
(2) All prior authorized
			 treatment are subject to retrospective review. If the information provided to
			 obtain PA cannot be validated in a retrospective review, payment shall be
			 denied or recovered.
(3) Hospitals
			 should develop their own internal monitoring system to determine if the
			 admitting physician has received PA for the service from the
			 Division.
(4) For the Plus Benefit
			 Package PA information refer to the PA chart in the Hospital Services Program
			 OAR 410-125-0080.
(5) Hospitals may
			 also verify PA requirements by calling the Division's Provider Services Unit or
			 the RN Benefit Hotline (contact phone numbers are located on the Division's
			 website).
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 410-125-0141 - DRG Rate Methodology

Current through Register Vol. 63, No. 7, July 1, 2024
(1)
			 Diagnosis Related Groups:
(a) Diagnosis
			 Related Groups (DRG) is a system of classification of diagnoses and procedures
			 based on the International Classification of Diseases, 10th Revision, Clinical
			 Modification (ICD-10-CM);
(b) The
			 DRG classification methodology assigns a DRG category to each inpatient
			 service, based on the patient's diagnoses, age, procedures performed, length of
			 stay, and discharge status.
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 125 - HOSPITAL SERVICES › Section 410-125-0142 - Graduate Medical Education Reimbursement for Public Teaching Hospitals

Current through Register Vol. 63, No. 7, July 1, 2024
(1) Graduate
			 Medical Education (GME) payment is reimbursement made to an institution for the
			 costs of an approved medical training program. The State makes GME payments to
			 any in-state public acute care hospital providing a major teaching program,
			 defined as a hospital with more than 200 residents or interns. Funding for
			 public teaching hospital GME is not included in the "capitation rates" paid to
			 managed care plans under the Oregon Health Plan resulting in hospitals with
			 medical teaching programs not being able to capture GME costs when contracting
			 with managed care plans.
(2) For
			 each qualifying public hospital, the payment amount is initially determined
			 based on hospital specific costs for medical education as reported in the
			 Medicare Cost Report for the most recent completed reporting year (becomes base
			 year).
(3) The GME payment is
			 calculated as follows:
(a) Total Direct
			 Medical Education (DME) costs consist of the costs for medical residency and
			 the paramedical education programs. Title XIX DME costs are determined based on
			 the ratio of Title XIX days to total days applied to the total DME.
(b) Indirect Medical Education (IME) costs
			 are derived by first computing the percent of IME to total Medicare inpatient
			 payments. This is performed by dividing the IME Adjustment reported in the
			 Medicare Cost Report by the sum of this amount and Medicare payments for DRG
			 amount -- other than outlier payments, inpatient program capital, and organ
			 acquisition. The resulting percent is then applied to net allowable costs
			 (total allowable costs less Total DME costs, computed as discussed in the
			 previous paragraph). Title XIX IME costs are then determined based upon the
			 ratio of Title XIX days to total days.
(c) The total net Title XIX GME is the sum of
			 Title XIX IME and DME costs. The GME reimbursement is made quarterly.
			 Reimbursement is limited to the availability of public funds, specifically, the
			 amount of public funds available for GME attributable to the Title XIX patient
			 population. GME is rebased yearly.
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 125 - HOSPITAL SERVICES › Section 410-125-0146 - Supplemental Reimbursement for Public Academic Teaching University Medical Practitioners

Current through Register Vol. 63, No. 7, July 1, 2024
(1)
			 Effective for dates of service on or after November 17, 2005, physician and
			 other practitioner services provided by practitioners affiliated with a public
			 academic medical center that meets the following eligibility standards shall be
			 eligible for a supplemental teaching practitioner's payment for these services
			 provided to eligible Medicaid recipients and paid for directly on a
			 fee-for-service basis, subject to subsections (3) and (4) of this rule. This
			 supplemental payment shall be equal to the difference between the Medicare
			 allowable and Medicaid reimbursement received.
(2) Eligible academic medical centers must
			 be:
(a) The hospital must be located within
			 the State of Oregon (border hospitals are excluded); and
(b) The hospital provides a major medical
			 teaching program, defined as a hospital with more than 200 residents or
			 interns.
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 125 - HOSPITAL SERVICES › Section 410-125-0150 - Disproportionate Share

