reglab/statecodes huggingface dataset:
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 133 - SCHOOL-BASED HEALTH SERVICES › Section 410-133-0320 - Documentation and Record keeping Requirements

Current through Register Vol. 63, No. 7, July 1, 2024
(1) Record keeping must conform and adhere to
			 federal, state, and local laws and regulations.
(2) Records must record history taken,
			 procedures performed, tests administered, results obtained, and conclusions and
			 recommendations made. Documentation may be in the form of a "SOAP" (subjective
			 objective assessment plan) note, or equivalent.
(3) Providers will retain information
			 necessary to support claims submitted to the Authority including: documentation
			 and supervision of the specific health services provided, the extent of the
			 health service provided, the dates and the name and credentials of medically
			 qualified staff who provided the service to the Medicaid-eligible student for
			 seven years from date of payment. This documentation must meet the requirements
			 of and must be made available pursuant to the requirements in the General
			 Rules, OAR 410-120-1360  Requirements for Financial, Clinical and Other Records.
			 These requirements may be met if the information is included in the IEP or IFSP
			 and the school medical provider maintains adequate supporting documentation at
			 the time the service is rendered, consistent with the requirements of OAR
			 410-120-1360:
(a) Supporting documentation
			 should:
(A) Be accurate, complete, and
			 legible;
(B) Be typed or recorded
			 using ink;
(C) Be signed by the
			 individual performing the service including their credentials or
			 position;
(D) Be signed and
			 initialed in accordance with licensing board requirements for each clinical
			 entry by the individual performing the service;
(E) Be reviewed and authenticated by the
			 supervising therapist in compliance with their licensing board requirements
			 (Also see covered services 410-133-0080  and not covered services
			 410-133-0200.);
(F) Be for covered
			 health services provided as specified for the service period indicated on the
			 Medicaid-eligible student's current IEP or IFSP.
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 133 - SCHOOL-BASED HEALTH SERVICES › Section 410-133-0340 - Client Rights and Record Confidentiality

Current through Register Vol. 63, No. 7, July 1, 2024
(1) School Medical (SM) providers are
			 required to provide The Authority, the Division of Medical Assistance Programs
			 (Division), the Department of Justice Medicaid Fraud Unit, Oregon Secretary of
			 State, or the Department of Health and Human Services, or their authorized
			 representatives, access to Medicaid-eligible student medical records when
			 requested as a condition of accepting Medicaid reimbursement from he
			 Authority.
(2) Medicaid client
			 rights of confidentiality must be respected in accordance with the provisions
			 of  42 CFR Part 431, Subpart F and ORS
			 411.320.
(3) School Medical providers are also subject
			 to the confidentiality laws applicable to student records, including student
			 medical records maintained as part of the education record.
Publications referenced are available from the
				  agency.
Stat. Auth.: ORS
				  413.042
Stats. Implemented: ORS
				  192.410-192.505
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 134 - HEALTHIER OREGON › Section 410-134-0000 - Purpose

Current through Register Vol. 63, No. 7, July 1, 2024
(1) The purpose of
			 this OAR Chapter 410, division 134 is to set forth the rules that are specific
			 to the Healthier Oregon program.
(2) The Healthier Oregon program is a medical
			 assistance benefit package equal to OHP Plus defined and described in OAR
			 410-120-1210.
(3) The Healthier
			 Oregon program is funded with state and federal dollars as described in OAR
			 410-134-0004.
Statutory/Other Authority: ORS
				  413.042
Statutes/Other Implemented: ORS
				  413.042,
				  414.025,
				  414.065,
				  414.231 &
				  414.706
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 134 - HEALTHIER OREGON › Section 410-134-0001 - Acronyms and Definitions

Current through Register Vol. 63, No. 7, July 1, 2024
(1) The
			 following acronyms and definitions within this rule specifically apply to the
			 Healthier Oregon program in its entirety.
(a)
			 The Authority incorporates acronyms and definitions in OAR 410-141-3500, OAR
			 410-120-0000  and OAR 410-200-0015;
(b) The acronyms and definitions adopted by
			 the Department of Human Services (Department) in chapters 411, 413, and
			 461;
(c) Public Health Division
			 chapter 333 division 4 definitions;
(d) Behavioral Health Division chapter 309
			 division 19 definitions.
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 134 - HEALTHIER OREGON › Section 410-134-0002

Current through Register Vol. 63, No. 7, July 1, 2024
Statutory/Other Authority: ORS
				  413.042
Statutes/Other Implemented: ORS
				  413.042
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 134 - HEALTHIER OREGON › Section 410-134-0003 - Healthier Oregon and Healthier Oregon Cover All Kids Coverage

