reglab/statecodes huggingface dataset:
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 147 - FQHC AND RHC SERVICES › Section 410-147-0480 - Cost Statement Instructions

Current through Register Vol. 63, No. 7, July 1, 2024
(1) The Division of Medical Assistance
			 Programs (Division) requires federally qualified health centers (FQHC) to
			 submit Cost Statements (DMAP 3027).
(2) Rural health clinics (RHCs) can choose to
			 submit either their Medicare Cost Report or the Cost Statement (DMAP 3027). If
			 the RHC files a Medicare Cost Report, the Division may request additional
			 information.
(3) The Division
			 reimburses some services, items and supplies fee-for-service, outside of a FQHC
			 or RHC's Prospective Payment System (PPS) encounter rate. For this reason,
			 clinics must exclude the costs for the following items from the cost statement:
(a) Contraceptive supplies and contraceptive
			 medications (see OAR 410-147-0280);
(b) Pharmacy. Requires separate enrollment,
			 refer to OAR chapter 410, division 121, Pharmaceutical Services Program
			 Rulebook for specific information;
(c) Durable medical equipment and supplies.
			 Requires separate enrollment, refer to OAR chapter 410, division 122, Durable
			 Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS);
(d) Targeted case management (TCM) services.
			 Requires separate enrollment, see OAR 410-147-0610, and refer to OAR chapter
			 410, division 138, Targeted Case Management for specific information;
			 and.
(e) Comprehensive
			 environmental lead investigation (refer to OAR 410-130-0245, Early and Periodic
			 Screening, Diagnostic and Treatment Program).
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 147 - FQHC AND RHC SERVICES › Section 410-147-0500 - Total Encounters for Cost Reports

Current through Register Vol. 63, No. 7, July 1, 2024
(1) Federally Qualified Health Centers and
			 Rural Health Clinics (FQHC/RHCs) are required to report the total number of
			 encounters for furnishing services outlined in
			 42
			 USC 1396d(a)(2)(C) and
			 1396d(a)(2)(B),
			 respectively.
(2) In general, the
			 Division of Medical Assistance Programs (DMAP) calculates a FQHC or RHC's
			 Prospective Payment System (PPS) encounter rate by dividing the total costs
			 incurred by a clinic for furnishing services as defined in
			 42
			 USC 1396d(a)(2)(B) or (C) by
			 the total number of all clinic visits, or "encounters." The intent of PPS is to
			 calculate the average cost of an encounter, and not the average cost of a
			 Medicaid billable encounter.
(3)
			 This rule provides guidance for cost reporting of all encounters. It is the
			 responsibility of the FQHC and RHC to report all encounters, except when
			 expressly directed not to elsewhere in this rule. FQHCs and RHCs are required
			 to include ALL:
(a) Encounters for all clients
			 regardless of payor;
(b) Encounters
			 for FQHC or RHC services that are not covered by Medicaid, Medicare, Third
			 Party Payor or other party, but otherwise have an associated cost for providing
			 the service whether billed to the client (e.g. uninsured, signed waiver on
			 file) or absorbed by the clinic; and;
(c) Encounters regardless of line placement
			 on the Health Evidence Review Commission's (HERC) Prioritized List of Health
			 Services. For the purpose of reporting encounters according to this rule,
			 encounters are not subject to the HERC Prioritized List, or service limitations
			 and benefit reductions implemented by the Division of Medical Assistance
			 Programs (DMAP).
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 147 - FQHC AND RHC SERVICES › Section 410-147-0520 - Depreciation

Current through Register Vol. 63, No. 7, July 1, 2024
OMB Circular A-87 and A-122, Section 13 is applicable with the
				following exception: depreciation and amortization must be calculated on a
				straight line basis less the estimated salvage value. The clinic must use the
				American Hospital Association guidelines "Estimated Useful Lives of Depreciable
				Hospital Assets" for determining asset lives when computing depreciation. For
				assets not covered by the guidelines and with costs of more than $500
				individually and $500 aggregate, the lives established by the clinic are
				subject to approval by Division of Medical Assistance Programs (Division).
				Depreciation and amortization schedules must be maintained.
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 147 - FQHC AND RHC SERVICES › Section 410-147-0540 - Related Party Transactions

Current through Register Vol. 63, No. 7, July 1, 2024
(1) A
			 "related party" is an individual or organization that is associated or
			 affiliated with, or has control of, or is controlled by the Federally Qualified
			 Health Center (FQHC) or Rural Health Clinic (RHC) furnishing the services,
			 facilities, or supplies:
(a) "Common
			 ownership" exists if an individual or individuals possess significant ownership
			 or equity in the provider and the institution or organization serving the
			 provider;
(b) "Control" exists if
			 an individual or an organization has the power, directly or indirectly,
			 significantly to influence or direct the actions or policies of an organization
			 or institution.
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 147 - FQHC AND RHC SERVICES › Section 410-147-0560 - Sanctions

Current through Register Vol. 63, No. 7, July 1, 2024
(1) Providers are
			 directed to Division of Medical Assistance Programs' General Rules OARs
			 410-120-1400  Provider Sanctions and 410-120-1460  Type and Conditions of
			 Sanctions; and Department of Human Services Administrative Services Division
			 and Director's Office OAR 407-120-360 Consequences of Non-Compliance and
			 Provider Sanctions.
(2) OARs
			 410-120-1510  and 407-120-0380  govern fraud and abuse. The Department is
			 authorized to take the actions necessary to investigate and respond to
			 substantiated allegations of fraud and abuse, including but not limited to
			 suspending or terminating the provider from participation in the medical
			 assistance programs
Stat. Auth.: ORS
				  409.050,
				  409.110 &
				  414.065
Stats. Implemented: ORS
				  414.065
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 147 - FQHC AND RHC SERVICES › Section 410-147-0610 - Targeted Case Management (TCM)