Current through Register Vol. 63, No. 7, July 1, 2024
(1) The
			 Disproportionate-share hospital (DSH) payment is an additional reimbursement
			 made to hospitals that serve a disproportionate share of low-income patients
			 with special needs.
(a) To receive DSH
			 payments, a hospital must have at least two obstetricians with staff privileges
			 at the hospital who have agreed to provide non-emergency obstetrical services
			 to Medicaid patients. For hospitals in a rural area (outside of a Metropolitan
			 Statistical Area, as defined by the Executive Office of Management and Budget),
			 the term "obstetrician" includes any physician with staff privileges at the
			 hospital that performs non-emergency obstetric procedures. This requirement
			 does not apply to a hospital in which a majority of inpatients are under 18
			 years of age, or a hospital that had discontinued or did not offer
			 non-emergency obstetric services as of December 21, 1987. No hospital may
			 qualify for disproportionate share payments unless the hospital has, at a
			 minimum, a Medicaid utilization rate of 1 percent. The Medicaid utilization
			 rate is the ratio of total paid Medicaid (Title XIX, non-Medicare) days to
			 total inpatient days. Newborn days, days in specialized wards, and
			 administratively necessary days are included. Days attributable to individuals
			 eligible for Medicaid in another State are also accounted for;
(b) Information on total inpatient days is
			 taken from the most recent Medicare Cost Report.
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 125 - HOSPITAL SERVICES › Section 410-125-0155 - Upper Limits on Payment of Hospital Claims

Current through Register Vol. 63, No. 7, July 1, 2024
(1) Supplemental payments:
(a) Private Hospital Supplemental Payments:
(A) From the private Upper Payment Limit
			 (UPL) gap, payments shall be made to all private Diagnosis Related Groups (DRG)
			 hospitals in the form of a per discharge payment applied to hospital specific
			 Medicaid fee-for-service discharges from the quarter preceding the month of the
			 payment;
(B) This payment will be
			 equal to one quarter of the gap amount divided by the total private DRG
			 hospital Medicaid fee-for-service discharges from the quarter proceeding the
			 month of payment;
(C) The
			 supplemental payments for Private Hospitals will not exceed the UPL for
			 inpatient hospital services.
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 125 - HOSPITAL SERVICES › Section 410-125-0162 - Hospital Transformation Performance Program

Current through Register Vol. 63, No. 7, July 1, 2024
(1) The Hospital Transformation Performance
			 Program (HTPP) is established by the Oregon Health Authority (Authority) to
			 allow hospitals to earn incentive payments by meeting specific performance
			 standards that advance health systems transformation, reduce hospital costs,
			 and improve patient safety.
(a) The total
			 amount of funds available through the program is equal to the federal financial
			 participation received from one-percentage point of the assessment. Hospitals
			 that pay an assessment on their net patient revenue, as required by OAR
			 410-050-0870, are eligible to participate.
(b) The performance standards shall be
			 established by the Authority based on recommendations of the Hospital
			 Performance Advisory Committee (Committee) and as approved by the Centers for
			 Medicare and Medicaid Services (CMS). The Committee shall be appointed by the
			 Authority director and comprise four hospital representatives, two Coordinated
			 Care Organization (CCO) representatives, and three members with expertise in
			 measuring health outcomes.
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 125 - HOSPITAL SERVICES › Section 410-125-0165 - Transfers and Reimbursement

Current through Register Vol. 63, No. 7, July 1, 2024
(1)
			 When a patient is transferred between hospitals, the transferring hospital is
			 paid on the basis of the number of inpatient days spent at the transferring
			 hospital multiplied by the Per Diem Inter-Hospital Transfer Payment
			 rate.
(2) The per diem
			 inter-hospital transfer payment rate = the DRG payment divided by the geometric
			 mean length of stay for the DRG. The geometric mean length of stay is reported
			 in the DRG tables on the Division website.
(3) Payment to the transferring hospital will
			 not exceed the DRG payment.
(4) The
			 final discharging hospital receives the full DRG payment.
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 410-125-0170 - Death Occurring on Day of Admission

Current through Register Vol. 63, No. 7, July 1, 2024
A hospital receiving DRG reimbursements will receive the DRG
				reimbursement for the inpatient stay when death occurs on the day of admission
				as long as at least one hospital benefit day is available.
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 410-125-0175 - Hospitals Providing Specialized Outpatient Services

Current through Register Vol. 63, No. 7, July 1, 2024
Some hospitals provide specific highly specialized outpatient
				services by arrangement with the Division. Reimbursement is made according to
				the terms of a written agreement or contract.
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 410-125-0180 - Public Rates