Current through Register Vol. 63, No. 7, July 1, 2024
(1) The Healthier
			 Oregon and Healthier Oregon Cover All Kids benefit package description,
			 benefits package identifier, eligibility criteria, and coverage is described in
			 this Rule.
(2) Healthier Oregon and
			 Healthier Oregon Cover All Kids benefit package descriptions:
(a) Benefit Package identifiers:
(A) BMH: for non-pregnant adults 21 and over
			 and Cover All Kids; or
(B) BMP: for
			 pregnant adults or individuals within their post-partum period, who are age 21
			 and over;
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 134 - HEALTHIER OREGON › Section 410-134-0004 - Billing

Current through Register Vol. 63, No. 7, July 1, 2024
(1) For information
			 about fraud and abuse refer to OAR 410-120-1510. For information about audits
			 refer to OAR 410-120-1396. For information about provider sanctions refer to
			 OAR 410-120-1397  through 1460.
(2)
			 The Authority will reimburse providers, when all billing requirements are met
			 pursuant to OAR 410-120-1280.
(3)
			 There is a list of conditions, always considered an emergency found at:
https://data.oregon.gov/Health-Human-Services/Oregon-Medicaid-CWM-Emergency-Diagnosis-Codes/4ppf-rfju/data
.
(a) CWM emergency claims, must use the
			 appropriate emergency admit type 1 for inpatient and outpatient
			 claims;
(b) or check the
			 appropriate emergency indicator on a professional claim.
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 134 - HEALTHIER OREGON › Section 410-134-0005 - Coverage and Billing for Citizenship Waived Medical and Citizenship Waived Medical Plus

Current through Register Vol. 63, No. 7, July 1, 2024
(1) The Citizenship
			 Waived Medical (CWM) and Citizenship Waived Medical Plus (CWM Plus) benefit
			 package ended on June 30, 2023. Prior to July 1, 2023, CWM Plus was referred to
			 as "CWX".
(2) Benefit and coverage
			 limitations for members who were eligible for, or retroactively determined to
			 be eligible for, the CWM and CWM Plus can be found under DMAP 65-2022, adopt
			 filed 06/30/2022, effective 07/01/2022.
(3) Citizenship Waived Medical (CWM) and CWM
			 Plus (previously referred to as "CWX") services delivered on or before June 30,
			 2023, may be billed if claims are timely submitted in accordance with OAR
			 410-120-1300. CWM and CWM Plus billing guidance can be found under DMAP
			 13-2023, minor correction filed 03/30/2023, effective 03/30/2023.
Statutory/Other Authority: ORS
				  413.042 & 414.065
Statutes/Other Implemented: ORS
				  413.042,
				  414.065, ORS
				  414.312,
				  414.430,
				  414.432 &
				  414.706
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 136 - MEDICAL TRANSPORTATION SERVICES › Section 410-136-3000 - Responsibility for Providing Non-emergent Medical Transportation

Current through Register Vol. 63, No. 7, July 1, 2024
(1) The Authority
			 shall provide non-emergent medical transportation (NEMT) for eligible clients
			 who receive their Oregon Health Plan (OHP) covered medical services on a
			 fee-for-service basis or are clients enrolled in coordinated care organizations
			 (CCO). The Authority shall discontinue providing this service to a client
			 enrolled in a CCO after the date the client is enrolled in a CCO. The CCO shall
			 provide and coordinate the service to their enrollees on and after the date of
			 the client's enrollment in the CCO pursuant to section (2) of this
			 rule.
(2) When a CCO begins
			 providing NEMT services for its enrollees, the Authority shall provide NEMT
			 services in the CCO's service area only to clients not enrolled in a CCO:
(a) The Authority may not pay for services
			 covered by a CCO. Reimbursement is a matter between the CCO and its
			 transportation brokerage and subcontractor. Reimbursement is a matter between
			 the CCO and its contracted brokerage and transportation providers;
(b) For clients enrolled in a CCO the
			 transportation provider must coordinate all transportation services with the
			 client's transportation brokerage or CCO prior to providing services.
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 136 - MEDICAL TRANSPORTATION SERVICES › Section 410-136-3010 - Coordinated Care Organizations

Current through Register Vol. 63, No. 7, July 1, 2024
(1)
			 The Authority contracts with Coordinated Care Organizations (CCOs) to provide
			 medical services for clients receiving Title XIX and Title XXI services for the
			 purpose of providing integrated and coordinated care services across physical
			 health, dental health, and non-emergent medical transportation (NEMT). OAR
			 chapter 410, division 120 including OAR 410-120-1210  describes services through
			 CCOs and division 141 including OAR 410-141-3920  through OAR 410-141-3965  describes NEMT requirements through CCOs.
(2) For clients enrolled in a CCO, NEMT
			 services are included in the budget provided to a CCO by the Authority. The CCO
			 shall provide NEMT services to its enrolled members.
(3) For clients enrolled in a CCO, all
			 transportation services must be coordinated through the member's CCO or the
			 CCO's designated transportation provider prior to receiving services.
Statutory/Other Authority: ORS
				  413.042 & ORS
				  414.625
Statutes/Other Implemented: ORS
				  414.625
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 136 - MEDICAL TRANSPORTATION SERVICES › Section 410-136-3020 - General Requirements for NEMT

