reglab/statecodes huggingface dataset:
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 130 - MEDICAL-SURGICAL SERVICES › Section 410-130-0230 - Administrative Medical Examinations and Reports

Current through Register Vol. 63, No. 7, July 1, 2024
(1) This rule does not apply to Managed
			 Health Care plans.
(2) These
			 services are covered only when requested by an CAF, APD, AMH, OYA, Child
			 Welfare branch office or approved by the Division of Medical Assistance
			 Programs (Division). The branch office may request an administrative medical
			 examination or a medical report (DMAP 729) to establish client eligibility for
			 an assistance program or casework planning.
(3) See the Administrative Examination and
			 Report Billing rule for complete billing instructions.
Publications: Publications referenced are available from the
				  agency.
Stat. Auth.: ORS
				  413.042
Stats. Implemented: ORS
				  414.025 &
				  414.065
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 130 - MEDICAL-SURGICAL SERVICES › Section 410-130-0240 - Medical Services

Current through Register Vol. 63, No. 7, July 1, 2024
(1) Coverage of
			 medical and surgical services is subject to the Health Evidence Review
			 Commission's (HERC) Prioritized List of Health Services (Prioritized List).
			 Medical and surgical services requiring prior authorization (PA) are listed in
			 Oregon administrative rule (OAR or rule) 410-130-0200, PA Table 130-0200-1, and
			 medical and surgical services that are Not Covered/Bundled services are listed
			 in OAR 410-130-0220, Table 130-0220-1.
(2) Coverage for acupuncture services by an
			 enrolled acupuncture provider are subject to the HERC Prioritized List and the
			 client's benefit plan.
(3)
			 Coverage for medically appropriate chiropractic services provided by an
			 enrolled chiropractor is subject to the HERC Prioritized List and benefit plan
			 for:
(a) Diagnostic visits including
			 evaluation and management services;
(b) Chiropractic care including manipulative
			 treatment;
(c) Laboratory and
			 radiology services.
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 130 - MEDICAL-SURGICAL SERVICES › Section 410-130-0245

Current through Register Vol. 63, No. 7, July 1, 2024
Publications: Publications referenced are available from the
				  agency.
Tables referenced are not included in rule text.
Click here for PDF copy
				  of table(s)
.
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 130 - MEDICAL-SURGICAL SERVICES › Section 410-130-0246 - Lead Screening

Current through Register Vol. 63, No. 7, July 1, 2024
(1) All children
			 enrolled in the Oregon Health Plan, including Fee-for-Service and MCEs, must
			 have blood lead screening tests. Children with Medical Assistance Program
			 coverage must have blood lead screening tests at age 12 months and 24 months.
			 Any child between ages 24 and 72 months with no record of a previous blood lead
			 screening test must receive one. Completion of a risk assessment questionnaire
			 does not meet the lead screening requirement for children under
			 Medicaid.
(2) Method of Blood
			 Collection: A single venous or capillary blood draw is acceptable for the blood
			 lead screening test. A result of less than 3.5 micrograms per deciliter from
			 either method is considered a negative result. A capillary blood lead level
			 greater than or equal to 3.5 micrograms per deciliter must be confirmed with
			 either a venous draw or a second capillary draw within 12 weeks.
(3) Lead poisoning in children under 18 years
			 of age and pregnant or lactating women is defined as a blood lead level greater
			 than or equal to 3.5 micrograms per deciliter from a venous draw or two
			 capillary blood lead tests greater than or equal to 3.5 micrograms per
			 deciliter drawn within 12 weeks of each other. See OAR
			 333-017-0000(18).
(4) Billing of
			 laboratory services is covered in: OAR 410-130-0680.
(a) For the collection of blood, use CPT
			 36415 for a venipuncture sample or CPT 36416 for capillary puncture
			 samples;
(b) To bill for
			 venipuncture or capillary blood lead screening, use Current Procedural
			 Terminology (CPT) code 83655.
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 130 - MEDICAL-SURGICAL SERVICES › Section 410-130-0255 - Immunizations, Vaccines for Children, and Immune Globulins

Current through Register Vol. 63, No. 7, July 1, 2024
(1) The Division covers immunizations as
			 recommended by the Advisory Committee on Immunization Practices (ACIP) and
			 approved by the Oregon Immunization Program. The approved ACIP recommendations
			 are found in Guideline Note 106 of the Health Evidence Review Commission's
			 Prioritized List of Health Services as referenced in OAR 410-141-0520,
http://www.oregon.gov/OHA/HPA/CSI-HERC/Pages/Prioritized-List.aspx
.
(2) Providers shall follow the (ACIP)
			 guidelines for immunization schedules. Exceptions include:
(a) On a case-by-case basis, provider may use
			 clinical judgment in accordance with accepted medical practice to provide
			 immunizations on a modified schedule, and;
(b) On a case-by-case basis, provider may
			 modify immunization schedule in compliance with the laws of the State of
			 Oregon, including laws relating to medical and non-medical exemptions for
			 immunizations.
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 130 - MEDICAL-SURGICAL SERVICES › Section 410-130-0365 - Ambulatory Surgical Center and Birthing Center Services