Current through Register Vol. 63, No. 7, July 1, 2024
Rates billed to Division of Medical Assistance Programs
				(Division) cannot exceed the facility's public billing rate.
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 410-125-0181 - Non-Contiguous and Contiguous Area Out-of-State Hospitals - Outpatient Services

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. Contiguous area hospitals
				are out-of state hospitals located less than 75 miles outside the Oregon
				border. Unless such hospitals have an agreement with the Division of Medical
				Assistance Programs (Division) regarding reimbursement for specialized
				services, these hospitals will be reimbursed as follows:
(1) Laboratory, diagnostic and therapeutic
			 radiology, nuclear medicine, CT scans, MRI services, other imaging services,
			 and maternity case management services will be reimbursed under a Division fee
			 schedule.
(2) All other outpatient
			 services will be reimbursed at 50 percent of billed charges. There is no cost
			 settlement.
(3) Notwithstanding
			 subsections (1)-(2) of this rule, this subsection becomes effective for dates
			 of service on and after January 1, 2006, but will not be operative as the basis
			 for payments until the Division determines all necessary federal approvals have
			 been obtained. Non-contiguous area hospitals are out-of-state hospitals located
			 more than 75 miles outside the Oregon border. Contiguous area hospitals are
			 out-of-state hospitals located less than 75 miles outside the Oregon border.
			 Unless such hospitals have an agreement with the Division regarding
			 reimbursement for specialized services, these hospitals will be reimbursed as
			 follows:
(a) Clinical laboratory services
			 will be reimbursed under a Division fee schedule;
(b) All other outpatient services will be
			 reimbursed at 50 percent of billed charges. There is no cost
			 settlement.
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 125 - HOSPITAL SERVICES › Section 410-125-0190 - Outpatient 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 outpatient
			 services is as follows:
(a) Interim
			 reimbursement for outpatient covered services is the hospital specific cost to
			 charge percentage from the last finalized cost settlement, except laboratory,
			 diagnostic and therapeutic radiology, nuclear medicine, CT scans, MRI services,
			 other imaging services, and maternity case management services which are based
			 on the Division of Medical Assistance Programs (Division) fee
			 schedule;
(b) Retrospective
			 cost-based reimbursement is made for all Fee-For-Service covered outpatient
			 services during the annual cost settlement period;
(c) Cost-based reimbursement is derived from
			 the most recent audited Medicare Cost Report and adjusted to reflect Medicaid
			 mix of services.
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 125 - HOSPITAL SERVICES › Section 410-125-0195 - Outpatient Services In-State DRG Hospitals

Current through Register Vol. 63, No. 7, July 1, 2024
(1) The National Drug Code (NDC) must be
			 included on all claim formats for physician administered drug codes required by
			 the Deficit Reduction Act of 2005.
(2) For discharges prior to January 1, 2012,
			 In-State Diagnostic Related Grouper (DRG) hospital outpatient and emergency
			 services are reimbursed under a cost-based methodology.
(a) Interim reimbursement:
(A) The interim reimbursement percentage is
			 developed using the cost-to-charge ratio methodology, derived from the Medicare
			 cost report, and applied to billed charges;
(B) The interim payment is the estimated
			 percentage needed to achieve 100 percent of hospital cost in aggregate;
			 and
(C) This interim percentage is
			 applied to all outpatient charges except for clinical laboratory services.
			 Interim reimbursement for clinical laboratory services is calculated according
			 to rates published in the Division of Medical Assistance Programs' (Division)
			 fee schedule.
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 125 - HOSPITAL SERVICES › Section 410-125-0200 - Time Limitation for Submission of Claims

Current through Register Vol. 63, No. 7, July 1, 2024
Division of Medical Assistance Programs (Division) will accept
				a claim up to 12 months after the date of service. The date of discharge is the
				date of service for an inpatient hospital claim.
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 410-125-0201 - Independent ESRD Facilities

Current through Register Vol. 63, No. 7, July 1, 2024
(1)
			 Independent End Stage Renal Dialysis (ESRD) Facilities:
(a) ESRD Facilities are reimbursed for
			 Continuous Ambulatory Peritoneal Dialysis.
(b) (CAPD), Continuous Cycling Peritoneal
			 Dialysis (CCPD), and Hemodialysis:
(A)
			 Composite at 80% of the Medicare allowed amount, except for Epoetin.
(B) Epoetin is reimbursed at 100% of the
			 Medicare maximum allowed amount.
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 125 - HOSPITAL SERVICES › Section 410-125-0210 - Third Party Resources and Reimbursement

