reglab/statecodes huggingface dataset:
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 146 - AMERICAN INDIAN/ALASKA NATIVE › Section 410-146-0120 - Maternity Case Management Services

Current through Register Vol. 63, No. 7, July 1, 2024
(1) The Division shall reimburse IHCP for MCM
			 services according to their encounter rate.
(2) MCM service is optional coverage for
			 Prepaid Health Plans (PHPs). Before providing MCM services to clients enrolled
			 in a PHP, determine if the PHP covers MCM services:
(a) If the PHP does not cover MCM services,
			 the provider may bill the Division directly per the clinic's encounter rate.
			 Prior authorization is not required if the PHP does not provide coverage for
			 MCM services;
(b) If the PHP does
			 cover MCM services, and services were furnished to a:
(A) Non-AI/AN client, the provider needs to
			 request the necessary authorizations from the PHP;
(B) AI/AN client enrolled with a PHP with
			 which the IHCP does not have an agreement, the IHCP may bill the Division
			 directly.
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 146 - AMERICAN INDIAN/ALASKA NATIVE › Section 410-146-0130 - Modifiers

Current through Register Vol. 63, No. 7, July 1, 2024
(1) The Division
			 uses HIPAA compliant modifiers for many services.
(2) The following services require the use of
			 a modifier for all services for all procedures:
(a) Family planning service -- FP, refer to
			 OAR 410-130-0585  Family Planning Services;
(b) Vaccine for children -- SL or 26, refer
			 to OAR 410-130-0255.
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 146 - AMERICAN INDIAN/ALASKA NATIVE › Section 410-146-0160 - Administrative Medical Examinations and Reports

Current through Register Vol. 63, No. 7, July 1, 2024
(1) The Division may not reimburse
			 administrative medical examinations and reports at an IHCP's IHS encounter
			 rate. Administrative medical examinations and reports are not eligible under
			 the Memorandum of Agreement (MOA). The Division shall reimburse providers for
			 Administrative Examinations and Reports on a fee-for-service basis outside the
			 IHS or cost-based encounter rate.
(2) AI/AN Health Care Facilities may be
			 reimbursed for administrative medical examinations and reports when requested
			 by a Department of Human Services branch office or approved by the Division.
			 The branch office may request an Administrative Medical Examination/Report
			 Authorization (OHP 729) to establish client eligibility for an assistance
			 program or casework planning.
(3)
			 Refer to OAR 410 division 150, Administrative Examination and Report Billing
			 Services, for specific requirements. See Administrative Exams Supplemental
			 Information guide for more detailed information on procedure codes and
			 descriptions.
Publications: Publications referenced are available from the
				  agency.
Statutory/Other Authority: ORS
				  413.042 & ORS
				  414.065
Statutes/Other Implemented: ORS
				  414.065
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 146 - AMERICAN INDIAN/ALASKA NATIVE › Section 410-146-0200 - Pharmacy

Current through Register Vol. 63, No. 7, July 1, 2024
(1) A valid
			 encounter excludes pharmaceutical or biologicals not generally provided during
			 a clinic visit:
(a) An IHS or Tribal 638
			 Pharmacy may select whether to be reimbursed by the Division for prescriptions,
			 including dispensing services, at the appropriate 340(B) or Federal Supply
			 Schedule Acquisition Rate (refer to OAR 410-121-0160) plus the dispensing fee
			 as determined by the state, or at the All-Inclusive Rate (AIR) published
			 annually by the IHS, inclusive of dispensing fees;
(b) An IHS or Tribal 638 Pharmacy may request
			 to change from the appropriate 340(B) or Federal Supply Schedule Acquisition
			 Rate plus a dispensing fee methodology, to the IHS All-Inclusive Rate (AIR)
			 methodology, or from the IHS AIR methodology to the appropriate 340(B) or
			 Federal Supply Schedule Acquisition Rate (AAC) plus dispensing fee methodology,
			 but no more frequently than four times in a calendar year. Requests must be
			 submitted at least 30 days in advance and shall be effective at the start of
			 the following quarter. If an IHS or Tribal 638 Pharmacy experiences
			 circumstances requiring a methodology change, the 30 day advance notice may be
			 waived and the process.
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 146 - AMERICAN INDIAN/ALASKA NATIVE › Section 410-146-0220 - Death With Dignity