Current through Register Vol. 63, No. 7, July 1, 2024
(1) Targeted Case Management (TCM) services
			 are provided and reimbursed through a separate program requiring enrollment as
			 a TCM provider.
(2) Refer to OAR
			 410 division 138, Targeted Case Management, for specific
			 requirements.
(3) If an FQHC or RHC
			 is participating in a TCM program, the clinic must notify the Division of
			 Medical Assistance Programs in writing and must include a description of the
			 TCM program. With the exception of maternity case management (MCM) services
			 authorized by OAR 410-147-0200, costs for TCM services cannot be included in a
			 clinic's cost statement and TCM services are prohibited from being billed
			 directly to the Division or a PHP under the FQHC or RHC's enrollment under OAR
			 410 division 147.
(4) A client may
			 only participate in a single TCM program. The Division does not allow multiple
			 TCM billings. This includes Maternity Case Management (MCM).
Stat. Auth.: ORS
				  409.050,
				  413.042 &
				  414.065
Stats. Implemented: ORS
				  414.065
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 148 - HOME ENTERAL/PARENTERAL NUTRITION AND IV SERVICES › Section 410-148-0000 - Foreword

Current through Register Vol. 63, No. 7, July 1, 2024
(1) The Home
			 Enteral/Parenteral Nutrition and IV Services rules are a user's manual designed
			 to assist providers in preparing health claims for medical assistance program
			 clients. The Home Enteral/Parenteral Nutrition and IV Services provider rules
			 are to be used in conjunction with the General Rules for Oregon Medical
			 Assistance Programs, the Oregon Health Plan administrative rules, the
			 Pharmaceutical Services Administrative Rules, and other relevant provider rules
			 and supplemental information.
(2)
			 The Home Enteral/Parenteral Nutrition and IV Services provider rules include
			 procedure codes with restrictions, and limitations. The Home EPIV code and fee
			 schedule, which is not a part of these rules, is not an exhaustive list of OHP
			 covered service codes. Please consult the Prioritized List of Health Services
			 for the Oregon Health Plan and the DMAP Maximum Allowable Table.
(3) The Division endeavors to furnish medical
			 providers with up-to-date billing, procedural information, and guidelines to
			 keep pace with program changes and governmental requirements.
(4) Providers should always follow the the
			 Division's administrative rules in effect on the date of service.
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 148 - HOME ENTERAL/PARENTERAL NUTRITION AND IV SERVICES › Section 410-148-0020 - Home Enteral/Parenteral Nutrition and IV Services

Current through Register Vol. 63, No. 7, July 1, 2024
(1) The Division of Medical Assistance
			 Programs (Division) will make payment for medically appropriate goods, supplies
			 and services for home enteral/parenteral nutrition and IV therapy on written
			 order or prescription.
(a) The order or
			 prescription must be dated and signed by a licensed prescribing practitioner,
			 legible and specify the service required, the ICD-10-CM diagnosis codes, number
			 of units and length of time needed.
(b) The prescription or written physician
			 order for solutions and medications must be retained on file by the provider of
			 service for the period of time specified in the Division's General Rules.
(c) An annual assessment and a new
			 prescription are required once a year for ongoing services.
(d) Also covered are services for
			 subcutaneous, epidural and intrathecal injections requiring pump or gravity
			 delivery.
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 148 - HOME ENTERAL/PARENTERAL NUTRITION AND IV SERVICES › Section 410-148-0040 - Requirements for Home Enteral/Parenteral Nutrition and IV Services

Current through Register Vol. 63, No. 7, July 1, 2024
(1) Home
			 Enteral/Parenteral Nutrition and IV Services:
(a) Home enteral/parenteral nutrition and IV
			 services must include training and/or education of client or support person on
			 nutritional supplement and /or equipment operation;
(b) When enteral/parenteral nutrition and IV
			 services are initiated in a hospital setting, reimbursement for training is
			 included in the hospital reimbursement and will not be made
			 separately;
(c) Reimbursement for
			 enteral/parenteral and IV services training when done in the home is included
			 in the payment for the nursing visit(s);
(d) Per diem reimbursement includes:
			 administrative service, pharmacy professional and cognitive services, including
			 drug admixture, patient assessment, clinical monitoring, and care coordination,
			 and all necessary infusion related supplies and equipment. Enteral/parenteral
			 formula, drugs and nursing visits are not included in per diem rates and must
			 be billed separately.
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 148 - HOME ENTERAL/PARENTERAL NUTRITION AND IV SERVICES › Section 410-148-0060 - Authorization