Current through Register Vol. 63, No. 7, July 1, 2024
(1) Ambulatory Surgical Centers (ASC) and
			 Birthing Centers (BC) must be licensed by the Oregon Health Division. ASC and
			 BC services are items and services furnished by an ASC or BC in connection with
			 a covered surgical procedure as specified in the Medical-Surgical Services rule
			 or in the Dental Services rule. Reimbursement is made at all-inclusive global
			 rates based on the surgical procedure codes billed.
(2) If the client has Medicare in addition to
			 Medicaid and Medicare covers a surgery, but not in an ASC setting, then the
			 surgery may not be performed in an ASC.
(3) Global rates include:
(a) Nursing services, services of technical
			 personnel, and other related services;
(b) Any support services provided by
			 personnel employed by the ASC or BC facility;
(c) The client's use of the ASC's or BC's
			 facilities including the operating room and recovery room;
(d) Drugs, biologicals, surgical dressings,
			 supplies, splints, casts, appliances, and equipment related to the provision of
			 the surgical procedure(s);
(e)
			 Diagnostic or therapeutic items and services related to the surgical
			 procedure;
(f) Administrative,
			 record-keeping, and housekeeping items and services;
(g) Blood, blood plasma, platelets;
(h) Materials for anesthesia;
(i) Items not separately identified in
			 section (4) of this rule.
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 130 - MEDICAL-SURGICAL SERVICES › Section 410-130-0368 - Anesthesia Services

Current through Register Vol. 63, No. 7, July 1, 2024
(1) Anesthesia
			 is not covered for procedures that are below the funding line on the Health
			 Services Commission's Prioritized List of Health Services (see OAR
			 410-141-0520).
(2) Effective
			 January 1, 2012 all anesthesia claims submitted must be billed in minutes only.
			 This includes;
(a) Claims for services
			 provided prior to 1/1/12 that are submitted for the first time in
			 2012;
(b) Resubmitted unpaid claims
			 for services provided prior to 1/1/12; and
(c) Adjustments made to claims for services
			 performed prior to 1/1/12. Units must be converted by the provider from units
			 to minutes.
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 130 - MEDICAL-SURGICAL SERVICES › Section 410-130-0380 - Surgery Guidelines

Current through Register Vol. 63, No. 7, July 1, 2024
(1) The
			 Division of Medical Assistance Programs (Division) reimburses all covered
			 surgical procedures as global packages. Global payments do not include initial
			 consultation or evaluation of the problem by the surgeon to determine the need
			 for surgery.
(2) Surgical
			 procedures listed in the Medical-Surgical Services administrative rules with
			 prior authorization (PA) indicated require authorization unless they are
			 emergent.
(3) Global payment for
			 major surgery includes:
(a)
			 Surgery;
(b) Pre-operative visits
			 within 15 days of the surgery (except the initial consultation);
(c) Initial admission history and
			 physical;
(d) Related follow-up
			 visits within 90 days after the surgery;
(e) Treatment of complications not requiring
			 a return trip to the operating room;
(f) Hospital discharge.
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 130 - MEDICAL-SURGICAL SERVICES › Section 410-130-0562 - Abortion

Current through Register Vol. 63, No. 7, July 1, 2024
For medically induced abortions by oral ingestion of medication
				use S0199 for all visits, counseling, lab tests, ultrasounds, and supplies.
				S0199 is a global package except for medication:
(1) Bill medications with codes S0190-S0191
			 and appropriate HCPCS codes.
(2)
			 For surgical abortions use CPT codes 59840 through 59857:
(3) For services related to surgical abortion
			 such as lab, ultrasound and pathology bill separately. Add modifier U4 (a
			 Division of Medical Assistance Programs (Division) modifier) for surgical
			 abortion related services.
(4) Use
			 the most appropriate ICD-10 diagnosis code.
Stat. Auth.: ORS
				  413.042
Stats. Implemented: ORS
				  414.025 &
				  414.065
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 130 - MEDICAL-SURGICAL SERVICES › Section 410-130-0580 - Hysterectomies and Sterilization

Current through Register Vol. 63, No. 7, July 1, 2024
(1)
			 Refer to OAR 410-130-0200  Prior Authorization, Table 130-0200-1 and
			 410-130-0220  Not Covered/Bundled Services, Table 130-0220-1.
(2) Hysterectomies performed for the sole
			 purpose of sterilization are not covered.
(3) All hysterectomies, except radical
			 hysterectomies, require prior authorization (PA).
(4) A properly completed Hysterectomy Consent
			 form (DMAP 741) or a statement signed by the performing physician, depending
			 upon the following circumstances, is required for all hysterectomies:
(a) When a woman is capable of bearing
			 children:
(A) Prior to the surgery, the
			 person securing authorization to perform the hysterectomy must inform the woman
			 and her representative, if any, orally and in writing, that the hysterectomy
			 will render her permanently incapable of reproducing;
(B) The woman or her representative, if any,
			 must sign the consent form to acknowledge she received that
			 information.
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 130 - MEDICAL-SURGICAL SERVICES › Section 410-130-0585 - Family Planning Services