Current through Register Vol. 63, No. 7, July 1, 2024
(1) Death
			 with Dignity is a covered service, except for those facilities limited by the
			 Assisted Suicide Funding Restriction Act of 1997 (ASFRA), and is incorporated
			 in the "comfort care" condition/treatment line on the HERC's Prioritized List
			 of Health Services.
(2) All Death
			 with Dignity services must be billed directly to the Division, even if the
			 client is in a prepaid health plan. Death with Dignity services are not part of
			 the AI/AN encounter rate.
(3)
			 Follow criteria outlined in OAR 410-130-0670.
Statutory/Other Authority: ORS
				  413.042 & ORS
				  414.065
Statutes/Other Implemented: ORS
				  414.065
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 146 - AMERICAN INDIAN/ALASKA NATIVE › Section 410-146-0240 - Transportation

Current through Register Vol. 63, No. 7, July 1, 2024
(1) The Division
			 may reimburse IHCP for medically appropriate sedan car or wheelchair van
			 transportation services provided to OHP AI/AN clients who receive medical
			 services through an IHCP. (Refer to OAR 410 Division 136, Medical
			 Transportation.)
(2) Federal
			 regulations in
			 42 CFR
			 431.53 require the state to ensure necessary
			 transportation for Medicaid recipients to and from providers. The IHCP must
			 ensure that:
(a) The service to be provided
			 is the most cost-effective method that meets the medical needs of the client;
			 and
(b) The service to be provided
			 at the point of origin and destination is a Division Medicaid-covered service
			 according to a client's OHP benefit package;
(c) In addition, AI/AN OHP clients may be
			 transported to the nearest Tribal Health facility and are not restricted to the
			 nearest (non-tribal) facility able to meet the client's medical needs.
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 146 - AMERICAN INDIAN/ALASKA NATIVE › Section 410-146-0440 - Prepaid Health Plan Supplemental Payments

Current through Register Vol. 63, No. 7, July 1, 2024
(1) Effective January 1, 2001, the Division
			 is required by
			 42 USC
			 1396a(bb) to make
			 supplemental payments to eligible Federally Qualified Health Centers (FQHC) and
			 Rural Health Clinics (RHC) that contract with Prepaid Health Plans (PHP).
			 American Indian/Alaska Native (AI/AN) program providers that are not FQHCs and
			 that elect to receive payment under Title XIX and XXI according to the Indian
			 Health Services (IHS) rate under the Memorandum of Agreement (MOA) effective
			 July 11, 1996 will also be eligible to receive supplemental payments in the
			 same manner as an FQHC under 1902(bb)(5).
(2) IHCPs reimbursed according to a
			 cost-based rate under the Prospective Payment System (PPS) are directed to
			 Oregon administrative rule (OAR) 410-147-0460, Prepaid Health Plan Supplemental
			 Payments.
(3) The PHP supplemental
			 payment represents the difference, if any, between the payment received by the
			 IHCP from the PHP for treating the PHP enrollee and the payment to which the
			 IHCP would be entitled if they had billed the Division directly for these
			 encounters according to the clinic's IHS rate.
(4) In accordance with federal regulations,
			 the provider must take all reasonable measures to ensure that in most
			 instances, with the exception of IHS or designated Tribal funds, Medicaid shall
			 be the payer of last resort. Providers must make reasonable efforts to obtain
			 payment first from other resources before submitting claims to the PHP (refer
			 to OAR 410-120-1140, Verification of Eligibility).
(5) When any other coverage is known to the
			 provider, the provider must bill the other resource prior to billing the PHP.
			 When a provider receives a payment from any source prior to the submission of a
			 claim to the PHP, the amount of the payment must be shown as a credit on the
			 claim in the appropriate field (see OAR 410-120-1280, Billing and 410-120-1340,
			 Payment).
(6) Supplemental payment
			 by the Division for encounters submitted by IIHCPs for purposes of this rule is
			 reduced by any and all payments received by the IHCP from outside resources,
			 including Medicare, private insurance, or any other coverage. IHCPs are
			 required to report all payments received on the Managed Care Data Submission
			 Worksheet, including:
(a) Medicaid PHPs;
(b) Medicare Advantage Managed
			 Care Organizations (MCO);
(c)
			 Medicare, including Medicare MCO supplemental payments; and
(d) Any third party resources (TPR).
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 146 - AMERICAN INDIAN/ALASKA NATIVE › Section 410-146-0460 - Compensation for Outstationed Eligibility Workers