Current through Register Vol. 63, No. 7, July 1, 2024
(1) The Authority may enroll governmental
			 transportation brokerages (local units of government) or other entities
			 contracted with the Authority as a "contractor" to arrange rides.
			 Transportation brokerages pay subcontractors for NEMT services. The Authority
			 may limit the enrollment with transportation brokerages to units of local
			 government; Transportation brokerages shall be enrolled as an Oregon Health
			 Plan (OHP) provider and meet all requirements of OAR 410-120-1260  prior to
			 delivering NEMT services or receiving payment. A governmental transportation
			 brokerage signing the Provider Enrollment Agreement constitute agreement to
			 comply with all applicable Authority OHP provider rules and federal and state
			 laws and regulations.
(2) The
			 actions described in this rule may not be delegated and must be performed by
			 the brokerage contracted with the Authority. The brokerage shall:
(a) Prior authorize and pay subcontractors
			 for the least costly but most appropriate mode of transport for the client's
			 medical needs to and from an OHP covered medical service. The most appropriate
			 and least costly ride may include requiring the client to share the ride with
			 other clients;
(b) Verify that the
			 client is obtaining OHP covered medical services in the client's local
			 area;
(c) Verify the client's OHP
			 eligibility and that the client's benefit package includes NEMT services on the
			 scheduled date of service for the requested transport. The brokerage shall
			 verify this through electronic eligibility information with the Authority
			 Electronic Data Interchange (EDI);
(d) Assess the client's access to other means
			 of transportation, such as driving their own car or getting a ride from a
			 friend, family member or neighbor;
(e) Verify the client's attendance for
			 continuing requests for rides if the medical provider could not affirm an
			 appointment for a previous ride;
(f) Schedule a ride with an alternate
			 subcontractor if the subcontractor originally assigned is unable to provide the
			 ride; and
(g) Assign rides to the
			 subcontractor based on an evaluation of several factors including, but not
			 limited to:
(A) Cost;
(B) The client's need for appropriate
			 equipment and transportation;
(C)
			 Any factors related to a subcontractor's capabilities, availability, and past
			 performance; and
(D) Any factors
			 related to the brokerage's need to maintain sufficient service capacity to meet
			 client needs.
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 136 - MEDICAL TRANSPORTATION SERVICES › Section 410-136-3040 - Vehicle Equipment and Subcontractor Standards

Current through Register Vol. 63, No. 7, July 1, 2024
(1) Brokerages shall require all
			 subcontractors, providers, and drivers to maintain their vehicles for the
			 comfort and safety of the clients. The vehicles shall meet the following
			 requirements:
(a) The interior of the vehicle
			 shall be clean;
(b) The
			 subcontractor, provider, or driver shall not smoke, aerosolize or vaporize an
			 inhalant or permit smoking, aerosolizing or vaporizing of an inhalant in the
			 vehicle at any time; and
(c) The
			 subcontractor, provider, or driver shall comply with appropriate local, state,
			 and federal transportation safety standards regarding passenger safety and
			 comfort. The vehicle shall include, but is not limited to, the following safety
			 equipment:
(A) Safety belts for all
			 passengers if the vehicle is legally required to provide safety
			 belts;
(B) A first aid
			 kit;
(C) A fire
			 extinguisher;
(D) Roadside
			 reflective or warning devices;
(E)
			 A flashlight;
(F) Tire traction
			 devices when appropriate;
(G)
			 Disposable gloves; and
(H) All
			 equipment necessary to transport clients using wheelchairs or stretchers in
			 accordance with the Americans with Disabilities Act of 1990 (as amended) (ADA),
			 Section 504 of the Rehabilitation Act of 1973, and Oregon Revised Statute
			 659A.103 if the subcontractor, provider, or driver uses the vehicle for these
			 modes of transport.
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 136 - MEDICAL TRANSPORTATION SERVICES › Section 410-136-3060 - Insurance Requirements