Current through Register Vol. 63, No. 7, July 1, 2024
(1) The Division of Medical Assistance
			 Programs (Division) establishes maximum allowable reimbursements for all
			 services. When clients have other third party payers, the payment made by that
			 payer is deducted from the Division maximum allowable payment.
(2) The Division will not make any additional
			 reimbursement when a third party pays an amount equal to or greater than the
			 Division reimbursement. The Division will not make any additional reimbursement
			 when a third party pays 100 percent of the billed charges, except when Medicare
			 Part A is the primary payer.
(3)
			 When Medicare is Primary:
(a) The Division
			 calculates the reimbursement for these claims in the same manner as described
			 in the Inpatient and Outpatient Rates Calculations Sections above;
(b) Payment is the Division allowable
			 payment, less the Medicare payment, up to the amount of the deductible and/or
			 coinsurance due. For clients who are Qualified Medicare Beneficiaries the
			 Division does not make any reimbursement for a service that is not covered by
			 Medicare. For clients who are Qualified Medicare/Medicaid Beneficiaries the
			 Division payment is the Division allowable, less the Part A payment up to the
			 amount of the deductible due for services by either Medicare or
			 Medicaid.
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 125 - HOSPITAL SERVICES › Section 410-125-0220 - Services Billed on the Electronic 837I or on the Paper UB-04 and Other Claim Forms

Current through Register Vol. 63, No. 7, July 1, 2024
(1) All inpatient
			 and outpatient services provided by the hospital or hospital employees, unless
			 otherwise specified below, are billed on the electronic 837I (837
			 Institutional) or on the paper CMS 1450 (UB-04) claim form.
(2) Professional staff and other providers:
			 Services provided by other providers or professional staff with whom the
			 hospital has a contract or agreement regarding provision of services and whom
			 the hospital reimburses a salary or a fee are billed on the electronic 837I or
			 paper CMS 1450 (UB-04) along with other inpatient or outpatient charges if such
			 costs are reported on the hospital's Medicare Cost Report as a hospital
			 cost.
(3) Residents and medical
			 students: Professional services provided by residents or medical students
			 serving in the hospital as residents or students at the time services are
			 provided are reimbursed by the Division of Medical Assistance Programs
			 (Division) through graduate medical education, for the hospitals that qualify
			 (See OAR 410-125-0141) for payments and may not be billed on the electronic
			 837I or paper CMS 1450 (UB-04).
(4)
			 Diagnostic and similar services provided by another provider or facility
			 outside the hospital: When diagnostic or short-term services are provided to an
			 inpatient by another provider or facility because the admitting hospital does
			 not have the equipment or facilities to provide all services required and the
			 patient is returned within 24 hours to the admitting hospital, the admitting
			 hospital should add the following charges to the inpatient electronic 837I or
			 paper CMS 1450 (UB-04) claim:
(a) Charges
			 from the other provider or hospital under the appropriate Revenue Code. The
			 admitting hospital is responsible for reimbursing the other provider or
			 hospital. The Division will not reimburse the other provider or hospital;
			 and
(b) Charges for transportation
			 to the other facility or provider. These must be billed under Revenue Code 542.
			 No prior authorization of the transport is required. The hospital will arrange
			 for the transport and pay the transportation provider for the transport. The
			 Division will not reimburse the transportation provider. This is the only
			 instance in which transportation charges can be billed on the electronic 837I
			 or paper CMS 1450 (UB-04).
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 125 - HOSPITAL SERVICES › Section 410-125-0221 - Payment in Full

Current through Register Vol. 63, No. 7, July 1, 2024
The payment made by Medicaid towards any inpatient or
				outpatient services, including cost outlier, disproportionate share, and
				capital payments, constitutes payment in full for the
				service.
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 410-125-0230 - Qualified Directed Payments