Current through Register Vol. 63, No. 7, July 1, 2024
(1)
			 Family planning services are those intended to prevent or delay pregnancy, or
			 otherwise control family size.
(2)
			 The Division of Medical Assistance Programs (Division) covers family planning
			 services for clients of childbearing age (including minors who are considered
			 to be sexually active).
(3) Family
			 Planning services include:
(a) Annual exams;
(b) Contraceptive education and
			 counseling to address reproductive health issues;
(c) Laboratory tests;
(d) Radiology services;
(e) Medical and surgical procedures,
			 including tubal ligations and vasectomies;
(f) Pharmaceutical supplies and devices.
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 130 - MEDICAL-SURGICAL SERVICES › Section 410-130-0587 - Family Planning Clinic Services

Current through Register Vol. 63, No. 7, July 1, 2024
(1) This rule pertains only to Family
			 Planning Clinics.
(2) To enroll
			 with the Division of Medical Assistance Programs (Division) as a family
			 planning clinic, a provider must also be enrolled with the Office of Family
			 Health as an Oregon Contraceptive Care (CCare) provider.
(3) Family planning clinics must follow all
			 applicable CCare and the Division rules.
(4) The Division will reimburse family
			 planning clinics an encounter rate only when the primary purpose of the visit
			 is for family planning.
(5) Bill
			 HCPCS code T1015 "Clinic visit/encounter, all-inclusive; family planning" for
			 all encounters where the primary purpose of the visit is contraceptive in
			 nature:
(a) This encounter code includes the
			 visit and any procedure or service performed during that visit including:
(A) Annual family planning exams;
(B) Family planning counseling;
(C) Insertions and removals of implants and
			 IUDs;
(D) Diaphragm
			 fittings;
(E) Dispensing of
			 contraceptive supplies and contraceptive medications;
(F) Contraceptive injections.
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 130 - MEDICAL-SURGICAL SERVICES › Section 410-130-0595 - Maternity Case Management

Current through Register Vol. 63, No. 7, July 1, 2024
(1) The
			 primary purpose of the Maternity Case Management (MCM) program is to optimize
			 pregnancy outcomes, including reducing the incidence of low birth weight
			 babies. MCM services are tailored to the individual client needs. These
			 services are provided face-to-face throughout the client's pregnancy, unless
			 specifically indicated in this rule.
(2) This program:
(a) Is available to all pregnant clients
			 receiving Medical Assistance Program coverage;
(b) Expands perinatal services to include
			 management of health, economic, social and nutritional factors through the end
			 of pregnancy and a two-month postpartum period;
(c) Must be initiated during the pregnancy
			 and before delivery;
(d) Is an
			 additional set of services over and above medical management of pregnant
			 clients;
(e) Allows billing of
			 intensive nutritional counseling services.
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 130 - MEDICAL-SURGICAL SERVICES › Section 410-130-0605 - Newborn Nurse Home Visiting Services

Current through Register Vol. 63, No. 7, July 1, 2024
(1) Definitions.
(a) "Comprehensive newborn nurse home visit"
			 has the meaning described in OAR 333-006-0010  a 333-006-0120;
(b) "HSD" means the Oregon Health Authority's
			 Health Systems Division;
(c)
			 "Public Health" means the Oregon Health Authority's Public Health
			 Division;
(d) "Eligible Client"
			 means an individual who is found eligible for Medicaid or the Children's Health
			 Insurance Program (CHIP) by the Oregon Health Authority (Authority) at the time
			 the services are furnished;
(e)
			 "Oregon Health Plan (OHP)" means the Medicaid program in Oregon that is known
			 as the OHP and governed by a series of laws passed by the Oregon Legislature
			 with the intention of providing universal access to healthcare to Oregonians.
			 OHP is also governed by many federal laws;
(f) "Newborn Nurse Home Visiting Program
			 (NNHV)" has the meaning described in OAR 333-006-0010. The program provides
			 services to Medicaid-eligible newborns and their families. The program is
			 governed by Public Health, Division 6, OAR 333-006-0000  to
			 333-006-333-006-0160. "Newborn Nurse Home Visiting Program" and "Universally
			 Offered Newborn Nurse Home Visiting Program" are synonymous and may be used
			 interchangeably;
(g) "Newborn nurse
			 home visits" means home visits provided under the Newborn Nurse Home Visiting
			 Program.
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 130 - MEDICAL-SURGICAL SERVICES › Section 410-130-0610

Current through Register Vol. 63, No. 7, July 1, 2024
Statutory/Other Authority: ORS
				  413.042
Statutes/Other Implemented: ORS
				  414.025  & 414.065
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 130 - MEDICAL-SURGICAL SERVICES › Section 410-130-0670 - Death With Dignity

