reglab/statecodes huggingface dataset:
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 120 - MEDICAL ASSISTANCE PROGRAMS › Section 410-120-1600 - Provider Appeals - Contested Case Hearings

Current through Register Vol. 63, No. 7, July 1, 2024
(1) A contested case procedure is a hearing
			 that is conducted by the Office of Administrative Hearings where a contested
			 case is appropriate and consistent with the provider appeal rules OAR
			 410-120-1560. If the request for contested case hearing was timely filed but
			 should have been filed as a claim redetermination or administrative review, or
			 client appeal, Division will refer the request to the proper appeal procedure
			 and notify the Provider, provider applicant, CCO or PHP provider.
(2) Contested case hearings are conducted in
			 accordance with the Attorney General's model rules at OAR 137-003-0501  to
			 137-003-0700.
(3) The party to a
			 provider contested case hearing is the provider, provider applicant, CCO or PHP
			 provider who requested the appeal. In the event that Division determines that a
			 CCO or PHP provider is entitled to a Contested Case Hearing under OAR
			 410-120-1560, the CCO or PHP Provider and the CCO or PHP are parties to the
			 hearing. A provider, CCO or PHP provider, CCO or PHP that is a corporation may
			 be represented by any of the persons identified in ORS
			 410.190.
(4) Informal conference: Division may notify
			 the provider(s) provider applicant, CCO or PHP provider (and CCO or PHP, if
			 applicable) of the time and place of an informal conference, without the
			 presence of the Administrative Law Judge (ALJ). The purposes of this informal
			 conference are:
(a) To provide an opportunity
			 to settle the matter;
(b) To make
			 sure the parties and the Authority understand the specific reason for the
			 action of the hearing request;
(c)
			 To give the parties and the Authority an opportunity to review the information
			 which is the basis for action;
(d)
			 To give the parties and the Authority the chance to correct any
			 misunderstanding of the facts; and
(e) The provider, provider applicant, CCO or
			 PHP provider (or CCO, PHP, if applicable) may, at any time prior to the hearing
			 date, request an additional informal conference with the Division and Authority
			 representative(s), which may be granted if the Division finds at its sole
			 discretion, the additional informal conference will facilitate the Contested
			 Case Hearing process or resolution of disputed issues.
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 120 - MEDICAL ASSISTANCE PROGRAMS › Section 410-120-1855 - Client's Rights and Responsibilities

Current through Register Vol. 63, No. 7, July 1, 2024
(1) Division of Medical Assistance Programs
			 (Division) clients shall have the following rights:
(a) To be treated with dignity and
			 respect;
(b) To be treated by
			 providers the same as other people seeking health care benefits to which they
			 are entitled;
(c) To refer oneself
			 directly to mental health, substance use disorder or family planning services
			 without getting a referral from a Primary Care Practitioner (PCP) or other
			 provider;
(d) To have a friend,
			 family member, or advocate present during appointments and at other times as
			 needed within clinical guidelines;
(e) To be actively involved in the
			 development of their treatment plan;
(f) To be given information about their
			 condition and covered and non-covered services to allow an informed decision
			 about proposed treatment(s);
(g) To
			 consent to treatment or refuse services, and be told the consequences of that
			 decision, except for court ordered services;
(h) To receive written materials describing
			 rights, responsibilities, benefits available, how to access services, and what
			 to do in an emergency;
(i) To have
			 written materials explained in a manner that is understandable to the Division
			 client;
(j) To receive necessary
			 and reasonable services to diagnose the presenting condition;
(k) To receive Division covered services that
			 meet generally accepted standards of practice and are medically
			 appropriate;
(L) To obtain covered
			 preventive services;
(m) To receive
			 a referral to specialty providers for medically appropriate covered
			 services;
(n) To have a clinical
			 record maintained that documents conditions, services received, and referrals
			 made;
(o) To have access to one's
			 own clinical record, unless restricted by statute;
(p) To transfer a copy of their clinical
			 record to another provider;
(q) To
			 execute a statement of wishes for treatment, including the right to accept or
			 refuse medical, surgical, substance use disorder or mental health treatment,
			 and the right to execute directives and powers of attorney for health care
			 established under ORS 127 as amended by the Oregon Legislative Assembly 1993
			 and the OBRA 1990 - ? Patient Self-Determination Act;
(r) To receive written notices before a
			 denial of, or change in, a benefit or service level is made, unless such notice
			 is not required by federal or state regulations;
(s) To know how to make a Complaint,
			 Grievance or Appeal with the Division and receive a response as defined in OAR
			 410-120-1860  and 410-120-1865;
(t)
			 To request an Administrative Hearing with the Oregon Health Authority
			 (Authority);
(u) To receive a
			 notice of an appointment cancellation in a timely manner;
(v) To receive adequate notice of Authority
			 privacy practices.
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 120 - MEDICAL ASSISTANCE PROGRAMS › Section 410-120-1860 - Contested Case Hearing Procedures