Current through Register Vol. 63, No. 7, July 1, 2024
Qualified Directed Payments (QDP) are payments made by the
				Oregon Health Authority (Authority) to Coordinated Care Organizations (CCOs)
				from three Quality and Access pools for distinct provider classes as
				follows:
(i) Rural Type A and Type B
			 hospitals,
(ii) Public Academic
			 Health Centers and
(iii) DRG
			 hospitals. Each provider class is defined in §438.6(c) Preprint forms
			 approved by the U.S. Department of health and Human Services Centers for
			 Medicare and Medicaid Services. QDPs are tied to inpatient and outpatient
			 encounters with Medicaid and Children's Health Insurance Program (CHIP) members
			 enrolled in Coordinated Care Organizations. However, the Authority does not
			 make Qualified Directed Payments for encounters with members who received
			 Citizenship Waived Medical (CWM) or CWM Plus Benefit Packages.
(1) Type A and Type B hospitals:
(a) The Authority shall make a qualified
			 directed payment only if the Type A or Type B hospital meets criteria
			 established by the Authority for the Type A or Type B hospital Quality and
			 Access program in accordance with applicable federal requirements, which may be
			 updated as needed.
(b) The
			 Authority shall make a qualified directed payment for each inpatient and
			 outpatient encounter; one encounter per member, per day, per
			 facility;
(c) QDP amounts shall be
			 at two separate rates; one for inpatient encounters and one for outpatient
			 encounters;
(d) Payment rates shall
			 be set by the Authority and may be adjusted based on actual utilization and
			 available Quality and Access Funds;
(e) The Authority shall create a monthly
			 report to assist CCOs in distributing funds to the appropriate hospital. The
			 report shall be distributed to each CCO and each Type A and Type B
			 hospital;
(f) Within five (5)
			 business days after receipt of the monthly report, the CCO shall submit an
			 electronic payment to an account established by the hospital for the amount
			 indicated on the report;
(g)
			 Adjustments shall be processed weekly through the Medicaid payment system and
			 included in the monthly report.
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 125 - HOSPITAL SERVICES › Section 410-125-0360 - Definitions and Billing Requirements

Current through Register Vol. 63, No. 7, July 1, 2024
(1) Total days on an inpatient claim must
			 equal the number of accommodation days. Do not count the day of discharge when
			 calculating the number of accommodation days.
(2) Inpatient services are reimbursed based
			 on the admission date and discharge diagnosis.
(3) Inpatient services are services to
			 patients who typically are admitted to the hospital before midnight and listed
			 on the following day's census, with the following exceptions:
(a) A patient admitted and transferred to
			 another acute care hospital on the same day is considered an inpatient;
(b) A patient who expires on the
			 day of admission is an inpatient; and
(c) Births.
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 125 - HOSPITAL SERVICES › Section 410-125-0400 - Discharge

Current through Register Vol. 63, No. 7, July 1, 2024
(1) A discharge
			 from a hospital is the formal release of a patient to home, to another facility
			 such as an intermediate care facility or nursing home, to a home health care
			 agency, or to another provider of health care services.
(2) For services beginning January 1, 1993,
			 and later, the transfer of a patient from acute care to a distinct part
			 physical rehabilitation unit (i.e., a unit exempt from the Medicare Prospective
			 Payment System) within the same hospital will be considered a discharge. The
			 admission to the rehabilitation unit is billed separately. All other transfers
			 occurring within a hospital, including transfers to Medicare PPS-exempt
			 psychiatric units, will not be considered discharges, and all charges for
			 services must be submitted on a single UB-04 billing for the
			 admission.
(3) Transfer from a
			 hospital occurs when an individual is formally released to another acute care
			 hospital, to a long-term acute care hospital, to a skilled nursing facility, or
			 an intermediate care facility. When a physician sends a patient directly to
			 another hospital for further inpatient care, the discharge should be billed as
			 a transfer, regardless of the mode of transportation.
(4) When the Division receives claims from
			 two hospitals for the same patient, and the date of discharge from one hospital
			 is the same as the date of admission to the other, the Division will assume
			 that a transfer has occurred. The Division will change the discharge status
			 code on the first claim to 02 (Transferred to Another Acute Care Facility),
			 automatically generating an adjustment if the claim has already been
			 adjudicated, unless discharge status on the claim is already 02 (Transfer) or
			 07 (Discharge AMA). If it is believed that the Division made an error in
			 assigning Discharge Status code 02 to a claim, the hospital may submit an
			 Adjustment Request along with supporting documentation from the medical
			 record.
(5) A transfer between
			 units within a hospital is not a transfer for billing purposes, except in the
			 case of transfers to distinct part physical rehabilitation units. Note that
			 transfers in the other direction from rehabilitative care to acute care are not
			 considered discharges from the rehabilitation unit unless the stay in the acute
			 setting exceeds seven days. Stays of seven days or less in the acute care
			 setting may not be billed separately.
(6) Some transfers, including transfers to
			 distinct part rehabilitation units, require 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 410-125-0401 - Definitions: Emergent, Urgent, and Elective Admissions