Current through Register Vol. 63, No. 7, July 1, 2024
(1) The Division of
			 Medical Assistance Programs (Division) requires authorization of payment for
			 the following items or services:
(a) All
			 enteral/parenteral or IV infusion pumps. The provider is required to submit
			 documentation with each request proving that other (non-pump) methods of
			 delivery do not meet the client's medical need;
(b) All nursing service visits, except the
			 assessment nursing visit, associated with home enteral/parenteral nutrition or
			 IV services;
(c) All oral
			 nutritional supplements;
(d) All
			 drugs and goods identified as requiring payment authorization in the
			 Pharmaceutical Services administrative rules (chapter 410, division 121).
			 Contact the Division's Pharmacy Benefit Manager to determine those items that
			 require prior authorization.
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 148 - HOME ENTERAL/PARENTERAL NUTRITION AND IV SERVICES › Section 410-148-0080 - Equipment Rental/Purchase/Repair

Current through Register Vol. 63, No. 7, July 1, 2024
(1) The following equipment shall be
			 authorized, if medically appropriate and when cost effective, on a rental basis
			 only:
(a) IV infusion pumps;
(b) Enteral formulae pumps.
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 148 - HOME ENTERAL/PARENTERAL NUTRITION AND IV SERVICES › Section 410-148-0095 - Client Copayments

Current through Register Vol. 63, No. 7, July 1, 2024
Copayments may be required for non-American Indian/Alaska
				Native clients for certain services. See OAR 410-120-1230  for specific
				details.
Stat. Auth.: ORS
				  413.042
Stats. Implemented: ORS
				  414.065
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 148 - HOME ENTERAL/PARENTERAL NUTRITION AND IV SERVICES › Section 410-148-0100 - Reimbursement

Current through Register Vol. 63, No. 7, July 1, 2024
(1) Drug
			 ingredients (medications) shall be reimbursed as defined in the Division of
			 Medical Assistance Programs (Division) Pharmaceutical Services administrative
			 rules (chapter 410, division 121).
(2) The following service/goods shall be
			 reimbursed on a fee-for-service basis according to the Division EPIV Fee
			 Schedule found in the Home Enteral/Parenteral Nutrition and IV Services on the
			 Division website:
(a) Enteral
			 formula;
(b) Oral nutritional
			 supplements which are medically appropriate and meet the criteria specified in
			 410-148-0260;
(c) Parenteral
			 nutrition solutions;
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 148 - HOME ENTERAL/PARENTERAL NUTRITION AND IV SERVICES › Section 410-148-0120 - Reimbursement Limitations for Clients in a Nursing Facility

Current through Register Vol. 63, No. 7, July 1, 2024
(1) The Division of Medical Assistance
			 Programs (Division) will not reimburse for the following services/supplies for
			 clients residing in a nursing facility:
(a)
			 Nursing service visits (including assessment visit). Refer to Aging and People
			 with Disabilities (APD) administrative rule covering all-inclusive
			 rate;
(b) Supplies and items
			 covered in the nursing facility All-inclusive rate. Refer to the Supplemental
			 Information section of the Home Enteral/Parenteral Nutrition and IV Services
			 provider website (
http://www.oregon.gov/OHA/HSD/OHP/Pages/Policy-Home-EPIV.aspx
)
			 for a listing of those supplies and items;
(c) Oral nutritional supplements that are in
			 addition to consumption of food items or meals.
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 148 - HOME ENTERAL/PARENTERAL NUTRITION AND IV SERVICES › Section 410-148-0140 - Billing Information

Current through Register Vol. 63, No. 7, July 1, 2024
(1) For
			 medications:
(a) Pharmacies billing
			 electronically bill through the Division of Medical Assistance Program
			 (Division) pharmacy benefit manager, point of sale. For more information on
			 point of sale, contact the DMAP pharmacy benefit manager's help desk;
(b) Only those pharmacies and Home
			 Enteral/Parenteral Nutrition and IV (EPIV) providers billing manually for
			 medications and home IV drug ingredients that are not billed through Point of
			 Sale may use the CMS 1500 claim form or the 837P electronic claim form
			 (instructions in home enteral/parenteral and IV services supplemental
			 guide;
(c) Providers who bill by
			 paper are required to complete a CMS 1500 claim form.
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 148 - HOME ENTERAL/PARENTERAL NUTRITION AND IV SERVICES › Section 410-148-0160 - Billing for Clients Who Have Both Medicare and Basic Health Care Coverage

Current through Register Vol. 63, No. 7, July 1, 2024
(1) The Divisin
			 of Medical Assistance Programs (Division) may be billed directly for services
			 provided to a client when the provider has established and clearly documented
			 in the client's record that the service provided does not qualify for Medicare
			 reimbursement.
(2) When the service
			 qualifies for Medicare reimbursement, bill as follows:
(a) When billing for home enteral/parenteral
			 nutrition services:
(A) Bill in the usual
			 manner to the local or designated Medicare Intermediary;
(B) After Medicare makes a payment
			 determination, bill the Division on the DMAP 505 form following the billing
			 instructions and using the procedure codes listed for the home
			 enteral/parenteral nutrition and IV Services in the fee schedule and
			 supplemental materials;
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 148 - HOME ENTERAL/PARENTERAL NUTRITION AND IV SERVICES › Section 410-148-0260 - Home Enteral Nutrition