Current through Register Vol. 63, No. 7, July 1, 2024
(1) These rules apply to all contested case
			 hearings provided by the Authority involving a client's health care benefits,
			 except as otherwise provided in OAR 410-141-3890. The hearings are conducted in
			 accordance with ORS 183.411 through
			 183.497 and the Attorney
			 General's model rules, OAR 137-003-0501  through 137-003-0700. When the term
			 "agency" is used in the Attorney General's model rules, it shall refer to the
			 Authority for purposes of this rule except for OAR 137-003-0528(1)(a). The
			 method described in OAR 137-003-0520(8)-(10)  is used in computing any period of
			 time prescribed in this division of rules (OAR 410 division 120) applicable to
			 timely filing of client requests for hearing. Due to operational conflicts, the
			 procedures needing revision and the expense of doing so, OAR
			 137-003-0528(1)(a), which allows hearing requests to be treated as timely based
			 on the date of postmark, does not apply to Authority contested cases.
(2) Medical provider appeals and
			 administrative reviews involving the Division are governed by OAR 410-120-1560  through 410-120-1600.
(3)
			 Grievances, complaints, and appeals for clients requesting or receiving medical
			 assistance from an MCE shall be governed exclusively by the procedures in OARs
			 410-141-3875  through 410-141-3915. This rule describes the procedures
			 applicable when MCE clients request and are eligible for an Authority contested
			 case hearing.
(4) Contested Case
			 Hearing Requests:
(a) A client has the right
			 to a contested case hearing in the following situations upon the timely
			 completion of a request for a hearing:
(A) The
			 Authority makes an adverse determination or action or, as it relates to an MCE,
			 an adverse benefit determination such as denial of client services, payment of
			 a claim, or to terminate, discontinue, or reduce a course of treatment, or
			 issues related to disenrollment in an MCE; or
(B) The right of a client to request a
			 contested case hearing is otherwise provided by statute or rule, including OAR
			 410-141-3885  when a client of an MCE may request a state
			 hearing.
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 120 - MEDICAL ASSISTANCE PROGRAMS › Section 410-120-1870

Current through Register Vol. 63, No. 7, July 1, 2024
Statutory/Other Authority: ORS
				  413.042
Statutes/Other Implemented: ORS
				  411.408,
				  414.025 &
				  414.065
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 120 - MEDICAL ASSISTANCE PROGRAMS › Section 410-120-1875 - Agency Hearing Representatives

Current through Register Vol. 63, No. 7, July 1, 2024
(1) Subject to the approval of the Attorney
			 General, an agency officer or employee is authorized to appear (but not make
			 legal argument) on behalf of the Authority in the following classes of
			 hearings:
(a) Contested case hearings
			 requested by Clients in accordance with OAR 410-120-1860  and 410-130-1865; and
(b) Contested case hearings
			 involving Providers in accordance with OAR 410-120-1560  to 410-120-1700.
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 120 - MEDICAL ASSISTANCE PROGRAMS › Section 410-120-1880 - Contracted Services

Current through Register Vol. 63, No. 7, July 1, 2024
(1) Except as
			 otherwise provided in OAR 410-120-1260  et seq. applicable to provider
			 enrollment or 410-141-3500, 410-141-3700  et seq. governing CCO or PHPs,
			 insurance and service contracts as provided for under ORS
			 414.115,
			 414.125,
			 414.135 and
			 414.145 may be implemented for
			 covered medical assistance services in any program area(s) of the Oregon Health
			 Authority (Authority) in order to achieve one or more of the following
			 purposes:
(a) To implement and maintain CCO
			 or PHP services;
(b) To ensure
			 access to appropriate Medical Services that would not otherwise be
			 available;
(c) To more fully
			 specify the scope, quantity, or quality of the services to be provided or to
			 specify requirements of the provider or to specify requirements of the
			 Authority in relation to the provider;
(d) To obtain services more cost effectively,
			 (e.g., to reduce the costs of program administration or to obtain comparable
			 services at less cost than the fee-for-service rate).
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 120 - MEDICAL ASSISTANCE PROGRAMS › Section 410-120-1920 - Institutional Reimbursement Changes

Current through Register Vol. 63, No. 7, July 1, 2024
(1) The Division of Medical Assistance
			 Programs (Division) is required under federal regulations,  42 CFR 447, to
			 submit specific assurances and related information to the Centers for Medicare
			 and Medicaid Services (CMS) whenever it makes a significant change in its
			 methods and standards for setting payment rates for inpatient hospital services
			 or long-term care facilities.
(2) A
			 "significant change" is defined as a change in payment rates that affects the
			 general method of payment to all providers of a particular type or is projected
			 to affect total reimbursement for that particular type of provider by six
			 percent or more during the 12 months following the effective date.
(3) Federal regulation specifies that a
			 public notice must be published in one of the following:
(a) A state register similar to the Federal
			 Register. For the Oregon Health Authority (Authority), the state register is
			 the Oregon Bulletin published by the Secretary of State;
(b) The newspaper of widest circulation in
			 each city with a population of 50,000 or more;
(c) The newspaper of widest circulation in
			 the state, if there is no city with a population of 50,000 or more;
(d) The Authority web site for public
			 notices.
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 120 - MEDICAL ASSISTANCE PROGRAMS › Section 410-120-1940 - Interest Payments on Overdue Claims