Current through Register Vol. 63, No. 7, July 1, 2024
(1)
			 Brokerages must obtain and maintain general and automobile liability coverage
			 for personal injury and death in accordance with ORS
			 30.271, Limitations on Liability
			 of State for Personal Injury and Death.
(2) Brokerages must obtain and maintain
			 general and automobile liability coverage for property damage and destruction
			 in accordance with ORS
			 30.273, Limitations on Liability
			 of Public Bodies for Property Damage or Destruction.
(3) The liability coverage required by
			 sections (1) and (2) of this rule shall include the State of Oregon, the
			 Authority and its divisions, officers, employees, and agents as additional
			 insureds but only as related to the brokerages' NEMT services.
(4) In lieu of purchasing liability coverage
			 under sections (1) and (2) of this rule, the Authority may authorize a
			 brokerage to establish and maintain a Self-Insurance Reserve Fund. The
			 following apply to requirements of the fund:
(a) The Authority shall establish the fund at
			 $1 million through the fixed rate for rides established in OAR 410-136-3200,
			 Reimbursement and Accounting for all Modes of Transport;
(b) The fund shall comply with Federal
			 Acquisition Regulation (FAR) Office of Management and Budget (OMB) Circular
			 87;
(c) If the brokerage
			 subsequently terminates its enrollment with the state as a Medicaid provider,
			 the brokerage shall refund the Authority the balance of any monies in the fund
			 within two (2) years from the termination of its enrollment or at the
			 conclusion of any claim or litigation related to the brokerage's NEMT services
			 for eligible clients;
(d) Once
			 funded, the fund shall be maintained at an amount not less than $1 million
			 through the fixed rate for rides established in OAR 410-136-3200, Reimbursement
			 and Accounting for all Modes of Transport;
(e) The Authority shall reconcile the fund
			 amount during the annual cost settlement process pursuant to OAR 410-136-3200,
			 Reimbursement and Accounting for all Modes of Transport, and shall increase or
			 decrease the fixed rate for rides to maintain the $1 million fund amount;
			 and
(f) The brokerage shall
			 maintain a separate account for the fund.
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 136 - MEDICAL TRANSPORTATION SERVICES › Section 410-136-3080 - Out-of-State Transportation

Current through Register Vol. 63, No. 7, July 1, 2024
(1)
			 "Out-of-state transportation" means transportation to or from any location
			 outside Oregon, with the exception of contiguous areas up to 75 miles outside
			 the Oregon border.
(2) The
			 brokerage shall arrange rides and pay for out-of-state transportation, as
			 defined in section (1) of this rule, to and from an out-of-state OHP covered
			 medical service when:
(a) The brokerage
			 confirms that the Authority authorized the out-of-state OHP covered medical
			 service per OAR 410-120-1180, Medical Assistance Benefits: Out-of-State
			 Services or the CCO authorized per OAR 410-141-3930  Transportation:
			 Out-of-Service Area and Out-of-State Transportation; and
(b) The client is eligible for transportation
			 services per OAR 410-136-3020, General Requirements for NEMT.
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 136 - MEDICAL TRANSPORTATION SERVICES › Section 410-136-3100 - Attendants for Child Transports

Current through Register Vol. 63, No. 7, July 1, 2024
(1)
			 This rule applies to non-emergent medical transportation (NEMT) for children
			 twelve (12) years of age and under who are eligible for NEMT services to and
			 from Oregon Health Plan (OHP) covered medical services. The rule also applies
			 to children and young adults with special physical or developmental needs,
			 regardless of age, hereafter referred to as "child" or "children."
(2) Parents or legal guardians must provide
			 an attendant to accompany the children while traveling to and from medical
			 appointments except when:
(a) The driver is a
			 DHS volunteer, DHS employee or an Authority employee;
(b) The child requires secured transport per
			 OAR 410-136-3120, Secured Transports; or
(c) An ambulance subcontractor transports the
			 child for NEMT services, and the brokerage reimburses the ambulance
			 subcontractor at the ambulance transport rate.
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 136 - MEDICAL TRANSPORTATION SERVICES › Section 410-136-3120 - Secured Transports

Current through Register Vol. 63, No. 7, July 1, 2024
(1) Secured
			 transport NEMT services are for the involuntary transport of clients who are in
			 danger of harming themselves or other individuals. Secured transports are
			 allowable when:
(a) The brokerage verified
			 that the subcontractor has met the requirements of the secured transport
			 protocol pursuant to OAR 309-033-0200  through 309-033-0970, and, therefore, the
			 subcontractor is able to transport the client who is in crisis or at immediate
			 risk of harming themselves or others due to mental or emotional problems or
			 substance abuse; and
(b) The
			 transport is to a Medicaid enrolled facility that the Authority recognizes as
			 being able to treat the immediate medical or behavioral health care needs of
			 the client in crisis.
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 136 - MEDICAL TRANSPORTATION SERVICES › Section 410-136-3140 - Transports of Clients Changing Hospitals or Other Facilities

Current through Register Vol. 63, No. 7, July 1, 2024
(1) Brokerages
			 shall arrange and pay for transporting an eligible client who has had a change
			 in condition, noted in the client's Oregon Department of Human Services (ODHS)
			 care plan, resulting in a need for a new service setting with a lower or higher
			 level of care. This includes clients who are changing levels of care between
			 their community-based care settings or between institutional and
			 community-based settings. The client's ODHS worker must request the
			 ride.
(2) Brokerages shall not
			 arrange or pay for:
(a) The transport or
			 return of an inpatient client from an admitting hospital to another hospital
			 (or facility) for diagnostic or other short-term services when the patient will
			 return to the admitting hospital within the first 24-hours of admission. The
			 subcontractor shall bill the admitting hospital directly for these
			 transports;
(b) The transport of a
			 client receiving long-term care service in their home or residing in a
			 long-term care facility for the sole purpose of shopping for another long-term
			 care facility, even if the client is looking for a new facility to receive a
			 lower or higher level of care;
(c)
			 The transport of a client moving from one type of facility to a facility of the
			 same type, such as from an adult foster home to another adult foster home;
			 and
(d) The transport of a client
			 who is relocating to another state, unless the transport is to receive an OHP
			 covered medical service pursuant to OAR 410-136-3080, Out-of-State
			 Transportation.
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 136 - MEDICAL TRANSPORTATION SERVICES › Section 410-136-3160 - Ground and Air Ambulance Transports