Current through Register Vol. 63, No. 7, July 1, 2024
(1) All
			 Death with Dignity services must be billed directly to the Division of Medical
			 Assistance Programs (Division), even if the client is in a managed care
			 plan.
(2) Death with Dignity is a
			 covered service, incorporated in the "comfort care" condition/treatment line on
			 the Health Services Commission's Prioritized List of Health Services.
(3) The following physician visits and
			 medical encounters are billable when performed by a licensed physician or
			 psychologist:
(a) The medical confirmation of
			 the terminal condition;
(b) The two
			 visits in which the client makes the oral request;
(c) The visit in which the written request is
			 made;
(d) The visit in which the
			 prescription is written;
(e)
			 Counseling consultation(s); and
(f)
			 Medication and dispensing.
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 130 - MEDICAL-SURGICAL SERVICES › Section 410-130-0680 - Laboratory and Radiology

Current through Register Vol. 63, No. 7, July 1, 2024
(1) The
			 following tables list the medical and surgical services that:
(a) Require prior authorization (PA) - OAR
			 410-130-0200  Table 130-0200-1 (PET scans require PA and are included in the
			 table), and;
(b) Are not
			 covered/bundled - OAR 410-130-0220  Table 130-0220-1.
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 130 - MEDICAL-SURGICAL SERVICES › Section 410-130-0700 - HCPCS Supplies and DME

Current through Register Vol. 63, No. 7, July 1, 2024
(1)
			 Use appropriate HCPCS codes to bill all supplies and DME.
(2) For items that do not have specific HCPCS
			 codes:
(a) Use unlisted HCPCS code;
(b) Bill at acquisition cost, purchase price
			 plus postage.
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 131 - PHYSICAL AND OCCUPATIONAL THERAPY SERVICES › Section 410-131-0040 - Physical and Occupational Therapy

Current through Register Vol. 63, No. 7, July 1, 2024
(1) The Division's Physical and Occupational
			 Therapy (PT/OT) Services rules are designed to assist licensed physical and
			 occupational therapists deliver health care services and prepare health claims
			 for clients with medical assistance program coverage. The limits,
			 authorization, and plan of treatment criteria apply to both rehabilitative and
			 habilitative therapy. The definition for both is the following:
(a) "Rehabilitative Services" means health
			 care services that help an individual re-establish, restore, or improve skills
			 and functioning for daily living that have been lost or impaired due to
			 illness, injury, or disability;
(b)
			 "Habilitative Services" means health care services that help an individual
			 keep, learn, or improve skills and functioning for daily living, designed to
			 establish skills that have not yet been acquired at an age-appropriate level.
			 Examples include therapy for a child who is not walking or talking at the
			 expected age;
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 131 - PHYSICAL AND OCCUPATIONAL THERAPY SERVICES › Section 410-131-0080 - Therapy Plan of Care and Record Requirements

Current through Register Vol. 63, No. 7, July 1, 2024
(1) There must be a rehabilitative or
			 habilitative therapy plan of care to receive payment.
(2) The Division shall authorize for the
			 level of care or type of service that meets the client's medical need
			 consistent with the Health Evidence Review Commission's (HERC) Prioritized List
			 of Health Services (Prioritized List) and guideline notes.
(3) The rehabilitative or habilitative
			 therapy plan must adhere to the licensing board requirements of care and shall
			 include:
(a) Client's name, ICD diagnosis
			 code, and type, amount, frequency, and duration of the proposed rehabilitative
			 or habilitative therapy;
(b)
			 Individualized, measurably objective functional goals;
(c) Documented need for extended service,
			 considering 60 minutes as the maximum length of a treatment session;
(d) Plan to address implementation of a home
			 management program as appropriate from the initiation of therapy
			 forward;
(e) Dated signature of the
			 therapist or the prescribing practitioner establishing the therapy plan of
			 care; and
(f) For home health
			 clients, any additional requirements included in OAR chapter 410 division
			 127.
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 131 - PHYSICAL AND OCCUPATIONAL THERAPY SERVICES › Section 410-131-0100

Current through Register Vol. 63, No. 7, July 1, 2024
Stat. Auth.: ORS
				  413.042
Stats. Implemented: ORS
				  414.065 &
				  688.135
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 131 - PHYSICAL AND OCCUPATIONAL THERAPY SERVICES › Section 410-131-0120 - Limitations of Coverage and Payment

Current through Register Vol. 63, No. 7, July 1, 2024
(1) The provision of PT/OT evaluations and
			 therapy services require a prescribing practitioner referral, and services
			 shall be supported by a therapy plan of care signed and dated by the
			 prescribing practitioner as specified in
			 42
			 CFR 440.110.
(2) PT/OT initial evaluations and
			 re-evaluations do not require PA and are not subject to prepayment review
			 (PPR), but are limited to the following:
(a)
			 Up to two initial evaluations in any 12-month period; and
(b) Up to four re-evaluation services in any
			 12-month period.
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 131 - PHYSICAL AND OCCUPATIONAL THERAPY SERVICES › Section 410-131-0160 - Prepayment Review (PPR) and Prior Authorization (PA) for Payment