Current through Register Vol. 63, No. 7, July 1, 2024
(1) Upon request by the provider, the
			 Division will pay interest on an overdue claim:
(a) A claim is considered "overdue" if
			 Division does not make payment within 45 days of receipt of a valid
			 claim;
(b) The interest rate shall
			 be the usual rate charged by the provider to the provider's clientele, but not
			 more than 2/3 percent per month or eight percent per year.
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 120 - MEDICAL ASSISTANCE PROGRAMS › Section 410-120-1960 - Payment of Private Insurance Premiums

Current through Register Vol. 63, No. 7, July 1, 2024
(1) Private Insurance Premium (PHI) and
			 Health Insurance Premium Payment (HIPP) are cost saving programs administered
			 by the Authority and the Department for Medicaid enrollees. When a Medicaid
			 client or eligible enrollee is covered by employer sponsored group health
			 insurance or private health insurance, the Authority or Department may choose
			 to reimburse all or a portion of the insurance premium, if it is determined to
			 be cost effective for the Authority or Department.
(2) The Authority or Department may pay
			 health insurance policy premiums or otherwise enter into agreements with other
			 health insurance plans that comply with ORS
			 414.115 to
			 414.145 on behalf of eligible individuals when:
(a)
			 The client is enrolled in a full coverage Medicaid program approved by the
			 Authority or Department (excluding CHIP and CWM);
(b) The policy is a comprehensive major
			 medical insurance plan (comparable to the Medicaid State Plan coverage) and at
			 a minimum provides the following:
(A)
			 Physician services;
(B)
			 Hospitalization (inpatient and outpatient);
(C) Outpatient lab, x-ray, immunizations;
			 and
(D) Full prescription drug
			 coverage.
(c) The
			 payment of premiums, co-insurance, and deductibles is likely to be
			 cost-effective, as determined under section (5) of this rule;
(d) An eligible applicant may be a
			 non-Medicaid individual living in or outside the household. The Authority or
			 Department may pay the entire premium (excluding the employer's portion) if
			 payment of the premium including the non-Medicaid individual is cost-effective
			 and if it is necessary to include that individual in order to enroll the client
			 in the health plan.
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 120 - MEDICAL ASSISTANCE PROGRAMS › Section 410-120-1980 - Requests for Information and Public Records

Current through Register Vol. 63, No. 7, July 1, 2024
(1) The Division of Medical Assistance
			 Programs (Division) will make non-exempt public records available for
			 inspection to persons making a public records request under ORS
			 192.410 to
			 192.500.
(2) The Division may charge a fee for copies
			 of non-exempt public records to cover actual costs per OAR 407-003-0010.
Stat. Auth.: ORS
				  413.042
Stats. Implemented: ORS
				  192.410 -
				  192.505
JUMP BACK TO OARs
				  410-120-0000   through
				  410-120-1295
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 120 - MEDICAL ASSISTANCE PROGRAMS › Section 410-120-1990 - Telehealth

Current through Register Vol. 63, No. 7, July 1, 2024
(1) The following definitions apply to the
			 Health System Divisions (Division) administrative rules applicable to the
			 medical assistance program.
(2)
			 "Asynchronous" means not simultaneous or concurrent in time. For the purpose of
			 this general rule, asynchronous telecommunication technologies for telemedicine
			 or telehealth services may include audio and video, audio without video, client
			 or member portal and may include remote monitoring. "Asynchronous" does not
			 include voice messages, facsimile, electronic mail or text messages.
(3) "Audio only" means the use of audio
			 technology, permitting real-time communication between a health care provider
			 and a member for the purpose of diagnosis, consultation or treatment. "Audio
			 only" does not include health services that are normally delivered by audio
			 telephone technology and normally not billed as separate services by a health
			 care provider, such as the sharing of laboratory results.
(4) "Meaningful access" means client or
			 member-centered access reflecting the following statute and standards:
(a) Pursuant to Title VI of the Civil Rights
			 Act of 1964, Section 1557 of the Affordable Care Act and the corresponding
			 Federal Regulation at 45 CFR Part 92 and The Americans with Disabilities Act
			 (ADA), providers telemedicine or telehealth services shall accommodate the
			 needs of individuals who have difficulty communicating due to a medical
			 condition, who need accommodation due to a disability, advanced age or who have
			 Limited English Proficiency (LEP) including providing access to auxiliary aids
			 and services as described in 45 CFR Part 92 ;
(b) National Culturally and Linguistically
			 Appropriate Services (CLAS) Standards at
https://thinkculturalhealth.hhs.gov/clas/standards
;
			 and
(c) As applicable to the client
			 or member, Tribal based practice standards:
https://www.oregon.gov/OHA/HSD/AMH/Pages/EBP.aspx
;
(d) "Synchronous" means an interaction
			 between a provider and a client or member that occurs at the same time using an
			 interactive technology. This may include audio only, video only, or audio with
			 video and may include remote monitoring.
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 120 - MEDICAL ASSISTANCE PROGRAMS › Section 410-120-2000 - HRSN SERVICES DELIVERY