Current through Register Vol. 63, No. 7, July 1, 2024
(1)
			 Codes that have PA indicated require prior authorization. Codes with BR
			 indicated are covered by report.
(2) Enteral nutrition formula. Use B4150
			 through B4156 when billing for tube fed nutritional formulae. If the product
			 dispensed is not shown in HCPCS description, select a category equivalent when
			 billing the Division of Medical Assistance Programs (Division).
(3) Oral nutritional supplements:
(a) Prior authorization is required on all
			 oral nutritional supplements;
(b)
			 Oral nutritional supplements can be billed through the on-line point of sale
			 pharmacy system, or by paper using the CMS 1500 claim form or the electronic
			 837P claim form. Use the product's NDC and HCPC code when billing the CMS 1500
			 or electronic 837P claim form;
(c)
			 If the product dispensed is not shown in one of the listed categories, select a
			 category that is equivalent when billing the Division;
(d) Oral nutritional supplements may be
			 approved when the following criteria has been met:
(A) Clients age 6 and above:
(i) Must have a nutritional deficiency
			 identified by one of the following:
(I)
			 Recent low serum protein levels; or
(II) Recent registered dietician assessment
			 shows sufficient caloric/protein intake is not obtainable through regular,
			 liquefied or pureed foods;
(ii) The clinical exception to the
			 requirements of (I) and (II) must meet the following:
(I) Prolonged history (i.e. years) of
			 malnutrition, and diagnosis or symptoms of cachexia, and
(II) Client residence in home, nursing
			 facility, or chronic home care facility, and
(III) Where (I) and (II) would be futile and
			 invasive
(iii) Must have
			 a recent unplanned weight loss of at least 10%, plus one of the following:
(I) Increased metabolic need resulting from
			 severe trauma; or
(II)
			 Malabsorption difficulties (e.g., short-gut syndrome, fistula, cystic fibrosis,
			 renal dialysis); or
(III) Ongoing
			 cancer treatment, advanced Acquired Immune Deficiency Syndrome (AIDS) or
			 pulmonary insufficiency.
(iv) Weight loss criteria may be waived if
			 body weight is being maintained by supplements due to patient's medical
			 condition (e.g., renal failure, AIDS)
(B) Clients under age 6:
(i) Diagnosis of 'failure to
			 thrive;
(ii) Must meet same
			 criteria as above, with the exception of % of weight
			 loss.
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 148 - HOME ENTERAL/PARENTERAL NUTRITION AND IV SERVICES › Section 410-148-0280 - Home Parenteral Nutrition

Current through Register Vol. 63, No. 7, July 1, 2024
(1)
			 Codes that have "PA" indicated require prior authorization. Codes with "BR"
			 indicated are covered by report.
(2) Standard Total Parenteral Nutrition
			 (TPN):
(a) Bill using HCPCS codes S9365
			 through S9368;
(b) Home infusion
			 for stand TPN includes the following drugs and products in the per diem rate:
(A) Non-specialty amino acids (e.g.,
			 aminosyn, freeamine, travasol)
(B)
			 Concentrated dextrose (e.g., D10, D20, D40, D50, D60, D70)
(C) Sterile water;
(D) Electrolytes (e.g., CaC12, KCL, KPO4,
			 MgSo4, NaAc, NaCl, NaPO4);
(E)
			 Standard multi-trace elements (e.g., MTE4, MTE5, MTE7);
(F) Standard multi-vitamin solutions (e.g.,
			 MVI-13).
(c) The
			 following items are not included in the per diem and should be billed
			 separately:
(A) Specialty amino acids for
			 renal failure, hepatic failure or for high stress conditions (e.g., aminess,
			 aminosyn-RF, nephramine, RenAmin, HepatAmine, Aminosyn-HBC, BranchAmin,
			 FreeAmine HBC, Trophamine);
(B)
			 Specialty amino acids with concentrations of 15% and above when medically
			 necessary for fluid restricted patients (e.g., Aminosyn 15%, Novamine 15%,
			 Clinisol 15%);
(C) Lipids
(D) Added trace elements, vitamins not from
			 standard multitrace element or multivitamin solution;
(E) Products serving non-nutritional purposes
			 (e.g., heparin, insulin, iron dextran).
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 148 - HOME ENTERAL/PARENTERAL NUTRITION AND IV SERVICES › Section 410-148-0300 - Other Home IV and Enteral/ Parenteral Administration Services

Current through Register Vol. 63, No. 7, July 1, 2024
(1) Codes that have
			 "PA" indicated require prior authorization. Codes with "BR" indicated are
			 covered by report.
(2) Catheter
			 Care Kits. All catheter care kit allowable amounts are determined on a per diem
			 basis (1 day = 1 unit):
(a) When performed as
			 a stand alone therapy, or during days not covered under per diem by another
			 therapy, bill using catheter care codes S5497 through S5521;
(b) The following supplies for non-routine
			 catheter procedures may be billed separately from per diem reimbursement:
(A) S5517 Catheter declotting supply kit, 1
			 day = 1 unit;
(B) S5518 Catheter
			 repair supply kit, 1 day = 1 unit;
(C) S5520 PICC insertion supply kit, 1 day =
			 1 unit;
(D) S5521 Midline insertion
			 supply kit, 1 day = 1 unit.
(E)
			 E0776 IV Pole -- Purchase.
(F)
			 E0776 with modifier RR IV Pole -- Rental, 1 day = 1 unit
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 148 - HOME ENTERAL/PARENTERAL NUTRITION AND IV SERVICES › Section 410-148-0320 - Billing Quantities, Metric Quantities and Package Sizes