Current through Register Vol. 63, No. 7, July 1, 2024
(1) Most OHP
			 clients have prepaid health services contracted for by the Authority through
			 enrollment in a Managed Care Entity (MCE).
(2) The provider shall verify whether an MCE
			 or the Division is responsible for reimbursement. Refer to OAR 410-120-1140  Verification of Eligibility and Coverage.
(3) If a client is enrolled in an MCE, there
			 may be PA requirements for some services that are provided through the MCE.
			 Providers shall comply with the MCE's PA requirements or other policies
			 necessary for reimbursement from the MCE before providing services to any OHP
			 client enrolled in an MCE. The physical or occupational therapy (PT/OT)
			 provider shall contact the client's MCE for specific instructions.
(4) A PT/OT provider assumes full financial
			 risk in providing services to a FFS client in providing services that are not
			 in compliance with Oregon Administrative Rules. See also OAR 410-120-1320  Authorization of Payment.
(a) PT/OT initial
			 evaluations and re-evaluations are not subject to PPR and do not require a
			 PA;
(b) To ensure reimbursement of
			 PT/OT services and procedures beyond the initial evaluation, the PT/OT provider
			 must submit all required supporting documentation:
(A) Upon submission of the first claim in a
			 series of claims in each therapy plan of care as established by prescribing
			 practitioner per OAR 410-131-0080  for claims subject to PPR;
(B) Request a PA within five working days
			 following 30 rehabilitative or 30 habilitative visits within a calendar year if
			 additional visits are necessary:
(i) PA
			 requests dated within five working days may be approved retroactively to
			 include services provided within five days prior to the date of the PA
			 request;
(ii) PA requests dated
			 beyond five working days may not be authorized retroactively and if authorized
			 shall be effective the date of the PA request. The Division recognizes the
			 facsimile or postmark as the PA date of request.
(c) All claims subject to PPR or
			 that require PA must include a therapy plan of care; and
(d) A PA is not required for Medicare-covered
			 PT/OT services provided to dual-eligible clients (Medicare clients who are also
			 Medicaid-eligible).
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 132 - PRIVATE DUTY NURSING SERVICES › Section 410-132-0020 - Private Duty Nursing Services

Current through Register Vol. 63, No. 7, July 1, 2024
(1) The practice of nursing is governed by
			 the following: Oregon State Board of Nursing, ORS
			 678.010 to
			 678.410, and Oregon State Board
			 of Nursing, chapter 851, divisions 031, 045, and 047.
(2) Private duty nursing is considered
			 supportive to the care provided to a client by the client's family, foster
			 parents, and delegated caregivers, as applicable. Nursing services shall be
			 medically appropriate. Medically appropriate for private duty nursing shift
			 care is determined by qualifying for services based on the Private Duty Nursing
			 Acuity Grid (DMAP 591). Increases or decreases in the level of care and number
			 of hours or visits authorized shall be based on a change in the client's
			 condition, program limitations, and the family, foster parents, or delegated
			 caregiver's ability to provide care.
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 132 - PRIVATE DUTY NURSING SERVICES › Section 410-132-0030 - Definitions

Current through Register Vol. 63, No. 7, July 1, 2024
(1) "Activities of
			 daily living or 'ADL'" means activities usually performed in the course of a
			 normal day in an individual's life including:
(a) Eating: Assisting the individual in
			 feeding or fluid intake by any means from a receptacle into the body, including
			 monitoring to prevent choking or aspiration;
(b) Bathing: Assisting the individual with
			 cleansing the body, washing hair, shaving, nail care, and using assistive
			 devices when necessary to get in and out of the bathtub or shower;
(c) Dressing: Assisting the individual with
			 putting on, fastening, and taking off all items of clothing, braces, and
			 artificial limbs, including obtaining and replacing items from their storage
			 area in the immediate environment;
(d) Toileting: Assisting the individual in
			 getting to and from, on and off, the toilet, commode, or bedpan for elimination
			 of feces and urine. This includes cleansing after elimination and adjusting
			 clothing as necessary;
(e)
			 Maintaining Continence: Including external cleansing of Foley catheter,
			 emptying catheter drainage bag, maintenance bowel care, changing and replacing
			 incontinence products, including colostomy or ileostomy bags;
(f) Transferring: Assisting the individual
			 with mobility, transfers, and repositioning by any means including use of an
			 assistive device and includes turning or adjusting padding for physical comfort
			 or pressure relief and encouraging or assisting with range of motion exercises.
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 132 - PRIVATE DUTY NURSING SERVICES › Section 410-132-0050 - Repealed

Current through Register Vol. 63, No. 7, July 1, 2024
Stat. Auth.: ORS
				  409.040 &
				  413.042
Stats. Implemented: ORS
				  414.065
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 132 - PRIVATE DUTY NURSING SERVICES › Section 410-132-0060 - Private Duty Nursing Transition into Maintenance