Current through Register Vol. 63, No. 7, July 1, 2024
The purpose of this rule is to establish the processes,
				standards, and obligations required to be followed or met in administering and
				delivering Health Related Social Needs (HRSN) Services.
(1) HRSN Services General Requirements;
			 Notices of Availability. HRSN Services are similar to Covered Services (as such
			 word is defined in OAR 410-120-0000); however, HRSN Services are not subject to
			 the medically necessary and appropriate standard for coverage under Oregon
			 Health Plan (OHP) but instead are included in and paid for under OHP in
			 accordance with this rule.
(a) Similarities
			 between HRSN Services and Covered Services include the right of Managed Care
			 Entity's (MCEs) to be compensated for the provision of HRSN Services (in
			 accordance with the HRSN Services Fee Schedule) and when Members request HRSN
			 Services eligibility and authorization, the MCE's obligation to provide Members
			 with:
(A) Notices outlined in this rule as
			 well as the same notices, in form and content, that are required for Covered
			 Services such as, for example, notices of Adverse Benefit Determinations under
			 42 CFR
			 438.404, and that comply with accessibility
			 requirements under OARs 410-141-3580  and 410-141-3585, and
			 42 CFR
			 438.10;
(B) Service Authorizations in accordance with
			 OAR 410-141-3835 (7), (8), (9)(d), (10), (11);
(C) Grievance and Appeal rights under OARs
			 410-141-3875  through OAR 410-14103915, OAR 410-120-1860, and 42 CFR Subpart F;
			 and
(D) HRSN Services delivery that
			 complies with the State 1115 Waiver, and in keeping with National Culturally
			 and Linguistically Appropriate Services (CLAS) Standards at
https://thinkculturalhealth.hhs.gov/clas/standards
.
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 121 - PHARMACEUTICAL SERVICES › Section 410-121-0021 - Organizations Authorized to Provide Pharmaceutical Prescription Services

Current through Register Vol. 63, No. 7, July 1, 2024
(1) Pharmacies, and
			 Medicare certified independent rural health clinics providing urgent medical
			 services for clients as defined in ORS
			 414.325(7) may
			 provide drug prescription services for fee-for-service Division of Medical
			 Assistance Programs (DMAP) clients and receive reimbursement from DMAP by
			 complying with all the following requirements:
(a) Comply with all applicable Federal and
			 State statutes, regulations and rules;
(b) Meet all current licensing and regulatory
			 requirements;
(c) Be enrolled as a
			 pharmacy provider with DMAP;
(d)
			 Pharmacies must have a current National Association of the Board of Pharmacy
			 (NABP) number to bill DMAP;
(e)
			 Medicare certified independent rural health clinics must have a pharmacist,
			 physician, or nurse practitioner, licensed to dispense and bill drug
			 prescriptions; and
(f) Comply with
			 DMAP pharmacy billing requirements.
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 121 - PHARMACEUTICAL SERVICES › Section 410-121-0030 - Practitioner-Managed Prescription Drug Plan

Current through Register Vol. 63, No. 7, July 1, 2024
(1) The Practitioner-Managed Prescription
			 Drug Plan (PMPDP) is a plan that ensures that OHP fee-for-service clients have
			 access to the most effective prescription drugs appropriate for their clinical
			 conditions at the best possible price:
(a)
			 Licensed health care practitioners, who are informed by the latest peer
			 reviewed research, make decisions concerning the clinical effectiveness of the
			 prescription drugs;
(b) Licensed
			 health care practitioners also consider the client's health condition, personal
			 characteristics, and the client's gender, race, or ethnicity.
(c) The PDL includes over-the-counter (OTC)
			 products determined to be cost-effective and clinically appropriate by the
			 Oregon Pharmacy and Therapeutics (P & T) Committee. Select OTC product
			 classes are included as a covered pharmacy benefit for Oregon FFS
			 members.
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 121 - PHARMACEUTICAL SERVICES › Section 410-121-0032 - Supplemental Rebate Agreements

Current through Register Vol. 63, No. 7, July 1, 2024
(1)
			 The Division of Medical Assistance Programs (Division) has both a, Centers for
			 Medicare and Medicaid Services (CMS) approved Supplemental Rebate Agreement and
			 a (CMS) approved Value based Agreement. These templates and instructions are
			 available on the Oregon Health Authority's (Authority) web site at:
www.oregon.gov/OHA/healthplan/pages/pharmacy-policy.aspx
(2) The Division negotiates Supplemental
			 Rebate Agreements for specific drug products through the Sovereign States Drug
			 Consortium (SSDC) multi-state pool and pharmaceutical manufacturers.
			 Negotiations are confidential, and shall not be disclosed, except in connection
			 with an agreement/contract or as may be required by law. Confidentiality is
			 required of any third party involved in administration of the
			 agreement/contract.
(3)
			 Manufacturers may submit supplemental rebate offers or value base offers for
			 consideration to include their drug(s) on the Practitioner's-Managed
			 Prescription Drug Plan (PMPDP) Preferred Drug List (PDL), OAR 410-121-0030  after gaining access to the SSDC secure web-based offer entry system.
(4) Manufacturers must abide by requirements
			 of the SSDC.
(5) The
			 Practitioner-Managed Prescription Drug List (PMPDP) also called the Preferred
			 Drug List (PDL) consist of drugs after the Food and Drug Administration (FDA)
			 has determined to be safe and effective and reimbursable as determined by the
			 Centers for Medicaid and Medicare Services (CMS), and evaluated using an
			 evidence-based review process by the Pharmacy & Therapeutics Committee (P
			 & T). If pharmaceutical manufacturers enter into supplemental rebate
			 agreements with the SSDC, the Authority may include that drug on the
			 PDL.
(6) Acceptance of the offer:
(a) The Division may accept an offer through
			 the SSDC;
(b) The SSDC shall notify
			 manufacturers of the status of their offer(s).
(c) Supplemental Agreements shall be executed
			 after signed by all parties, approved by CMS if required, and added to the
			 PMPDP Preferred Drug List by the Administrative rule process.
(d) The Division may contract for the
			 functions of tracking utilization, invoicing, and dispute resolution for
			 supplemental rebate products.
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 121 - PHARMACEUTICAL SERVICES › Section 410-121-0033 - Polypharmacy Profiling