Current through Register Vol. 63, No. 7, July 1, 2024
(1) Use the
			 following metric conversions when billing;
(a) Fluid Ounce -- 30 ml;
(b) Pint -- 480 ml;
(c) Quart -- 960 ml;
(d) Gallon -- 3,840 ml;
(e) Ounce (solids) -- 30 gm;
(f) Pound (solids) -- 454 gm.
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 149 - COMPREHENSIVE PRIMARY CARE PLUS DEMONSTRATION FOR FFS OHP CLIENTS › Section 410-149-0100 - Definitions

Current through Register Vol. 63, No. 7, July 1, 2024
(1) "Alternative
			 Payment Methodology (APM)" means a payment mechanism that is at least a partial
			 alternative to fee-for-service (FFS) payments for Track 2 practice sites. APMs
			 shall allow Track 2 practice sites the flexibility to provide comprehensive
			 care outside of the constraints of a billable office visit.
(2) "Attributed Members" means those Oregon
			 Health Plan (OHP) clients assigned to the CPC+ practice under the Comprehensive
			 Primary Care Plus (CPC+)demonstration who are not enrolled with a managed care
			 plan or CCO for physical health services.
(3) "Care Management Fees" means per-member
			 per-month (PMPM) incentive payments issued by the Oregon Health Authority
			 (Authority) to CPC+ practice sites for attributed members.
(4) "Participating Providers" means the
			 health care providers practicing within the practice site approved by CMS to
			 participate in CPC+.
(5)
			 "Patient-Centered Primary Care Home" means a primary care practice site that
			 has applied and achieved recognition as a PCPCH at a particular tier level by
			 the Authority.
(6) "Performance
			 Based Incentive Payment (PBIP)" means a PMPM payment made to the CPC+
			 practices, based on annual performance on quality measures, patient experience
			 of care, and utilization measures.
(7) "Practice" means the practice site that
			 has been selected by CMS to participate in the CPC+ demonstration.
(8) "Track 1 Practice" means a CPC+ practice
			 designation issued by CMS as one of two possible designations that stipulate
			 the advanced care requirements and payment options available to the
			 practice.
(9) "Track 2 Practice"
			 means a CPC+ practice designation issued by CMS as one of two possible
			 designations that stipulate the advanced care requirements and payment options
			 available to the practice.
Statutory/Other Authority: ORS 413.042
Statutes/Other Implemented: ORS 413.042, 413.259 &
				  414.065
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 149 - COMPREHENSIVE PRIMARY CARE PLUS DEMONSTRATION FOR FFS OHP CLIENTS › Section 410-149-0110 - Technical Requirements for Participation in the Authority CPC+ Demonstration

Current through Register Vol. 63, No. 7, July 1, 2024
(1) The
			 CPC+ practice site shall be recognized by the Authority as a Patient-Centered
			 Primary Care Home (PCPCH) under the 2017 PCPCH recognition standards, or a
			 later set of standards.
(2)
			 Individual CPC+ practice sites shall be enrolled with Oregon Medicaid with a
			 site specific Oregon Medicaid ID number.
(3) The CPC+ practice site shall execute the
			 Comprehensive Primary Care Plus Agreement with the Authority.
(4) The practice must have access to the
			 Oregon Medicaid Management Information System (MMIS) Provider Web Portal to
			 attribute members for care management and PBIPs.
Statutory/Other Authority: ORS 413.042
Statutes/Other Implemented: ORS 413.042, 413.259 &
				  414.065
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 149 - COMPREHENSIVE PRIMARY CARE PLUS DEMONSTRATION FOR FFS OHP CLIENTS › Section 410-149-0120 - CPC+ Practice Reimbursement and Program Integrity

Current through Register Vol. 63, No. 7, July 1, 2024
(1) All funds received through the CPC+
			 demonstration shall be used to support the participating practice
			 site.
(2) As a condition of
			 payment, a participating CPC+ practice shall require and ensure that its
			 participating providers and staff implement the care delivery requirements set
			 forth in their Comprehensive Primary Care Agreement.
(3) Practices shall be entitled to care
			 management fees for all attributed members that had a primary care visit in the
			 prior 18 months from January 1, 2017, and any new attributed members with a
			 primary care visit after January 1, 2017. Under the care management fees, no
			 changes to FFS rates shall be made as additional compensation for services
			 provided.
(4) No part of the care
			 management fee, APM, or PBIPs may be used as an inducement for practices to
			 promote or otherwise affect the provision of any health care item or service
			 owned or distributed by the Authority.
(5) PBIP may be issued prospectively and
			 reconciled to the practice's actual performance score once quality and
			 utilization measurement data becomes available.
(6) Care management fees are provided for
			 care management services and not healthcare service delivery and not subject to
			 Oregon insurance laws and regulations on provider contracting and payment. Any
			 healthcare services rendered by the provider shall be governed by the
			 participating provider agreement between the provider and the
			 Authority.
(7) The enrolled CPC+
			 practice must use aggregate payments received solely to support infrastructure
			 and provide salary support in meeting the terms, conditions, and milestones of
			 CPC+ as directed by CMS.
(8) If the
			 practice fails to comply with the terms and conditions of the CPC+
			 demonstration, the Authority may seek reimbursement for any fees paid to the
			 practice.
(9) The Authority shall
			 give the practice prior notice that it has determined the practice was not
			 making a good faith effort to comply with the terms and conditions of the CPC+
			 demonstration and allow the practice an opportunity to take corrective action,
			 within 90 days of the notice send date, to avoid having to reimburse fees to
			 the Authority.
Statutory/Other Authority: ORS 413.042
Statutes/Other Implemented: ORS 413.042, 413.259 &
				  414.065
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 149 - COMPREHENSIVE PRIMARY CARE PLUS DEMONSTRATION FOR FFS OHP CLIENTS › Section 410-149-0130 - Care Management Fees