Current through Register Vol. 63, No. 7, July 1, 2024
(1) Transporting a client via ambulance is
			 required when a medical facility or provider states the client's medical
			 condition requires the presence of a health care professional during the
			 emergency or non-emergency transport. This includes neonatal
			 transports.
(2) For non-emergent
			 medical transportation (NEMT) services, the brokerage shall authorize the
			 transport.
(3) Brokerages shall
			 provide ambulance or stretcher transports with a medical technician when:
(a) A client's medical condition requires a
			 stretcher;
(b) The length of
			 transport would require a personal care attendant; and
(c) The client does not have an attendant who
			 can assist with personal care during the ride.
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 136 - MEDICAL TRANSPORTATION SERVICES › Section 410-136-3180 - Reimbursement for Ground and Air Ambulance Transports

Current through Register Vol. 63, No. 7, July 1, 2024
(1) The following applies to how the Oregon
			 Health Authority (Authority) shall reimburse providers of NEMT ground and air
			 ambulance services that brokerages arrange for eligible clients. This applies
			 to clients receiving services through the fee-for-service delivery system or a
			 Coordinated Care Organization (CCO).
(2) Brokerages shall submit documentation to
			 the Authority stating the brokerage authorized the transportation. The
			 documentation also shall inform the Authority to reimburse at the Authority's
			 base rate or another amount the brokerage specifies. Ambulance providers shall
			 bill the Authority for payment of authorized rides.
(3) If brokerage does not specify another
			 amount, the Authority's reimbursement shall include:
(a) The base rate established in the
			 Authority's fee schedule posted on the OHP Web page at
www.oregon.gov/OHA/HSD/OHP/Pages/Fee-Schedule.aspx
.
			 The base rate for NEMT ground and air ambulances includes:
(A) Any procedures or services provided, all
			 medications, non-reusable supplies or oxygen and all direct or indirect costs.
			 "Indirect costs" include general operating costs, personnel costs, neonatal
			 intensive care teams employed by the ambulance subcontractor, use of reusable
			 equipment and any other miscellaneous medical items or special handling that
			 may be required in the course of transport;
(B) The first ten miles for ground ambulance
			 transports; and
(C) Mileage for air
			 ambulance transports.
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 136 - MEDICAL TRANSPORTATION SERVICES › Section 410-136-3200 - Reimbursement and Accounting for all Modes of Transports

Current through Register Vol. 63, No. 7, July 1, 2024
(1) The following applies to the rate the
			 Oregon Health Authority (Authority) pays brokerages:
(a) The Authority shall calculate and pay a
			 brokerage a fixed rate for rides based on the following formula: Direct costs
			 plus indirect costs divided by the number of projected monthly rides. "Direct
			 costs" are transportation costs plus administrative costs;
(b) The Authority shall notify the brokerages
			 of their specific ride rates; and
(c) The Authority shall assess any needed
			 modifications to this rate:
(A)
			 Quarterly;
(B) When the Authority
			 changes any program affecting eligibility or scope; or
(C) If other factors impact the brokerage's
			 cost of delivering service.
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 136 - MEDICAL TRANSPORTATION SERVICES › Section 410-136-3220 - Brokerage Reimbursements to Subcontractors

Current through Register Vol. 63, No. 7, July 1, 2024
(1) Brokerages shall reimburse their
			 non-emergent medical transportation (NEMT) subcontractors for the most
			 cost-effective route from point of origin to point of destination that most
			 benefits the client's condition.
(2) Brokerages shall establish a base rate
			 with its subcontractors. "Base rate" for all modes of transportation except
			 ground and air ambulance means the rate the brokerage and its subcontractors
			 agree on for each mode of transportation.
(3) If a subcontractor uses an ambulance as a
			 stretcher car or van, the brokerage shall reimburse the subcontractor using the
			 base rate for stretcher cars or vans.
(4) As an exception section (3) of this rule,
			 brokerages shall pay ambulance subcontractors at the ambulance rate instead of
			 the stretcher car or van rate when the transport exceeds two hours,
			 necessitating a health care professional to care for the client during the
			 ride.
(5) Brokerages shall not
			 reimburse their subcontractors for waiting for clients to get to the vehicle or
			 for assisting clients to get in or out of a vehicle.
(6) Brokerages may reimburse their
			 subcontractors for waiting time:
(a) In
			 special situations, such as when the subcontractor must wait for a client who
			 is using the subcontractor's gurney and cannot transfer to a gurney at a
			 medical facility; or
(b) Because of
			 a medical issue during the ride, such as:
(A)
			 The client is nauseous or is vomiting after dialysis or chemotherapy;
			 or
(B) The client needs to stop to
			 get prescription medication or medical supplies related to the medical
			 service.
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 136 - MEDICAL TRANSPORTATION SERVICES › Section 410-136-3240 - Client Reimbursed Mileage, Meals and Lodging