Current through Register Vol. 63, No. 7, July 1, 2024
(1) The Division
			 of Medical Assistance Programs may impose prescription drug payment limitations
			 on clients with more than 15 unique fee-for-service drug prescriptions in a
			 six-month period.
(2) The Division
			 will review the client's drug therapy in coordination with the client's
			 prescribing practitioner to evaluate for appropriate drug therapy.
(3) Appropriate drug therapy criteria will
			 include, but is not limited to, the following:
(a) Overuse of selected drug
			 classes;
(b) Under-use of generic
			 drugs;
(c) Therapeutic drug
			 duplication;
(d) Drug to disease
			 interactions;
(e) Drug to drug
			 interactions;
(f) Inappropriate
			 drug dosage;
(g) Drug selection for
			 age;
(h) Duration of
			 treatment;
(i) Clinical abuse or
			 misuse.
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 121 - PHARMACEUTICAL SERVICES › Section 410-121-0040 - Prior Authorization Required for Drugs and Products

Current through Register Vol. 63, No. 7, July 1, 2024
(1)
			 Prescribing practitioners shall obtain prior authorization (PA) for the drugs
			 and categories of drugs requiring PA in this rule, using the procedures set
			 forth in OAR 410-121-0060.
(2)
			 Except as provided in section (3) of this rule, all drugs and categories of
			 drugs including, but not limited to, those drugs and categories of drugs that
			 require PA shall meet the following requirements for coverage:
(a) Each drug shall be prescribed for
			 conditions funded by the Oregon Health Plan (OHP) in a manner consistent with
			 the Health Evidence Review Commission (HERC) Prioritized List of Health
			 Services (OAR 410-141-3820  through 410-141-3825). If the medication is for a
			 non-covered diagnosis, the medication may not be covered unless there is a
			 co-morbid condition for which coverage would be allowed. The use of the
			 medication shall meet corresponding treatment guidelines and be included within
			 the client's benefit package of covered services and not otherwise excluded or
			 limited;
(b) Each drug shall also
			 meet other criteria applicable to the drug or category of drug in these
			 pharmacy provider rules, including PA requirements imposed in this
			 rule.
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 121 - PHARMACEUTICAL SERVICES › Section 410-121-0060 - How to Get Prior Authorization for Drugs

Current through Register Vol. 63, No. 7, July 1, 2024
(1) A prescriber electing to order a drug
			 requiring PA may have any licensed medical personnel in their office request
			 the PA. The PA request may be transmitted to the Oregon Pharmacy Help Desk by
			 any of the following methods:
(a) Call the
			 Oregon Pharmacy Help Desk
(b) FAX
			 the request form shown in the Pharmaceutical Services Supplemental Information
			 on the Oregon Health Authority's website to the Oregon Pharmacy Help
			 Desk
(c) Transmit the request
			 electronically via the secure MMIS web portal.
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 121 - PHARMACEUTICAL SERVICES › Section 410-121-0061 - Durable Medical Equipment, Medical Supplies, and Medical Surgical Services (Physician Administered Drugs)

Current through Register Vol. 63, No. 7, July 1, 2024
Follow the guidelines in the Durable Medical Equipment and
				Medical Supplies (OAR 410 Division 122), Home Enteral/Parenteral Nutrition and
				IV Services (OAR chapter 410, division 148), and Medical Surgical Services (OAR
				chapter 410, division 130) administrative rules and supplemental information
				for billing and prior authorization of these medical supplies and services.
				This information is available on the Oregon Health Authority's web
				site.
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 121 - PHARMACEUTICAL SERVICES › Section 410-121-0100 - Drug Use Review

Current through Register Vol. 63, No. 7, July 1, 2024
(1) Drug Use Review
			 (DUR) in Division of Medical Assistance Programs (Division) is a program
			 designed to measure and assess the proper utilization, quality, therapy,
			 medical appropriateness, appropriate selection and cost of prescribed
			 medication through evaluation of claims data. This is done on both a
			 retrospective and prospective basis. This program shall include, but is not
			 limited to, education in relation to over-utilization, under-utilization,
			 therapeutic duplication, drug-to-disease and drug-to-drug interactions,
			 incorrect drug dosage, duration of treatment and clinical abuse or misuse:
(a) Information collected in a DUR program
			 that identifies an individual is confidential;
(b) Staff of the Drug Use Review
			 (DUR)/Pharmacy & Therapeutics (P And T) Committee and contractors may have
			 access to identifying information to carry out intervention activities approved
			 by the Division. The Division, DUR/P And T Committee or contractors shall
			 adhere to all requirements of the Health Insurance Portability and
			 Accountability Act (HIPAA) and all Division policies relating to confidential
			 client information.
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 121 - PHARMACEUTICAL SERVICES › Section 410-121-0111 - Pharmacy and Therapeutics Committee