Current through Register Vol. 63, No. 7, July 1, 2024
(1) The Division may provide reasonable
			 compensation for activities directly related to the receipt and initial
			 processing of applications for individuals to apply for Medicaid at
			 outstationed locations other than state offices.
(2) The Division may provide reasonable
			 compensation to eligible IHCPs for outreach activities performed by
			 Outstationed Outreach Workers (OSOW) equal to 100 percent of direct costs.
(3) IHCPs must submit a budget
			 each December 1 to the Division for review of the clinic OSOW costs for
			 approval before any OSOW compensation is made each January 1.
(4) IHCPs must be compliant with OAR
			 410-120-0045  Applications for Medical Assistance at provider locations to be
			 eligible for compensation under this rule.
(5) For staff employed by a clinic and
			 performing outreach activities at less than full time, the clinic must
			 calculate the percent of time spent performing OSOW services and maintain
			 adequate documentation to support the percentage of time claimed. The percent
			 must be used to calculate personnel expenses incurred by an IHCP as outlined in
			 section (7) of this rule and that are directly attributed to outreach
			 activities performed by the employee.
(6) Case management is excluded from OSOW
			 reimbursement. If an OSOW also does case management, calculate the OSOW expense
			 as outlined in section (5) above.
(7) Direct cost expenses allowed for OSOW
			 reimbursement:
(a) Personnel costs for OSOWs:
(A) Salary/wages;
(B) Taxes;
(C) Fringe benefits provided to OSOW;
(D) Premiums paid by the IHCP for
			 private health insurance.
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 146 - AMERICAN INDIAN/ALASKA NATIVE › Section 410-146-5000 - Indian Managed Care Entities

Current through Register Vol. 63, No. 7, July 1, 2024
(1) Definitions.
			 The definitions in OAR 410-141-3500  apply to this rule unless context dictates
			 otherwise. In addition, for purposes of this rule:
(a) "The Authority" means the Oregon Health
			 Authority;
(b) "Contract" means an
			 agreement between the State of Oregon and an Indian Managed Care Entity to
			 provide Primary Care Case Management services to eligible members;
(c) "Indian Managed Care Entity (IMCE)" means
			 a managed care entity that is controlled by the Indian Health Service, a Tribe,
			 Tribal Organization, or Urban Indian Organization, or a consortium thereof, as
			 described in
			 42 U.S.C. §
										1396u-2(h)(4)(B) and  42 C.F.R. §
										438.14(a);
(d)
			 "Client" means an Oregon Health Plan client who is American Indian or Alaska
			 Native (AI/AN) as defined at
			 25
			 USC 1603(13),
			 1603(28),
			 or
			 1679(a),
			 or who has been determined eligible as an Indian, under
			 42 CFR
			 136.12; or as defined under
			 42
			 CFR 438.14(a).;
(e) "Member" means a client enrolled with an
			 IMCE;
(f) "Primary Care Case
			 Management (PCCM) Services" means the location, coordination and monitoring of
			 primary health care services for members. PCCM services may include:
(A) The provision of intensive telephonic or
			 face-to-face case management, including operation of a nurse triage advice
			 line;
(B) The development of
			 enrollee care plans;
(C) The
			 execution of contracts with, or oversight responsibilities for, the activities
			 of fee-for-service (FFS) providers in the FFS program;
(D) The provision of payments to FFS
			 providers on behalf of the State;
(E) The provision of enrollee outreach and
			 education activities;
(F) The
			 operation of a customer service call center;
(G) Review of provider claims, utilization,
			 and practice patterns to conduct provider profiling or practice
			 improvement;
(H) Implementation of
			 quality improvement activities, including administering enrollee satisfaction
			 surveys or collecting data necessary for performance measurement of
			 providers;
(I) Coordination with
			 behavioral health systems/providers; and
(J) Coordination with long-term services and
			 supports systems/providers.
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 147 - FQHC AND RHC SERVICES › Section 410-147-0000 - Foreword