Current through Register Vol. 63, No. 7, July 1, 2024
(1) EMERGENT ADMISSION -- an admission which
			 occurs after the sudden onset of a medical condition manifesting itself by
			 acute symptoms of sufficient severity (including severe pain) such that a
			 prudent layperson, who possesses an average knowledge of health and medicine
			 could reasonably expect the absence of immediate medical attention to result
			 in:
(a) Placing their health or the health of
			 an unborn child in serious jeopardy;
(b) Serious impairment of bodily functions;
			 or
(c) Serious dysfunction of any
			 bodily organ or part. "Immediate medical attention" is defined as medical
			 attention which could not be delayed by 24 hours.
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 125 - HOSPITAL SERVICES › Section 410-125-0410 - Readmission

Current through Register Vol. 63, No. 7, July 1, 2024
(1) A patient whose
			 readmission for surgery or follow-up care is planned at the time of discharge
			 must be placed on leave of absence status, and both admissions must be combined
			 into a single billing. The Division of Medical Assistance Programs (Division)
			 will make one payment for the combined service. Examples of planned
			 readmissions include, but are not limited to, situations where surgery could
			 not be scheduled immediately, a specific surgical team was not available,
			 bilateral surgery was planned, or when further treatment is indicated following
			 diagnostic tests but cannot begin immediately.
(2) A patient whose discharge and readmission
			 to the hospital is within thirty (30) days for the same or related diagnosis
			 must be combined into a single billing. Division shall make one payment for the
			 amount appropriate for the combined service.
(3) This rule does not apply to:
(a) Readmissions for an unrelated
			 diagnosis;
(b) Readmissions
			 occurring more than 30 days after the date of discharge;
(c) Readmissions for a diagnosis that may
			 require episodic (a series) acute care hospitalizations to stabilize the
			 medical condition such as, but not limited to: diabetes, asthma, or chronic
			 obstructive pulmonary disease. See billing instructions in the Hospital
			 Supplemental guide on the Division's website for additional
			 information.
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 125 - HOSPITAL SERVICES › Section 410-125-0450 - Provider Preventable Conditions

Current through Register Vol. 63, No. 7, July 1, 2024
(1) Health Care-Acquired Conditions (HCAC):
(a) Formally known as Medicare's list of
			 "hospital acquired conditions" (HAC) that apply to inpatient hospital settings
			 with dates of admission on or after January 1, 2011 except those hospitals
			 exempt from the reporting requirements.
(b) For inpatient hospital admissions on or
			 after July 1, 2012, all in-state, contiguous and non-contiguous hospitals must
			 report health care-acquired conditions.
(A) A
			 HCAC is a condition that is reasonably preventable and was not present or
			 identified at the hospital admission.
(B) A "present on admission" (POA) indicator
			 is a status code the hospital uses on an inpatient claim that indicates if a
			 condition was present at the time the order for inpatient admission occurs. A
			 POA indicator can also identify a condition that developed during an outpatient
			 encounter. This includes, but is not limited to the emergency department,
			 observation, and outpatient surgery.
(C) The Division of Medical Assistance
			 Program (Division) shall use the most recent list of conditions identified as
			 non-payable by Medicare. The Division may revise through addition or deletion
			 the selected conditions at any time during the fiscal year.
(D) Diagnosis-related groups (DRG) and
			 percentage paid hospitals must submit a POA indicator for the principal
			 diagnosis and every secondary diagnosis code. A valid POA indicator must be
			 included all inpatient hospital claims. Claims without a valid POA indicator
			 shall be denied.
(E) Critical
			 Access Hospitals (CAH) must implement the POA reporting requirements by
			 September 1, 2013.
(F) For a
			 complete list of HCACs and billing instructions please see the hospital
			 supplemental guide.
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 125 - HOSPITAL SERVICES › Section 410-125-0550 - X-Ray or EKG Procedures Furnished in Emergency Room