Current through Register Vol. 63, No. 7, July 1, 2024
(1) Pursuant to Oregon Laws 2011, chapter 720
			 (HB 2100), the Drug Use Review Board (DUR Board) is abolished and the tenure of
			 office for the members of the DUR Board expires. The legislature transferred
			 the duties, functions and powers previously vested in the DUR Board to the
			 Pharmacy and Therapeutics (P And T) Committee. This rule is retroactively
			 effective on September 5, 2011, the date the P And T Committee was created and
			 the DUR Board was abolished by HB 2100 and expires whenever the Oregon Health
			 Authority (Authority) suspends the rule.
(2) Unless otherwise inconsistent with these
			 administrative rules or other laws, any administrative rule or agency policy
			 with reference to the DUR Board or a DUR Board volunteer, staff or contractor
			 shall be considered to be a reference to the P And T Committee or a P And T
			 Committee volunteer, staff or contractor. The current preferred drug list
			 (PDL), prior authorization process, and utilization review process developed by
			 the DUR Board remains in effect until such time as the Authority, after
			 recommendations and advice from the P And T Committee, modifies them through
			 the adoption of new administrative rules or policies and procedures.
(3) The P And T Committee shall advise the
			 Oregon Health Authority (Authority) on the:
(a) Implementation of the medical assistance
			 program retrospective and prospective programs, including the type of software
			 programs to be used by the pharmacist for prospective drug use review and the
			 provisions of the contractual agreement between the state and any entity
			 involved in the retrospective program;
(b) Implementation of the Practitioner
			 Managed Prescription Drug Plan (PMPDP);
(c) Adoption of administrative rules
			 pertaining to the P And T Committee;
(d) Development of and application of the
			 criteria and standards to be used in retrospective and prospective drug use
			 review and safety edit programs in a manner that ensures that such criteria and
			 standards are based on compendia, relevant guidelines obtained from
			 professional groups through consensus-driven processes, the experience of
			 practitioners with expertise in drug therapy, data and experience obtained from
			 drug utilization review program operations. The P And T Committee must have an
			 open professional consensus process, establish an explicit ongoing process for
			 soliciting and considering input from interested parties, and make timely
			 revisions to the criteria and standards based on this input and scheduled
			 reviews;
(e) Development,
			 selection and application of and assessment for interventions being educational
			 and not punitive in nature for medical assistance program prescribers,
			 dispensers and patients.
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 121 - PHARMACEUTICAL SERVICES › Section 410-121-0135 - Pharmacy Management Program

Current through Register Vol. 63, No. 7, July 1, 2024
(1)
			 The Pharmacy Management Program promotes the appropriate use of quality
			 pharmaceutical services by identifying and correcting overutilization of
			 services.
(2) The Pharmacy
			 Management Program limits some fee-for-service clients to receiving their
			 prescription drugs through the following sources:
(a) A single retail pharmacy to pick up
			 prescriptions;
(b) The Division of
			 Medical Assistance Program (Division) mail order pharmacy contractor; and
(c) A specialty pharmacy.
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 121 - PHARMACEUTICAL SERVICES › Section 410-121-0143 - Client Confidentiality

Current through Register Vol. 63, No. 7, July 1, 2024
Pharmacists are responsible for maintaining the confidentiality
				of client information in compliance with HIPAA standards. Facilities shall
				provide adequate privacy for patient consultations.
Stat. Auth.: ORS
				  409.110 &
				  413.042
Stats. Implemented: ORS
				  414.065
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 121 - PHARMACEUTICAL SERVICES › Section 410-121-0145 - Prescription Requirements

Current through Register Vol. 63, No. 7, July 1, 2024
(1) Division
			 of Medical Assistance Programs (DMAP) will make payment for covered drugs
			 supplied on drug order or prescription of a licensed practitioner and dispensed
			 by a pharmacist. Dispensings include new prescriptions, refills of existing
			 prescriptions, and over-the-counter (OTC) medications.
(a) Each drug order or prescription filled
			 for a DMAP client must be retained in the pharmacy's file at the pharmacy's
			 place of business; and,
(b) All
			 drug orders or prescriptions must comply with the Oregon State Board of
			 Pharmacy rules and regulations as listed in OAR 855 division 041.
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 121 - PHARMACEUTICAL SERVICES › Section 410-121-0146 - Dispensing Limitations

Current through Register Vol. 63, No. 7, July 1, 2024
(1) The
			 Division of Medical Assistance Programs (Division) shall reimburse the pharmacy
			 for dispensed medication the lesser of:
(a)
			 The quantity indicated by the prescriber on the prescription;
(b) The quantity indicated by the Division
			 dispensing limitations as outlined in this rule; or
(c) The quantity needed for Prescription
			 Synchronization.
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 121 - PHARMACEUTICAL SERVICES › Section 410-121-0147 - Exclusions and Limitations