Current through Register Vol. 63, No. 7, July 1, 2024
(1) The Division of
			 Medical Assistance Programs" (DMAP) Federally Qualified Health Center (FQHC)
			 and Rural Health Clinic (RHC) rules are designed to assist FQHCs and RHCs to
			 deliver health care services and prepare health claims for clients with Medical
			 Assistance Program coverage.
(2)
			 The FQHC and RHC rules contain important information including general program
			 policy, provider enrollment, and maintenance of financial records, special
			 programs, and billing information.
(3) It is the clinic's responsibility to
			 understand and follow all DMAP rules that are in effect on the date services
			 are provided.
(4) Typically rules
			 are modified twice a year, April for technical changes and October for
			 technical and/or program changes. Technical changes refer to operational
			 information. All provider rules can be found on the DMAP website.
(5) FQHCs and RHCs must use rules contained
			 in the FQHC and RHC rules. Do not use other provider rules unless specifically
			 directed in rules contained in the FQHC and RHC rules. DMAP General Rules and
			 the Oregon Health Plan (OHP) Administrative Rules are intended to be used in
			 conjunction with all program rules including the FQHC and RHC provider
			 rules.
(6) The Health Services
			 Commission's Prioritized List of Health Services is found in the OHP
			 Administrative Rules (OAR 410-141-0520) and defines the services covered under
			 DMAP.
(7) An FQHC is defined as a
			 clinic that is recognized and certified by the Centers for Medicare and
			 Medicaid Services (CMS) as meeting federal requirements as an FQHC.
(8) An RHC is defined as a clinic that is
			 recognized and certified by CMS as meeting federal requirements for payment for
			 RHC services.
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 147 - FQHC AND RHC SERVICES › Section 410-147-0020 - Professional Ambulatory Services

Current through Register Vol. 63, No. 7, July 1, 2024
(1)
			 Providers must use the following rules in conjunction with all individual
			 program rules to determine service coverage and limitations for Oregon Health
			 Plan (OHP) clients according to their benefit packages: Medical, EPSDT,
			 Diagnostic, Dental, Vision, Physical Therapy, Occupational Therapy, Podiatry,
			 Mental Health, Alcohol and Chemical Dependency, Maternity Case Management,
			 Speech, Hearing, and Home Health services are governed by the Federally
			 Qualified Health Center (FQHC) and Rural Health Clinic (RHC) rules (OAR 410
			 division 147), General Rules (410 division 120), OHP Administrative Rules
			 (410-141-0480, 410-141-0500, and 410-141-0520), and the Health Services
			 Commission's (HSC) Prioritized List of Health Services (List), and the Oregon
			 Health Authority (Authority) rules related to Provider Enrollment and Claiming
			 (943-0120-300 through 0380).
(2)
			 Federally Qualified Health Centers (FQHCs) and Rural Health Clinics (RHCs) are
			 eligible for reimbursement of covered professional services provided within the
			 scope of the clinic and within the individual practitioner's scope of license
			 or certification. See also OAR 410-147-0120(6). For the purposes of this rule,
			 a clinic's "scope" refers to authorization or certification to provide services
			 if required:
(a) For FQHCs only, services
			 must be provided in accordance with the FQHC's scope as approved by the Health
			 Resources and Services Administration (HRSA) Notice of Grant Award
			 Authorization; and
(b) Both FQHCs
			 and RHCs must provide services within the scope of the Addictions and Mental
			 Health Division (AMH) certification for the facility, if required. See OAR
			 410-147-0320(3) and (5).
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 147 - FQHC AND RHC SERVICES › Section 410-147-0040 - ICD-9-CM Diagnosis and CPT/HCPCs Procedure Codes