Current through Register Vol. 63, No. 7, July 1, 2024
(1) The
			 Authority shall provide care management fees as a PMPM payment to practice
			 sites for FFS OHP attributed members. These payments shall be used to:
(a) Provide up-front investment in
			 participating practices; and
(b)
			 Assist practices to continue practice transformation efforts and offer
			 comprehensive integrated services for patients.
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 149 - COMPREHENSIVE PRIMARY CARE PLUS DEMONSTRATION FOR FFS OHP CLIENTS › Section 410-149-0140 - Performance Based Incentive Payments (PBIP)

Current through Register Vol. 63, No. 7, July 1, 2024
(1) To assess quality performance and
			 eligibility for the CPC+ PBIP, both Track 1 and Track 2 practices shall be
			 required to report electronic clinical quality measures (eCQM) to CMS annually
			 at the practice site level.
(2)
			 Additional PMPM payments shall be available based on performance measures
			 included in eCQM from CMS and utilization measures calculated by the Authority:
(a) Practices must report to CMS on the
			 amount of eCQMs required by CMS for the measurement period in order to receive
			 PBIP payments;
(b) PBIP payments
			 may be issued prospectively prior to eCQM performance results and reconciled at
			 a later date when eCQM performance is available.
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 149 - COMPREHENSIVE PRIMARY CARE PLUS DEMONSTRATION FOR FFS OHP CLIENTS › Section 410-149-0150 - CPC+ Alternative Payment Methodology

Current through Register Vol. 63, No. 7, July 1, 2024
(1) The APM for Track 2 practices is a lump
			 sum payment based upon a percentage of expected revenue calculated from annual
			 reimbursements for FFS Medicaid members in the third and second year prior
			 (e.g., For CY2021 annual reimbursements will be based on the average of CY2018
			 and CY2019). FFS payments shall be reconciled or adjusted down by the same
			 percentage of the APM payment (e.g., 10 percent lump sum payment for one year
			 causes FFS payments issued throughout the same year to be reduced by 10
			 percent):
(a) This structure is intended to
			 allow Track 2 practices flexibility to deliver comprehensive care outside of
			 the constraints of billable office visits;
(b) Track 1 practices are not eligible for
			 the APM;
(c) Track 2 practices
			 shall receive lump sum APM payments based on expected revenue for FFS Medicaid
			 beneficiaries beginning in 2021;
(d) The Authority will apply the ratio of
			 lump sum APM payments and FFS claims payments that the Track 2 practice
			 selected with CMS for the CPC+ initiative, each demonstration year.
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 150 - ADMINISTRATIVE EXAMINATION AND BILLING SERVICES › Section 410-150-0005 - Purpose

Current through Register Vol. 63, No. 7, July 1, 2024
The Administrative Examination and Report rules are provided
				for use in conjunction with the General Rules of the Division of Medical
				Assistance Programs (DMAP) to assist providers in completing examinations
				requested and in preparing claims for administrative evaluations and reports.
				Division 150 rules do not apply to managed care plans.
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 150 - ADMINISTRATIVE EXAMINATION AND BILLING SERVICES › Section 410-150-0010 - Definitions

Current through Register Vol. 63, No. 7, July 1, 2024
(1) Administrative
			 Examination - A medical or psychological evaluation required by the Department
			 of Human Services (DHS), Oregon Health Authority (OHA), or Oregon Youth
			 Authority (OYA) to assist in determining eligibility and for casework planning
			 for various programs. An evaluation must be written and must contain a
			 diagnosis, prognosis, and supporting objective findings. Functional impairments
			 and expected duration of impairment must be included.
(2) Administrative Medical Reports -- Copies
			 of existing records from a specified date. Progress notes, laboratory tests,
			 x-ray reports, special test results and copies of other pertinent records must
			 be included.
(3) Good Cause -
			 Circumstances beyond a person's control, or if a serious illness or death,
			 medical, mental or emotional, learning or language impairment impeded ability
			 to comply with necessary actions timely.
Statutory/Other Authority: ORS
				  413.042
Statutes/Other Implemented: ORS
				  414.065
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 150 - ADMINISTRATIVE EXAMINATION AND BILLING SERVICES › Section 410-150-0040 - Request Requirements

Current through Register Vol. 63, No. 7, July 1, 2024
(1)
			 Administrative Medical Examinations and Reports" is defined in Oregon
			 Administrative Rule (OAR) 410-120-0000.
(2) A completed DMAP 729 Administrative
			 Medical Examination/Report Authorization is authorization for the provider to
			 furnish services.
(3) Only an
			 employee of the Department of Human Services (Department), or Oregon Youth
			 Authority (OYA), or the Health Systems Division (Division) may request an
			 administrative medical examination or report. Department, OYA and Division
			 employees must request administrative medical examinations and reports in
			 compliance with the policies outlined in the Division worker guide located at
			 http://www.oregon.gov/OHA/HSD/OHP/Tools/DMAP%20Worker%20Guide.pdf.
(4) Claims may only be submitted by a
			 Division-enrolled provider who:
(a) Is
			 contracted with the Department, OYA or the Division to provide Administrative
			 Medical Examinations and Reports;
(b) Meets acceptable source criteria for the
			 agency making the request; and
(c)
			 Has received a completed DMAP 729 form.
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 150 - ADMINISTRATIVE EXAMINATION AND BILLING SERVICES › Section 410-150-0070 - Billing Instructions for Administrative Examinations