Current through Register Vol. 63, No. 7, July 1, 2024
(1) The brokerage must prior authorize a
			 client's mileage, meals, and lodging to an Oregon Health Plan (OHP) covered
			 medical service in order for the client to qualify for reimbursement. If the
			 brokerage prior authorized the travel costs, a client may request reimbursement
			 up to 45 days after the travel.
(2)
			 The client must return any documentation the brokerage requires before
			 receiving reimbursement. Documentation required shall include a receipt for
			 lodging.
(3) A client must be
			 reimbursed within fourteen (14) days of the brokerage after verification of the
			 client's attendance at the appointment for the reimbursement request received.
(a) A brokerage may hold reimbursements under
			 the amount of $10 until the client's reimbursement reaches $10; or
(b) A brokerage must issue the client a
			 notice within fourteen (14) days if the client reimbursement is denied for any
			 reason. If the client reimbursement request is incomplete the brokerage shall
			 take an additional fourteen (14) days to assist the client in completing the
			 submission;
(c) The fourteen (14)
			 days in section (3) of this rule occur after a client requests
			 reimbursement.
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 136 - MEDICAL TRANSPORTATION SERVICES › Section 410-136-3260 - Modifications Based on Client Circumstances

Current through Register Vol. 63, No. 7, July 1, 2024
(1) A client may request modification of
			 non-emergent medical transportation (NEMT) services when the NEMT driver:
(a) Threatens to harm the client or others in
			 the vehicle;
(b) Drives or engages
			 in other behavior that places the client or others in the vehicle at risk of
			 harm; or
(c) Presents a perceived
			 or direct threat to the client or others in the vehicle.
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 136 - MEDICAL TRANSPORTATION SERVICES › Section 410-136-3280 - Client Rights and Confidentiality

Current through Register Vol. 63, No. 7, July 1, 2024
(1) Brokerages shall treat all information
			 gathered on the client as privileged and confidential communications. The
			 brokerage shall apply confidentiality policies to all requests for information
			 from outside sources. Nothing prohibits the disclosure of information in
			 summaries, statistical reports or other forms as long as the document does not
			 identify particular individuals and cannot lead to the identification of
			 individuals. Brokerages and any subcontractors may share information as
			 necessary to serve the client effectively. The brokerage shall not divulge the
			 information without the written consent of the client, the responsible parent
			 of a minor child or the client's legal guardian. The use or disclosure of
			 information is limited to persons directly administrating NEMT
			 services.
(2) Brokerages and their
			 subcontractors shall comply with OAR 943-014-0300  through 943-014-0320  pertaining to access control if the Authority grants them access to any secure
			 computer system or information asset.
(3) Brokerages and their subcontractors shall
			 comply with the Authority's non-discrimination and modification rules found at
			 OAR 943-005-0000  to 943-005-0070.
(4) The brokerage shall not deny or allow
			 subcontractors to deny any client NEMT services based on race, color, sex,
			 gender, gender identity, gender presentation, sexual orientation, religion,
			 national origin, creed, marital status, age, health status or the presence of
			 any sensory, mental, intellectual, developmental, IQ score, or physical
			 disability.
(5) Brokerages must
			 treat clients and require subcontractors and all drivers to treat clients in
			 accordance with OAR 410-120-1855, Client Rights and Responsibilities, including
			 but not limited to:
(a) To ensure clients and
			 their representatives have communications and materials explained in their
			 preferred spoken or sign language;
(b) To ensure clients receive written
			 materials describing rights, responsibilities, benefits available, how to
			 access services, and what to do in an emergency.
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 136 - MEDICAL TRANSPORTATION SERVICES › Section 410-136-3300 - Reports and Documentation