Current through Register Vol. 63, No. 7, July 1, 2024
(1) The appropriate ICD-10-CM diagnosis code
			 or codes from 001.0 through V99.9 must be used to identify:
(a) Diagnoses;
(b) Symptoms;
(c) Conditions;
(d) Problems;
(e) Complaints; or
(f) Other reasons for the encounter/visit.
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 147 - FQHC AND RHC SERVICES › Section 410-147-0060 - Prior Authorization

Current through Register Vol. 63, No. 7, July 1, 2024
(1) Most
			 Oregon Health Plan (OHP) clients have prepaid health services, contracted for
			 by the Oregon Health Authority (Authority) through enrollment in a Prepaid
			 Health Plan (PHP). Client's who are not enrolled in a PHP, receive services on
			 an "open card" or "fee-for-service" (FFS) basis.
(2) It is the responsibility of the Provider
			 to verify whether a PHP or DMAP is responsible for reimbursement. Refer to OAR
			 410-120-1140  Verification of Eligibility.
(3) If a client is enrolled in a PHP there
			 may be Prior Authorization (PA) requirements for some services that are
			 provided through the PHP. It is the FQHC or RHC's responsibility to comply with
			 the PHP's PA requirements or other policies necessary for reimbursement from
			 the PHP before providing services to any OHP Client enrolled in a PHP. The FQHC
			 or RHC needs to contact the client's PHP for specific instructions.
(4) Clients who are enrolled in a PHP can
			 receive family planning services, human immunodeficiency virus (HIV) and
			 acquired immune deficiency syndrome (AIDS) prevention services (excludes any
			 treatment for HIV or AIDS) through an FQHC or RHC without PA from the PHP as
			 provided under the terms of Oregon's Section 1115 (CMS) Waiver. If the FQHC or
			 RHC does not have a contract or other arrangements with a PHP, and the PHP
			 denies payment, the Division of Medical Assistance Programs (DMAP) will
			 reimburse for these services per a clinic's encounter rate (see OAR
			 410-147-0120(12)(b)).
(5) If a
			 client receives services on a "fee-for-service" basis, a PA may be required by
			 DMAP for certain covered services or items before the service can be provided
			 or before payment will be made. An FQHC or RHC assumes full financial risk in
			 providing services to a "fee-for-service" client prior to receiving
			 authorization, or in providing services that are not in compliance with Oregon
			 Administrative Rules (OARs). See OAR 410-120-1320  Authorization of Payment and
			 any applicable program rules.
(6)
			 If the service or item is subject to Prior Authorization, the FQHC or RHC must
			 follow and comply with PA requirements in these rules, the General Rules and
			 applicable program rules, including but not limited to:
(a) The service is adequately documented (see
			 OAR 410-120-1360, Requirements for Financial, Clinical and Other Records).
			 Providers must maintain documentation in the provider's files to adequately
			 determine the type, medical appropriateness, or quantity of services
			 provided;
(b) The services provided
			 are consistent with the information submitted when authorization was
			 requested;
(c) The services billed
			 are consistent with those services provided; and
(d) The services are provided within the
			 timeframe specified on the authorization of payment document.
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 147 - FQHC AND RHC SERVICES › Section 410-147-0080 - Prepaid Health Plans (PHPs)