Current through Register Vol. 63, No. 7, July 1, 2024
(1) The following
			 items are not covered for payment by the Division of Medical Assistance
			 Programs (Division) Pharmaceutical Services Program:
(a) Except as provided in section (2) of this
			 rule, drug products for diagnoses below the funded line on the Health Evidence
			 Review Commission (HERC) Prioritized List of Health Services or an excluded
			 service under Oregon Health Plan (OHP) coverage;
(b) Home pregnancy kits;
(c) Fluoride for individuals over 18 years of
			 age;
(d) Expired drug
			 products;
(e) Drug products from
			 non-rebatable manufacturers, with the exception of selected oral nutritionals,
			 vitamins, and vaccines;
(f) Active
			 Pharmaceutical Ingredients (APIs) and Excipients as described by Centers for
			 Medicare and Medicaid (CMS);
(g)
			 Drug products that are not assigned a National Drug Code (NDC)
			 number;
(h) Drug products that are
			 not approved by the Food and Drug Administration (FDA);
(i) Drug products dispensed for Citizenship
			 Waived Medical (CWM) client benefit type except when prescribed as an emergency
			 medical service as defined by OAR 410-134-0003(3). The CWM benefit plan ended
			 on June 30, 2023;
(j) Drug Efficacy
			 Study Implementation (DESI) drugs (see OAR 410-121-0420);
(k) Medicare Part D covered drugs or classes
			 of drugs for fully dual eligible clients (see OAR 410-121-0149, 410-120-1200  & 410-120-1210).
(L) Drug
			 products prescribed to establish or reestablish fertility or
			 pregnancy;
(m) Drug products when
			 prescribed for the treatment of sexual or erectile dysfunction;
(n) Drug products when prescribed for weight
			 loss; and
(o) Drug products when
			 primarily prescribed for cosmetic purposes or hair growth.
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 121 - PHARMACEUTICAL SERVICES › Section 410-121-0148 - Dispensing in a Nursing Facility or Community Based Care Living Facility

Current through Register Vol. 63, No. 7, July 1, 2024
A pharmacy serving Division of Medical Assistance Program's
				(Division) clients in a nursing facility or a Community Based Care Living
				Facility must dispense medication in a manner consistent with Board of Pharmacy
				rules as set out in OAR 855-041.
(1)
			 For the purposes of this rule, "Long term care facility" includes skilled
			 nursing facilities and intermediate care facilities consistent with the
			 definitions in ORS 443.400 to
			 443.455.
(2) An intermediate care facility is a
			 facility providing regular health related care and services to individuals at a
			 level above room and board, but less than hospital or skilled nursing levels
			 ORS 442.015.
Stat. Auth.:
				  404.110,
				  413.042 &
				  414.065
Stats. Implemented: ORS
				  414.065
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 121 - PHARMACEUTICAL SERVICES › Section 410-121-0150 - Billing Requirements

Current through Register Vol. 63, No. 7, July 1, 2024
(1) All 340B
			 covered entities that fill Medicaid patient prescriptions with drugs purchased
			 at the prices authorized under Section 340B of the Public Health Service Act
			 shall bill Medicaid at the actual acquisition cost, plus the entity's assigned
			 professional dispensing fee.
(2)
			 Pharmacies that purchase drugs at Nominal Price outside of 340B or the Federal
			 Supply Schedule shall bill their actual acquisition cost.
(3) With the exception of Indian Health
			 Service pharmacies and Tribal 638 pharmacies, pharmacies who purchase drugs
			 through the Federal Supply Schedule must bill their actual acquisition cost.
			 Refer to AI/AN rules OAR chapter 410, division 146 for billing rules for Indian
			 Health Service pharmacies and Tribal 638 pharmacies.
(4) When billing the Health Systems Division
			 (Division) for drug products, the provider:
(a) May not bill in excess of the usual and
			 customary charge to the general public:
(A)
			 The sum of charges for both the product cost and dispensing fee may not exceed
			 a pharmacy's usual and customary charge for the same or similar
			 service;
(B) When billing the
			 Division for a prescription, the pharmacy shall bill the lowest amount accepted
			 from any member of the general public who participates in the pharmacy
			 provider's savings or discount program;
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 121 - PHARMACEUTICAL SERVICES › Section 410-121-0155 - Reimbursement

Current through Register Vol. 63, No. 7, July 1, 2024
(1) The Division
			 shall pay the lesser of the provider's billed amount or the ingredient cost
			 plus a professional dispensing fee.
(2) The ingredient cost is established by the
			 Division as follows:
(a) The Oregon Average
			 Actual Acquisition Cost (OR-AAAC) of the drug;
(b) In cases where no OR-AAAC is available,
			 the National Average Drug Acquisition Cost (NADAC);
(c) In cases where no OR-AAAC and no NADAC is
			 available, the Wholesale Acquisition Cost (WAC).
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 121 - PHARMACEUTICAL SERVICES › Section 410-121-0160 - Dispensing Fees