Current through Register Vol. 63, No. 7, July 1, 2024
(1)
			 Brokerages shall maintain documentation of rides denied and rides provided to
			 clients. This documentation shall include, but is not limited, to:
(a) The name of the client and the person
			 requesting the ride on behalf of the client, if applicable;
(b) The client's Oregon Health Plan (OHP)
			 medical care identification number;
(c) The date and time of the request for
			 transportation;
(d) The mode of
			 transport authorized for the client and a justification for authorizing a mode
			 of transport that is not reasonably understandable;
(e) The location for picking-up the client
			 and the destination;
(f) The
			 medical reason for the appointment;
(g) The availability of other transportation
			 resources and the justification for authorizing a ride when the client has
			 other resources;
(h) The
			 subcontractor assigned to give the ride and the date and time the brokerage
			 notified the subcontractor of the assignment;
(i) The name of the employee who approved a
			 ride and the name of the driver for the ride, as applicable; and
(j) In the case of a denial of a ride:
(A) The name of the employee who denied a
			 ride;
(B) The name of the employee
			 who performed the secondary review before denying the ride;
(C) The reason for the denial and the
			 applicable OAR that supports the denial;
(D) The date on the notice of action the
			 brokerage mailed to the client;
(E)
			 Documentation on the brokerage's review, resolution, or disposition of the
			 matter, if applicable, including the reason for the decision and the date of
			 the resolution or disposition; and
(F) Notations of oral and written
			 communications with the client and documentation of the outcome of any appeal
			 of a denied service.
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 136 - MEDICAL TRANSPORTATION SERVICES › Section 410-136-3320 - Audits

Current through Register Vol. 63, No. 7, July 1, 2024
(1) The Oregon
			 Health Authority (Authority), the Oregon Secretary of State Audits Division,
			 the Oregon Department of Justice, Medicaid Fraud Control Unit (MFCU) and the
			 federal government may audit the brokerage's and its subcontractor's records at
			 least annually. When the Authority determines that an overpayment has been made
			 to a brokerage, the amount of overpayment is subject to recovery. The audit
			 shall include, but is not limited to, the following areas:
(a) Financial status;
(b) Performance and quality of the
			 service;
(c) Efficiency and
			 effectiveness of the program's operation; and
(d) The relationship between the funds
			 provided by the Authority and the amounts expended by brokerages or billed by
			 subcontractors and that the use of funds is reasonable and necessary to provide
			 quality service.
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 136 - MEDICAL TRANSPORTATION SERVICES › Section 410-136-3340 - Brokerage Service Areas

Current through Register Vol. 63, No. 7, July 1, 2024
(1)
			 Brokerages enrolled with the Oregon Health Authority (Authority) shall arrange
			 and pay for NEMT services to all eligible clients in the counties shown in
			 Table 136-3340.
(2) Oregon Health
			 Plan (OHP) clients shall use only the brokerages available in their county of
			 residence unless they have permission from their local brokerage to use another
			 brokerage.
(3) Nothing in this rule
			 precludes brokerages from coordinating to provide rides to clients in another
			 brokerage if it would be more cost effective or provide better service for the
			 client.
Table referenced is available from the Oregon Health
				  Authority (OHA) and on the Authority's website.
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 136 - MEDICAL TRANSPORTATION SERVICES › Section 410-136-3360 - Discontinuation of Brokerage as Enrolled Provider

Current through Register Vol. 63, No. 7, July 1, 2024
(1) A brokerage may discontinue being an
			 enrolled provider for NEMT services only with notice to the Oregon Health
			 Authority (Authority). The following establishes the requirements for notice:
(a) If the reason is for the brokerage's
			 convenience:
(A) The effective date must be
			 at least 90 days after the brokerage sends written notice; and
(B) the effective date must be on the first
			 calendar date of the month.
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 136 - MEDICAL TRANSPORTATION SERVICES › Section 410-136-3370 - General Requirements for GEMT

Current through Register Vol. 63, No. 7, July 1, 2024
(1) The Ground Emergency Medical
			 Transportation (GEMT) program is a voluntary program that makes supplemental
			 payments to eligible GEMT providers who furnish qualifying emergency ambulance
			 services to Oregon Health Authority (Authority) Medicaid recipients:
(a) The supplemental payment covers the gap
			 between the eligible GEMT provider's total allowable costs for providing GEMT
			 services as reported on the Centers for Medicare and Medicaid Services (CMS)
			 approved cost report and the amount of the base payment, mileage, and all other
			 sources of reimbursement;
(b) The
			 Authority makes supplemental payments only up to the amount uncompensated by
			 all other sources of reimbursement. Total reimbursements from Medicaid
			 including the supplemental payment may not exceed one hundred percent of actual
			 costs;
(c) The supplemental
			 payments shall be made at least annually on a lump-sum basis after the
			 conclusion of each state fiscal year. These payments are not an increase to
			 current fee-for-service (FFS) reimbursement rates;
(d) This supplemental payment applies only to
			 GEMT services rendered to Oregon FFS Medicaid recipients by eligible GEMT
			 providers on or after July 1, 2017.
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 136 - MEDICAL TRANSPORTATION SERVICES › Section 410-136-3371 - Provider Requirements and Payment Processing for the CCO GEMT Supplemental Payments