Current through Register Vol. 63, No. 7, July 1, 2024
(1) When an examination is needed,
			 administrative examination codes are authorized by the branch office.
(2) Medical and ancillary services providers
			 must bill using the Provider Web Portal at https://www.or-medicaid.gov or on a
			 CMS-1500, mailed to the address listed on the OHP 729 at
https://www.oregon.gov/oha/HSD/OHP/Pages/Policy-
			 Admin-Exam.aspx
.
(3)
			 Hospital services must be billed on a UB-04.
(4) Record copying fees imposed by a copy
			 service provider must be billed on a CMS - 1500.
(5) For Administrative Examination billing,
			 the following are required on the appropriate billing form:
(a) The procedure codes specified on the OHP
			 729;
(b) The diagnosis code
			 Z02.89.
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 150 - ADMINISTRATIVE EXAMINATION AND BILLING SERVICES › Section 410-150-0090 - TITLE: Billing Instructions - Licensed Polygraphist

Current through Register Vol. 63, No. 7, July 1, 2024
(1) Billing for licensed polygrapher services
			 must be submitted using the Provider Web Portal at https://www.ormedicaid. gov
			 or on a CMS-1500, mailed to the address listed on the OHP 729.
(2) A polygraph does not qualify as a health
			 care service, therefore it is not subject to Health Insurance Portability and
			 Accountability Act (HIPAA) regulations.
Statutory/Other Authority: ORS
				  413.032,
				  413.042,
				  414.065,
				  414.330  to
				  414.414,
				  414.312  & 414.316
Statutes/Other Implemented: ORS
				  414.065,
				  414.334,
				  414.361,
				  414.371,
				  414.353  & 414.354
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 151 - Early and Periodic Screening, Diagnostic and Treatment › Section 410-151-0000 - Early and Periodic Screening, Diagnostic and Treatment Program

Current through Register Vol. 63, No. 7, July 1, 2024
(1) The Early and
			 Periodic Screening, Diagnostic and Treatment (EPSDT) program offers
			 comprehensive and preventive health care services to EPSDT Beneficiaries in
			 accordance with  42 CFR
			 § 441  Subpart B. EPSDT provides EPSDT
			 Medically Necessary and EPSDT Medically Appropriate Medicaid-covered services
			 to treat any physical, dental, vision, developmental, nutritional, and mental
			 and behavioral health conditions. Coverage for EPSDT Beneficiaries includes all
			 services coverable under the Oregon Health Plan (OHP), when EPSDT Medically
			 Necessary and EPSDT Medically Appropriate for the EPSDT Beneficiary.
(2) The EPSDT rules in this division relating
			 specifically to the provision of OHP services for EPSDT Beneficiaries take
			 precedence over any and all general rules relating to the provision of OHP
			 services to the general OHP population set forth in Oregon Administrative Rules
			 Chapters 410 and 309.
(3)
			 Physicians or other practitioners of the healing arts as defined in OAR
			 410-120-0000  within the scope of their practice under State law may provide OHP
			 services to EPSDT Beneficiaries.
Statutory/Other Authority: ORS
				  413.042
Statutes/Other Implemented: ORS
				  414.025,
				  414.065 &
				  414.150
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 151 - Early and Periodic Screening, Diagnostic and Treatment › Section 410-151-0001 - Definitions

Current through Register Vol. 63, No. 7, July 1, 2024
The definitions in this rule apply to the Early and Periodic
				Screening, Diagnostic and Treatment (EPSDT) program only.
(1) "EPSDT Dentally Appropriate"
(a) Means dental services, items, or dental
			 supplies that are:
(A) Recommended by a
			 licensed health practitioner practicing within the scope of their license;
			 and
(B) Safe, effective, and
			 appropriate for an EPSDT Beneficiary based on standards of good dental practice
			 and generally recognized by the relevant scientific or professional community
			 based on the best available evidence, which includes medical literature and
			 expert consensus opinion and takes into account EPSDT Beneficiary values;
			 and
(C) Impactful in improving
			 access to care, ability to actively participate in care, work, school, or
			 social activities; and not solely for the convenience or preference of an EPSDT
			 Beneficiary, caregiver, or a provider of the service, item, or dental supply;
			 and
(D) The most cost-effective
			 level or type of health services, items, or supplies that are covered services
			 that can be safely and effectively provided to an EPSDT Beneficiary.
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 151 - Early and Periodic Screening, Diagnostic and Treatment › Section 410-151-0002 - Coverage Requirements

Current through Register Vol. 63, No. 7, July 1, 2024
(1) The
			 coverage requirements for services to EPSDT Beneficiaries set forth in this
			 Rule supersede any other coverage standards or requirements set forth in any
			 other Medical Assistance rules that are applicable to non-EPSDT Beneficiaries,
			 regardless of whether the other standards or requirements conflict or are
			 otherwise inconsistent with the EPSDT coverage requirements in this
			 Rule.
(2) The Oregon Health
			 Authority (the Authority) and Managed Care Entities (MCEs) must cover services
			 that are EPSDT Medically Necessary and EPSDT Medically Appropriate (or EPSDT
			 Dentally Appropriate) for EPSDT Beneficiaries, even if:
(a) The services are not included or paired
			 on the Prioritized List of Health Services (defined in OAR 410-120-0000);
			 or
(b) The service is below the
			 funding line on the Prioritized List of Health Services.
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 151 - Early and Periodic Screening, Diagnostic and Treatment › Section 410-151-0003 - Utilization Management Requirements