Current through Register Vol. 63, No. 7, July 1, 2024
(1) Effective
			 January 1, 2018, professional dispensing fees allowable for services shall be
			 reimbursed as follows:
(a) All enrolled chain
			 affiliated pharmacies with ten or more pharmacies under common ownership shall
			 be reimbursed at a rate of $9.80 per claim. A "chain affiliated pharmacy" shall
			 be defined as a pharmacy that is part of a group of pharmacies under common
			 ownership and does not include fully independent pharmacies or franchise
			 pharmacies;
(b) Independently owned
			 pharmacies in communities that are the only enrolled pharmacy within a fifteen
			 (15) mile radius from another pharmacy shall be reimbursed at a dispensing fee
			 of $14.30 per claim;
(c) All 340B
			 pharmacies operated by a 340B covered entity shall be reimbursed at a rate of
			 $14.30 per claim;
(d) All other
			 enrolled independently owned pharmacies excluding those in 410-121-0160(b) and
			 (c)  shall be reimbursed based on an individual pharmacy's annual claims volume
			 as follows:
(A) Less than 30,000 claims a
			 year = $14.30;
(B) Between 30,000
			 and 69,999 claims per year = $11.91;
(C) 70,000 or more claims per year =
			 $9.80.
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 121 - PHARMACEUTICAL SERVICES › Section 410-121-0185 - Pharmacy Based Immunization Delivery

Current through Register Vol. 63, No. 7, July 1, 2024
(1) Pursuant to ORS
			 689.645 and the Board of Pharmacy administrative rules 855-019-0270  through
			 855-019-0290, pharmacists may prescribe and administer vaccines to persons who
			 are at least seven years of age.
(2) To receive reimbursement for vaccine
			 administration and serum for adults (ages 19 and older), the pharmacy may bill
			 either:
(a) Through Point-of-Sale (POS) using
			 the appropriate National Drug Code (NDC) for the serum, and the administration
			 fee shall automatically be applied equivalent to Current Procedural Terminology
			 (CPT) codes 90470-90474 ; or
(b)
			 Bill on a CMS-1500, OHP 505, or Provider Web Portal professional claim using
			 the appropriate immunization CPT code for the serum; or
(c) Bill as a Provider Web Portal pharmacy
			 claim.
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 121 - PHARMACEUTICAL SERVICES › Section 410-121-0190 - Medication Therapy Management Services and Clozapine Therapy Monitoring

Current through Register Vol. 63, No. 7, July 1, 2024
(1) Clozapine
			 monitoring protocol requires enhanced record keeping and reporting to the drug
			 manufacturer's registry in order to dispense the medication. Dispensing
			 pharmacy must meet all drug manufacturers requirements including data
			 reporting.
(2) Clozapine
			 monitoring includes documentation of client's diagnosis, dosage, dosage
			 changes, appropriate laboratory reports (e.g. white blood cell counts),
			 evaluation intervals, and submission of appropriate information to drug
			 manufacturer to allow dispensing of medication;
(3) Clozapine monitoring is to be billed
			 using appropriate Medication Therapy Management Services (MTMS) Current
			 Procedural Terminology (CPT) code with the modifier TC appended. This is
			 limited to no more than 5 units in 30 day time period per client, including the
			 30 day period from the date of discontinuation of clozapine therapy;
(4) Clozapine monitoring must be billed by a
			 pharmacy;
(5) MTMS rendered
			 outside of clozapine management must be performed by a licensed pharmacist and
			 must be billed to appropriately reflect the performing provider. These
			 encounters must be billed using the appropriate MTMS CPT code without the TC
			 modifier.
Stat. Auth.: ORS
				  413.042 &
				  414.065
Stats. Implemented: ORS
				  414.065
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 121 - PHARMACEUTICAL SERVICES › Section 410-121-0200 - Billing Forms

Current through Register Vol. 63, No. 7, July 1, 2024
Guidelines for using the Prescription Drug Invoice 1.2
				Universal Claim Form.
(1) When a paper
			 claim form is needed, this form is used to bill for all pharmacy services, home
			 blood glucose monitors, and related diabetic supplies. These services must be
			 billed with a National Drug Code (NDC).
(2) The provider may bill on the form when a
			 valid Medical Care Identification has been presented (Refer to OAR 410-120-1140  Verification of Eligibility).
(3)
			 All completed 1.2 Universal Claim Forms must be mailed to the Health Systems
			 Division (Division).
(4) All other
			 durable medical equipment and certain Enteral/Parenteral Nutrition and IV
			 Services must be billed on the CMS-1500, using the billing instructions found
			 in the Division's Durable Medical Equipment and Medical Supplies administrative
			 rules (division 122) and Supplemental Information, and the Division's Home
			 Enteral/Parenteral Nutrition and IV Services Administrative rules (division
			 148) and Supplemental Information. These services are billed with HCPCS
			 procedure codes.
Publications referenced are available from the
				  agency.
Statutory/Other Authority: ORS
				  413.042 &
				  414.065
Statutes/Other Implemented: ORS
				  414.065
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 121 - PHARMACEUTICAL SERVICES › Section 410-121-0220 - Instructions for Completion of the Prescription Drug Invoice

Current through Register Vol. 63, No. 7, July 1, 2024
(1) The 1.2
			 Universal Claim Form is the required billing form for pharmacies billing on a
			 paper claim. Use the standard instructions for completion of the 1.2 Universal
			 Claim Form.
(2) Enter all
			 applicable information for billing of prescription drug claims for clients on
			 the Oregon Health Plan.
Statutory/Other Authority: ORS
				  413.042,
				  414.034  &
				  414.065
Statutes/Other Implemented: ORS
				  414.065