Current through Register Vol. 63, No. 7, July 1, 2024
The Division pays for only one interpretation of an x-ray or
				EKG procedure furnished to an emergency room patient, and that is for the
				interpretation and report that directly contributed to the diagnosis and
				treatment of the patient. A second interpretation of an x-ray or EKG is
				considered to be for quality control purposes only, and is not reimbursable.
				Payment will be made for a second interpretation only under unusual
				circumstances, such as questionable finding for which the physician performing
				the initial interpretation believes another physician's expertise is
				needed.
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 410-125-0600 - Non-Contiguous Out-of-State Hospital Services

Current through Register Vol. 63, No. 7, July 1, 2024
(1) Non-contiguous out-of-state hospitals are
			 those hospitals located more than 75 miles from the Oregon border.
(2) The hospital must be enrolled as a
			 provider with Oregon Medical Assistance Programs to receive payment. Contact
			 the Division for information on enrollment.
(3) Billings are sent to the
			 Division.
(4) When the service
			 provided is emergent or urgent, no prior authorization is required. The claim
			 should be sent to the Division along with documentation supporting the emergent
			 or urgent requirement for treatment.
(5) In a non-emergency situation, prior
			 authorization is required for all services. Contact the Division.
(6) Claims must be billed on the electronic
			 837I or on a paper CMS 1450 (UB-04), unless other arrangements are made for
			 billing through the Division.
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 410-125-0620 - Special Reports and Exams and Medical Records

Current through Register Vol. 63, No. 7, July 1, 2024
Refer to the Division Administrative Exams and Reports Billing
				rules (chapter 410 division 150) for information and instructions on billing
				for administrative exams and reports.
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 410-125-0640 - Third Party Payers - Other Resources, Client Responsibility and Liability

Current through Register Vol. 63, No. 7, July 1, 2024
(1)
			 Medicare: Do not send claims to the Division of Medical Assistance Programs
			 (Division) until they have been billed to and adjudicated by Medicare:
(a) Exception: Take home drugs and other
			 services, which are not covered by Medicare, may be billed directly to the
			 Division without billing Medicare first;
(b) See: billing instructions in the Hospital
			 Services Supplemental Information on the Division website for additional
			 information on billing Medicare claims.
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 125 - HOSPITAL SERVICES › Section 410-125-0641 - Medicare

Current through Register Vol. 63, No. 7, July 1, 2024
(1) A
			 Medicare/Medicaid claim can automatically be sent to the Division after
			 adjudicated by Medicare. This saves the effort of a second submission, as well
			 as ensuring a more accurate and speedier payment by the Division. Medicare will
			 automatically transmit the correct Medicare payment, coinsurance, and
			 deductible information to the Division.
(2) Hard copy billings sent to Medicare can
			 also be automatically sent to the Division. Refer to the Hospital Services
			 Supplemental Information for specific billing instructions.
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 410-125-0720 - Adjustment Requests

Current through Register Vol. 63, No. 7, July 1, 2024
(1) Most
			 overpayment and under-payments are resolved through the adjustment process.
			 Only paid claims can be adjusted. If no payment was made, the claim must be
			 submitted using a CMS 1450 (UB-04) for processing. All overpayments must be
			 reported. Overpayments will be taken from future payments.
(2) Much of the information required on the
			 Adjustment Request Form is printed on the paper Remittance Advice or the
			 electronic 835. Documentation may be submitted to support the request. Attach a
			 copy of the claim and paper Remittance Advice or the electronic 835 to the
			 Adjustment Request (DMAP 1036). Adjustment requests must be submitted in
			 writing to the Division.
(3)
			 Complete adjustment instructions can be found in Hospital Services Supplemental
			 Information.
Publications: Publications 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 410-125-1020 - Filing of Cost Statement

Current through Register Vol. 63, No. 7, July 1, 2024
(1) The
			 hospital must file an annual Calculation of Reasonable Cost (DMAP 42), covering
			 the latest fiscal period of operation of the hospital with Division of Medical
			 Assistance Programs (Division):
(a) A
			 Calculation of Reasonable Cost statement is filed for less than an annual
			 period only when necessitated by the hospital's termination of their agreement
			 with the Division, a change in ownership, or a change in the hospital's fiscal
			 period;
(b) The hospital must use
			 the same fiscal period for the Division 42 as that used for its Medicare
			 report. If it doesn't have an agreement with Medicare, the hospital must use
			 the same fiscal period it uses for filing its federal tax return;
(c) The report must be filed for both
			 inpatient and outpatient services, even if the service is paid under a
			 prospective payment system or fee schedule (e.g., Diagnosis-Related Groups
			 (DRG) payments, outpatient clinical laboratory, etc.);
(d) In the absence of an agreement with
			 Medicare, the hospital must use the same fiscal period as that used for filing
			 their Federal tax return.
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 125 - HOSPITAL SERVICES › Section 410-125-1040 - Accounting and Record Keeping