Current through Register Vol. 63, No. 7, July 1, 2024
(1) Definitions:
(a) "Coordinated Care Organization" has the
			 meaning defined in OAR 410-141-3500.
(b) "Ground Emergency Medical Transportation
			 Provider" and "GEMT Provider" each means a GEMT provider that meets all the
			 eligibility requirements as defined in the
			 42 CFR §
										438.6(c) Preprint.
(c) "Ground Emergency Medical Transportation
			 Services" and "GEMT Services" each means the act of transporting an individual
			 by ground from any point of origin to the nearest medical facility capable of
			 meeting the emergency medical needs of the patient as described in the
			 42 CFR §
										438.6(c) Preprint.
(d) "Managed Care Entity" has the meaning
			 defined in OAR 410-141-3500.
(e)
			 "Participating Provider" has the meaning defined in OAR 410-141-3500.
(f) "Qualified Directed Payment" means a
			 supplemental payment made by the Authority to CCOs for GEMT providers'
			 qualifying services when rendered by provider classes as defined in
			 42 CFR §
										438.6(c) Preprint forms
			 approved by Centers for Medicare and Medicaid Services (CMS).
(g) "Supplemental Payment" means a payment
			 amount set by the Authority for each approved procedure code to supplement
			 allowable costs for GEMT services.
(h) "§438.6(c) Preprint" means a
			 42 CFR §
										438.6(c) Preprint approved
			 by U.S. Department of Health and Human Services CMS for Qualified Directed
			 Payments to GEMT Providers for GEMT Services rendered during the applicable CCO
			 contract rating period.
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 136 - MEDICAL TRANSPORTATION SERVICES › Section 410-136-3372 - General Requirements for Ground Emergency Medical Transportation Emergency Medical Services Transport Private Provider Program

Current through Register Vol. 63, No. 7, July 1, 2024
(1) The Ground Emergency Medical
			 Transportation (GEMT) Emergency Medical Services Transport (EMST) private
			 provider program makes supplemental payments to eligible GEMT EMST private
			 providers who furnish qualifying emergency ambulance services to Oregon Health
			 Authority (Authority) Medicaid recipients:
(a) The supplemental payment is for an add-on
			 reimbursement fee to the base rates for eligible emergency medical
			 transportation services. The supplemental payment is an add on to the base
			 rates for eligible emergency medical transportation services, excludes
			 Emergency Medical Services (EMS) air transports. The calculation is based on
			 the gross receipts reported on the Centers for Medicare and Medicaid Services
			 (CMS) approved data request template;
(b) The Authority makes supplemental payments
			 only up to the amount calculated by the gross receipts. Total reimbursements
			 from Medicaid including the supplemental payment may not exceed one hundred
			 percent of actual costs;
(c) The
			 supplemental payment shall cover GEMT EMST private providers and shall be
			 applied in lump sum payment at least annually to eligible providers using the
			 Healthcare Common Procedure Coding System (HCPCS) emergency transport codes.
			 OHA will apply the supplemental payment only to GEMT EMST private provider
			 services rendered to FFS Medicaid members by eligible GEMT EMST Private
			 Providers on or after April 1, 2023;
(d) The supplemental payments shall be made
			 at least annually;
(e) The base
			 rates for GEMT EMST private providers shall not change with this amendment to
			 Oregon's Medicaid's State Plan that authorizes federal participation in this
			 program.
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 136 - MEDICAL TRANSPORTATION SERVICES › Section 410-136-3373 - Ground Emergency Medical Transportation - Emergency Medical Services Transport Private Provider Program - Quality Assurance Fee Requirements and Qualifications

Current through Register Vol. 63, No. 7, July 1, 2024
(1)
			 Quality Assurance Fee (QAF) assessment for the Ground Emergency Medical
			 Transportation (GEMT) Emergency Medical Services Transport (EMST) private
			 provider program:
(a) The amount of the QAF
			 is assessed at least annually;
(b)
			 The amount of the QAF is five percent (5%) of the gross receipts for the
			 12-month period for the calendar year. The amount of the QAF collected in
			 calendar year 2022 or until the Coordinated Care Organizations (CCO) portion of
			 the program is established will be less than the 5% to only account for the Fee
			 for Service portion of the total transports. Any projections must be based on
			 the data reported in the data request template;
(c) The eligible GEMT EMST private provider
			 shall file the data request template form approved by the Authority on or
			 before the 45th day following the term in which the assessment is due.
(A) The QAF payment shall be paid at the same
			 time required for filing the data request template form.
(B) The GEMT EMST private provider shall
			 provide all information required on the data request template form when
			 due.
(C) Failure to file or pay
			 when due shall be a delinquency;
(d) GEMT EMST private provider shall report
			 the data in the data request template form five business days after the date
			 upon which the report is due. The Authority shall notify qualified providers
			 not less than thirty days prior to the due date. After sending written notice
			 to GEMT EMST private provider, the Authority may impose a penalty of $100 per
			 day against GEMT EMST private provider for every day that the report is
			 overdue. Any funds resulting from the penalty imposed under this section shall
			 be deposited in the General Fund to be available for general governmental
			 purposes; and
(e) All QAFs and
			 interest collected shall be deposited into the Emergency Medical Services Fund
			 established.