Current through Register Vol. 63, No. 7, July 1, 2024
(1) Private duty nursing services become
			 maintenance care when any one of the following situations occurs:
(a) Medical and nursing documentation
			 supports that the condition of the client is stable/predictable;
(b) The plan of care does not require a
			 licensed nurse to be in continuous attendance;
(c) The client, family, foster parents, or
			 caregivers have been taught the nursing services and have demonstrated the
			 skills and ability to carry out the plan of care;
(d) The combined score on the Acuity Grid and
			 Psychosocial Grid is less than 54.
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 132 - PRIVATE DUTY NURSING SERVICES › Section 410-132-0070 - Documentation Requirements

Current through Register Vol. 63, No. 7, July 1, 2024
(1)
			 Documentation of services provided shall be maintained in the client's place of
			 residence by the private duty nurse until discharged from service. Payment may
			 not be made for services where the documentation does not support the
			 definition of skilled nursing. Documentation shall meet the standards of the
			 Oregon State Board of Nursing.
(2)
			 The private duty nurse shall ensure completion and documentation of a
			 comprehensive assessment of the client's capabilities and needs for nursing
			 services within seven days of admission. Comprehensive assessments shall be
			 updated and submitted to the responsible unit by the next work day after any
			 significant change of condition and reviewed by the responsible unit within the
			 Oregon Health Authority at least every 60 days. Some examples of significant
			 change in condition are hospital admission, emergency room visit, and change in
			 status, death, or discharge from care.
(3) The nursing care plan shall document that
			 the private duty nurse, through case management and coordination with all
			 interdisciplinary staff and agencies, provides services to attain or maintain
			 the highest practicable physical, mental, and psychosocial well-being of each
			 client in accordance with a written, dated, nursing care plan. The nursing care
			 plan shall:
(a) Be completed within seven
			 days after admission for children and adolescents with short-term needs who are
			 served through the Division. The nursing care plan shall be reviewed, updated,
			 and submitted whenever the client's needs change, but at least every 60 days;
(b) Describe the medical, nursing,
			 and psychosocial needs of the client and how the private duty nurse will
			 actively coordinate and facilitate meeting those needs. This description of
			 needs shall include interventions, measurable objectives, goals, and time
			 frames in which the goals and objectives will be met and by whom;
(c) Include the rehabilitation potential
			 including functional limitations related to Activities of Daily Living (ADL),
			 types and frequency of therapies, and activity limitations per physician order;
(d) Include services related to
			 school-based care according to the IEP and the Individualized Family Service
			 Plan, if applicable;
(e) Show
			 coordination of all services being provided including, but not limited to, the
			 client or representative, registered nurse (RN) case manager, Department case
			 worker, physician, other disciplines involved, and all other care providers
			 involved in the client's treatment plan;
(f) Include a statement of the client's
			 potential toward discharge. Timelines shall be included in the plan outline;
(g) Be available to and followed
			 by all caregivers involved with the client's care.
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 132 - PRIVATE DUTY NURSING SERVICES › Section 410-132-0080 - Limitations

Current through Register Vol. 63, No. 7, July 1, 2024
(1) General
			 pertains to both shift care and visits:
(a)
			 Private duty nursing is not covered if the client is:
(A) Twenty-one years of age or older;
(B) A resident of a nursing
			 facility;
(C) A resident of a
			 licensed intermediate care facility for individuals with intellectual
			 disabilities (ICF/ID);
(D) In a
			 hospital;
(E) In a licensed
			 residential care facility;
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 132 - PRIVATE DUTY NURSING SERVICES › Section 410-132-0100 - Prior Authorization

Current through Register Vol. 63, No. 7, July 1, 2024
(1)
			 Private duty nursing providers shall obtain prior authorization (PA) for all
			 services.
(2) Providers shall
			 request PA as follows (see the Private Duty Nursing Services Supplemental
			 Information booklet for contact information):
(a) For individuals served by the MFC), from
			 the Departments MFC Program;
(b)
			 For clients enrolled in the fee-for-service (FFS) Medical Case Management (MCM)
			 program, from the MCM contractor;
(c) For members enrolled in a coordinated
			 care organization (CCO) or prepaid health plan (PHP), from the CCO or the PHP;
(d) For all other clients, from
			 the Division.
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 132 - PRIVATE DUTY NURSING SERVICES › Section 410-132-0120 - Billing Information

Current through Register Vol. 63, No. 7, July 1, 2024
(1) If the
			 client has not enrolled in a CCO or PHP, bill with the appropriate Division
			 unique procedure codes and follow the instructions on how to complete the
			 CMS-1500.
(2) Client copayments
			 may be required for certain services. See OAR 410-120-1230  for specific
			 details.
(3) Claims shall be
			 submitted on a CMS-1500, electronically or on paper. Paper claims shall be sent
			 to the Division.
(4) Contact the
			 Division's Electronic Billing Representative for information about electronic
			 billing.
(5) Bill on a CMS-1500
			 and enter the appropriate TPR Explanation Code in Field 9 when billing for
			 clients with Medicare.
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 132 - PRIVATE DUTY NURSING SERVICES › Section 410-132-0180 - Procedure Codes