Current through Register Vol. 63, No. 7, July 1, 2024
(1)
			 All records for a given fiscal period must be kept for three years after the
			 Medicare audit for that period has been finalized.
(2) Each hospital is required to make its
			 financial records available for auditing within the state of Oregon at a
			 location specified by the provider.
(3) All hospital records are subject to
			 inspection and review by the Division personnel and Department of Health and
			 Human Services personnel during the period the records are required to be
			 held.
(4) All expenses must be
			 documented in detail as a part of the record. All capital expenditures
			 requiring approval under the Certificate of Need process, and not having such
			 approval, will be disallowed.
(5)
			 Hospitals without a Medicare agreement must use the Hospital Administrative
			 Services (HAS) system of reporting.
(6) Record keeping and reporting must be
			 based on date of service, not date of payment. Billings for patients determined
			 by the Division to be eligible for Title XIX or Program 5 must be included as
			 accruals, even those billings not yet paid.
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 410-125-1070 - Type A and Type B Hospitals

Current through Register Vol. 63, No. 7, July 1, 2024
(1) Type A and Type B hospitals must submit
			 the following information to the Division of Medical Assistance Programs
			 (Division):
(a) The aggregate percent
			 increase in patient charges and the effective date of the increase within 30
			 days following the end of their fiscal year for increases in the preceding
			 year. Aggregate percent increase in patient charges is defined as the percent
			 increase in patient revenues due to charge increases; and
(b) The amount of payment received by the
			 hospital, from each Division contracted managed care plan and third-party
			 payers, for inpatient and outpatient hospital services provided to managed care
			 members, within the hospital's fiscal year.
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 125 - HOSPITAL SERVICES › Section 410-125-1080 - Documentation

Current through Register Vol. 63, No. 7, July 1, 2024
(1) Federal
			 regulations require Medicaid providers to maintain records that fully support
			 the extent of services for which payment has been requested, and that such
			 records be furnished to the Division upon request (42 CFR
			 431.107).
(2) When requested by the Division or its
			 medical review contractor, hospitals must submit sufficient medical
			 documentation to verify the emergency nature, medical necessity, quality and
			 appropriateness of treatment, and appropriateness of the length of stay for
			 inpatient and outpatient hospital services. The Division may request sufficient
			 information to evaluate the accuracy and appropriateness of ICD-10-CM Coding
			 for the claim. In addition, the Division may request an itemized billing for
			 all services provided. The Division will specify in its request what
			 documentation is required.
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 410-125-2000 - Access to Records

Current through Register Vol. 63, No. 7, July 1, 2024
(1) Providers
			 must furnish requested medical and financial documentation within 30 calendar
			 days from the date of request. Failure to comply within 30 calendar days shall
			 result in recovery of payment(s) made by the Division for services being
			 reviewed.
(2) The Division conducts
			 post payment review of admissions and claim records. The Division may request
			 records from a hospital or may request access to records while at the
			 hospital.
(3) The hospital has 30
			 days to provide the Division with copies of records. In some cases, there may
			 be a more urgent need to review records.
(4) The Medical Payment Recovery Unit (MPRU)
			 conducts recovery activities for the Division involving third party liability
			 resources. MPRU may request records from the hospital. This unit has the same
			 right to medical and financial information as the Division.
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 410-125-2020 - Post Payment Review

Current through Register Vol. 63, No. 7, July 1, 2024
(1) All
			 services provided by a hospital in the inpatient or outpatient setting are
			 subject to post-payment review by the Division. Both emergency and
			 non-emergency services may be reviewed. Claims for services may be reviewed to
			 determine:
(a) The medical necessity of the
			 admission or outpatient services provided;
(b) The appropriateness of the length of
			 stay;
(c) The appropriateness of
			 the plan of care;
(d) The accuracy
			 of the ICD-10 coding and DRG assignment;
(e) The appropriateness of the setting
			 selected for service delivery;
(f)
			 The quality of care of the services provided;
(g) The nature of any service coded as
			 emergent;
(h) The accuracy of the
			 billing;
(i) The care furnished is
			 appropriately documented.