Current through Register Vol. 63, No. 7, July 1, 2024
(1) The Oregon Health Authority (Authority)
			 and Managed Care Entities (MCEs) do not have the right to pre-establish limits
			 or caps on the amount of services or number of visits covered for EPSDT
			 Beneficiaries. Instead, coverage decisions must be made in accordance with OAR
			 410-151-0002. However, it is acceptable to establish limits (for example, 10
			 physical therapy visits) subject to prior authorization for coverage of
			 additional services.
(2) The
			 Authority and MCEs do not have the right to require prior authorization for any
			 EPSDT screening services.
(3) The
			 Authority and MCEs shall promptly complete prior authorization procedures in
			 accordance with OAR 410-141-3835  and OAR 410-130-0200  and the individual
			 program chapter 410 and 309 OARs as applicable.
(4) The Authority and MCEs shall ensure
			 prompt delivery of EPSDT Medically Necessary and EPSDT Medically Appropriate
			 (or EPSDT Dentally Appropriate) services to EPSDT Beneficiaries.
Statutory/Other Authority: ORS
				  413.042
Statutes/Other Implemented: ORS
				  414.025,
				  414.065 &
				  414.150
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 151 - Early and Periodic Screening, Diagnostic and Treatment › Section 410-151-0004 - Screening Exams

Current through Register Vol. 63, No. 7, July 1, 2024
(1) Periodic EPSDT
			 screening exams shall be provided in accordance with the Bright Futures
			 Periodicity Schedule (
https://downloads.aap.org/AAP/PDF/periodicity_schedule.pdf
)
			 and must include:
(a) A comprehensive health
			 and developmental history including assessment of both behavioral health and
			 physical health development;
(b)
			 Assessment of nutritional status;
(c) Comprehensive unclothed physical exam
			 including inspection of teeth and gums;
(d) Appropriate immunizations;
(e) Lead testing as required by OAR
			 410-130-0246;
(f) Other appropriate
			 laboratory tests (including but not limited to anemia test and sickle cell
			 test) based on age and EPSDT Beneficiary risk;
(g) Health education including anticipatory
			 guidance; and
(h) Appropriate
			 hearing and vision screening.
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 151 - Early and Periodic Screening, Diagnostic and Treatment › Section 410-151-0005 - Referrals

Current through Register Vol. 63, No. 7, July 1, 2024
(1) When a medical,
			 behavioral health, nutritional, or dental condition is discovered during the
			 EPSDT screening process, the EPSDT Beneficiary shall be referred to an
			 appropriate provider for further diagnosis and, when EPSDT Medically Necessary
			 and EPSDT Medically Appropriate (or EPSDT Dentally Appropriate), receive
			 treatment.
(2) The screening
			 provider shall explain the need for the referral to the EPSDT Beneficiary, and,
			 when applicable, the EPSDT Beneficiary's parent or guardian.
(3) If the EPSDT Beneficiary, EPSDT
			 Beneficiary's parent, guardian, or legal authority agrees to the referral, the
			 referring provider shall offer assistance in finding an appropriate referral
			 provider and making an appointment.
(4) The EPSDT Beneficiary's MCE or the
			 Authority shall also make available care coordination as needed.
Statutory/Other Authority: ORS
				  413.042
Statutes/Other Implemented: ORS
				  414.025,
				  414.065 &
				  414.150
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 151 - Early and Periodic Screening, Diagnostic and Treatment › Section 410-151-0006 - Transportation and scheduling assistance

Current through Register Vol. 63, No. 7, July 1, 2024
In accordance with the responsibilities in OAR 410-136-3000 Medical Transportation Services, the Authority or the MCE must offer and
				provide, when requested by the EPSDT Beneficiary or their parent or
				guardian:
(1) Transportation
			 assistance to covered services;
(2)
			 Scheduling assistance for appointments for covered services.
Statutory/Other Authority: ORS
				  413.042
Statutes/Other Implemented: ORS
				  414.025,
				  414.065 &
				  414.150
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 151 - Early and Periodic Screening, Diagnostic and Treatment › Section 410-151-0007 - Notice and hearing requirements.

Current through Register Vol. 63, No. 7, July 1, 2024
If the Authority or an MCE takes action to deny, suspend,
				reduce or terminate services for an EPSDT Beneficiary, it must provide the
				EPSDT Beneficiary, and, as applicable, the EPSDT Beneficiary's parent or
				guardian, with a written notice that complies with the requirements in OAR
				410-141-3885  and OAR 410-120-1865, which require, without limitation:
(1) A statement of the intended action and
			 effective date;
(2) The specific
			 reasons and legal support for the action;
(3) An explanation of the EPSDT Beneficiary's
			 appeal and hearing rights;
(4) The
			 EPSDT Beneficiary's rights to representation.
Statutory/Other Authority: ORS
				  413.042
Statutes/Other Implemented: ORS
				  414.025,
				  414.065 &
				  414.150