Current through Register Vol. 63, No. 7, July 1, 2024
(1) All private
			 duty nursing services require prior authorization.
(2) Private duty nursing visit:
(a) T1030 - Nursing care in the home by
			 registered nurse per diem;
(b)
			 T1031 - Nursing care in the home by licensed practical nurse per diem.
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 132 - PRIVATE DUTY NURSING SERVICES › Section 410-132-0200 - Provider Enrollment

Current through Register Vol. 63, No. 7, July 1, 2024
(1)
			 Registered nurses and licensed practical nurses shall submit a copy of
			 licensure every two years upon renewal by the Oregon State Board of Nursing to
			 be enrolled or continue enrollment as a Division provider.
(2) If the Division provider is a nursing
			 employment/staffing agency, the agency shall:
(a) Be licensed in the State of Oregon as an
			 in-home care agency with a comprehensive licensure as defined in OAR 333-536 or
			 Home Health Agency OAR 333-027;
(b) Conduct a background check through the
			 Department CRIMS;
(c) Provide a
			 copy of the state licensure to the Authority upon request.
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 133 - SCHOOL-BASED HEALTH SERVICES › Section 410-133-0060 - Health Services

Current through Register Vol. 63, No. 7, July 1, 2024
(1) A
			 School-based Health Service is a health service for a Medicaid-eligible student
			 that meets the coverage requirements in OAR 410-133-0080  and that:
(a) Addresses physical or mental disabilities
			 and health-related service needs and devices that help the child or student
			 keep, learn, or improve skills and functioning that adversely affects the child
			 or student's educational performance; and
(b) Is identified in a student's
			 Individualized Education Program (IEP) or the Individualized Family Service
			 Plan (IFSP); and
(c) Is recommended
			 by a physician or other licensed health care practitioner within the scope of
			 practice under state law.
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 133 - SCHOOL-BASED HEALTH SERVICES › Section 410-133-0080 - Coverage

Current through Register Vol. 63, No. 7, July 1, 2024
The Authority may reimburse school medical (SM) providers for
				covered health services that meet all the following criteria:
(1) The health service must be "necessary and
			 appropriate," considered as a covered service under the Oregon Health Plan
			 (OHP) Prioritized List of health services, and the health service may not be
			 excluded under OAR 410-133-0200  Not Covered Services.
(2) The health service must be required by a
			 Medicaid-eligible student's physical or mental condition that adversely affects
			 the child/student's educational performance and that helps the child/student
			 keep, learn, or improve skills and functioning as specified on the
			 Individualized Education Program (IEP) or Individualized Family Service Plan
			 (IFSP) and further described in the treatment plan and the evaluation of the
			 student.
(3) The health service,
			 individual, or group may include corrective health services treatments and
			 Medicaid-covered related services as described in a student's IEP or IFSP:
(a) The payment rate for health services
			 includes case management and necessary supplies for these services. Additional
			 reimbursement for such services is not paid separately from the health
			 service;
(b) These services must be
			 provided by medically qualified staff that meet the standards of licensing or
			 certification for the health service being provided as described in OAR
			 410-133-0120  and comply with the respective medical provider's governing
			 definitions, scope of practice, documentation requirements, and licensure or
			 certification.
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 133 - SCHOOL-BASED HEALTH SERVICES › Section 410-133-0160 - Licensed Practitioner Recommendation

Current through Register Vol. 63, No. 7, July 1, 2024
Requests for payment for covered health services required by a
				Medicaid-eligible student's Individualized Education Program (IEP) or
				Individualized Family Service Plan (IFSP) must be supported by written
				recommendation from a physician or a licensed health care practitioner acting
				within the scope of their practice for the treatment provided. The
				recommendation must be current for the treatment provided as specified on the
				IEP or IFSP.
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 133 - SCHOOL-BASED HEALTH SERVICES › Section 410-133-0180 - Duplication of Service

Current through Register Vol. 63, No. 7, July 1, 2024
(1) The
			 School Medical (SM) provider that utilizes a contractor to provide health
			 services may only bill Oregon Health Authority or the Division of Medical
			 Assistance Programs (Division) for health services when the school medical (SM)
			 provider and the contracted provider have previously agreed that the contractor
			 will not also bill for the same service.
(2) Duplicate billings are not allowed and
			 payments will be recovered. Billings for health services to Medicaid-eligible
			 students will be considered as duplicate if the same services are billed by
			 more than one Educational Agency (EA) to address the same need. For example: an
			 Education Service District (ESD) and a local school district cannot both bill
			 the same services provided to the student.
(3) A unit of service can only be billed
			 once; under one procedure code, under one provider number.
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 133 - SCHOOL-BASED HEALTH SERVICES › Section 410-133-0220 - Billing and Payment

Current through Register Vol. 63, No. 7, July 1, 2024
(1) The School
			 Medical (SM) provider must bill the Oregon Health Authority (Authority), also
			 termed Department, in accordance with OAR 410-120-0035; and must bill at a cost
			 rate no greater than the education agency's cost rate for the applicable
			 discipline reviewed and accepted by the Authority based on the cost
			 determination process described in OAR 410-133-0245.
(2) Services must be billed on a CMS-1500 or
			 by electronic media claims (EMC) submission using only those procedure codes
			 and modifiers specified for the School-Based Health Services (SBHS) program. If
			 the SM provider submits their claims electronically, the SM provider must
			 become a trading partner with the Authority and comply with the requirements
			 for Electronic Data Interchange (EDI) pursuant to Chapter 943 Division 120
			 rules and Chapter 410 Division 120 rules.
(3) The Authority will accept a claim up to
			 12 months from the date of service. See Department Provider Rules 943-120-0340
			 Claim and PHP Encounter Submission and General Rules 410-120-1300  Timely
			 Submission of Claims.
(4) Third
			 party liability. In general, the Medicaid program is the payor of last resort
			 and a provider is required to bill other resources before submitting the claim
			 to Medicaid. This requirement means that other payment sources, including other
			 federal or state funding sources, must be used first before the Authority can
			 be billed for covered health services. However, the following exceptions apply
			 to the requirement to pursue third party resources:
(a) For health services provided under the
			 Individuals with Disabilities Education Act (IDEA), Medicaid pays before Oregon
			 Department of Education (ODE) or the Educational Agency (EA), to the extent the
			 health service is a covered service provided to a Medicaid-eligible student
			 documented as required under these rules, and subject to the applicable
			 reimbursement rate;
(b) If
			 School-Based Health Services (SBHS) are provided under Title V of the Social
			 Security Act (Maternal and Child Health Services Block Grant), Medicaid-covered
			 Health Services provided by a Title V grantee are paid by Medicaid before the
			 Title V funds;
(c) The Centers for
			 Medicare and Medicaid Services (CMS) recognize that while schools are legally
			 liable to provide IDEA-related health services at no cost to the eligible
			 students, Medicaid reimbursement is available for these services because
			 section 1903(c) of the ACT requires Medicaid to be primary to the U.S.
			 Department of Education for payment of the health-related services provided
			 under IDEA.
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 133 - SCHOOL-BASED HEALTH SERVICES › Section 410-133-0245 - Cost Determination and Payment

Current through Register Vol. 63, No. 7, July 1, 2024
(1) The Oregon Health Authority (Authority)
			 will make rate determinations for the purposes of payment under OAR
			 410-133-0220  based on annual cost determinations submitted by local education
			 agencies (EA's).
(2) Cost
			 determinations will:
(a) Be based on the EA's
			 prior year's annual audited costs;
(b) Establish an hourly and 15-minute
			 increment rate for the current year billed;
(c) Use the current year Oregon Department of
			 Education (ODE)-approved indirect rate for the EA;
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 133 - SCHOOL-BASED HEALTH SERVICES › Section 410-133-0280 - Rebilling

Current through Register Vol. 63, No. 7, July 1, 2024
In order to correct a claim reimbursed for services provided to
				a Medicaid-eligible student, the School Medical (SM) provider must request an
				adjustment. The paid claim must be corrected on the Individual Adjustment
				Request Form (OHP 1036) to allow revision of the original claim. Providers may
				perform online claim submissions and adjustments using the Authority's web
				portal. The link can be found at: https://www.or-medicaid.gov [File Link Not
				Available]. Rebilling additional units of service on a CMS-1500 for the same
				timeframe would be denied as duplicate services. See 410-120-1300  Timely
				Submission of Claims and 410-120-1397  Recovery of Overpayments to Providers -
				Recoupments and Refunds.
Forms referenced available from the
				  agency.
Statutory/Other Authority: ORS
				  413.042 & 414.065
Statutes/Other Implemented: ORS
				  413.042 & 414.065
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 133 - SCHOOL-BASED HEALTH SERVICES › Section 410-133-0300 - Procedure Codes

Current through Register Vol. 63, No. 7, July 1, 2024
(1) The provider
			 must use the procedure code from the School-Based Health Services table that
			 best describes the specific service provided and a modifier that describes the
			 discipline providing the service. Refer to 410-133-0080  Coverage for service
			 requirements and limitations.
(2)
			 Unit values equal 15 minutes of service unless otherwise stated. These time
			 units must be documented in the Medicaid-eligible student's records under the
			 services billed and accounted for under one code only.
(3) Visit. A service measurement of time for
			 billing and reimbursement efficiency. One visit equals the school provider's
			 hourly cost rate for category of service provided (i.e., occupational therapy,
			 physical therapy, speech therapy, etc.) specified in an IEP or IFSP, divided by
			 60 to yield a cost per minute; per minute cost is then multiplied by amount of
			 service time provided in minutes. For billing purposes, a visit is always
			 presented as one visit.
Stat. Auth.: ORS
				  413.042 &
				  414.065
Stats. Implemented: ORS
				  413.042 &
				  414.065