Current through Register Vol. 63, No. 7, July 1, 2024
(1)
			 Most Oregon Health Plan (OHP) clients have prepaid health services, contracted
			 for by the Oregon Health Authority (Authority) through enrollment in a Prepaid
			 Health Plan (PHP). Clinics serving eligible OHP clients who are enrolled in a
			 PHP must secure authorization from the PHP prior to providing PHP-covered
			 services or case management services. Federally Qualified Health Centers (FQHC)
			 and Rural Health Clinics (RHC) must request an authorization or referral from
			 the PHP before providing any services to clients enrolled in a PHP unless the
			 FQHC or RHC have contracted with the PHP to provide PHP-covered services. If an
			 FQHC or RHC has an arrangement or contract with a PHP, the clinic is
			 responsible to follow PHP rules and prior authorization requirements. See OAR
			 410 division 141 for OHP Program Rules and; 410-147-0060, Prior
			 Authorization.
(2) The Division of
			 Medical Assistance Programs (DMAP) encourages FQHCs and RHCs to contact each
			 PHP in their local service area for the purpose of requesting inclusion in
			 their panel of providers.
(3) PHPs
			 contracting with FQHCs or RHCs, for the provision of providing services to
			 their members, are required by
			 42 USC
			 1396 b(m)(2)(A)(ix) to provide payment to the
			 FQHC or RHC that is not less than the level and amount of payment which the PHP
			 would make for services furnished by a non-FQHC/RHC provider.
(4) Payment for services provided to
			 PHP-enrolled clients (PHP members) is a matter between the FQHC or RHC and the
			 PHP authorizing the services except as otherwise provided in OAR 410-141-0410,
			 OHP Primary Care Managers. If a PHP denies payment to an FQHC or RHC because
			 arrangements were not made with the PHP prior to providing the service, the
			 Division will not reimburse the FQHC or RHC under the encounter rate, except as
			 outlined in Section (5) of this rule (see OAR 410-141-0120, OHP PHP Provision
			 of Health Care Services).
(5) FQHCs
			 and RHCs can provide family planning services or HIV/AIDS prevention services
			 to eligible PHP members without authorization or a referral from the PHP. The
			 FQHC and RHC must bill the PHP first. If the PHP will not reimburse for the
			 service, then the clinic may bill DMAP. Refer to ORS
			 414.153, Authorization for
			 payment for certain point of contact services.
(6) PHPs will execute agreements with
			 publicly funded providers, unless cause can be demonstrated to DMAP's
			 satisfaction why such an agreement is not feasible for authorization of payment
			 for point of contact services in the following categories (refer to ORS
			 414.153):
(a) Immunizations;
(b) Sexually transmitted diseases;
			 and
(c) Other communicable
			 diseases.
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 147 - FQHC AND RHC SERVICES › Section 410-147-0085 - Client Copayments

Current through Register Vol. 63, No. 7, July 1, 2024
(1) The
			 Division of Medical Assistance Programs (DMAP) Medical Care Identification will
			 indicate which Oregon Health Plan (OHP) clients are responsible for copayments
			 for services.
(2) DMAP requires
			 copayments from clients with certain benefit packages. See OAR 410-120-1230,
			 Client Copayment, and Table 120-1230-1 for specific details.
(3) A client may owe more than one copayment
			 during a 24-hour period. DMAP may require copayments for each medical, dental,
			 mental health or alcohol and chemical dependency encounter on the same date of
			 service. Refer to OAR 410-147-0140, Multiple Encounters.
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 147 - FQHC AND RHC SERVICES › Section 410-147-0120 - Division Encounter and Recognized Practitioners

Current through Register Vol. 63, No. 7, July 1, 2024
(1) The Division of Medical Assistance
			 Programs (Division) reimburses Federally Qualified Health Center (FQHC) and
			 Rural Health Clinic (RHC) services according to the Prospective Payment System
			 (PPS) as follows:
(a) When the service(s)
			 meet the criteria of a valid encounter as defined in Sections (2) through (4)
			 of this rule;
(b) Reimbursement is
			 limited to the Division's Medicaid-covered services according to a client's
			 Oregon Health Plan (OHP) benefit package. These services include ambulatory
			 services included in the State Plan under Title XIX or Title XXI of the Social
			 Security Act. Other services that are not defined in this rule or the State
			 Plan under Title XIX or Title XXI of the Social Security Act are not reimbursed
			 by the Division.
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 147 - FQHC AND RHC SERVICES › Section 410-147-0140 - Multiple Encounters

Current through Register Vol. 63, No. 7, July 1, 2024
(1) An
			 encounter is defined in OAR 410-147-0120.
(2) The following services may be considered
			 as multiple encounters when two or more service encounters are provided on the
			 same date of service with distinctly different diagnoses (see OAR 410-147-0120  and individual program rules listed below for specific service requirements and
			 limitations):
(a) Medical section (3) of this
			 rule and OAR chapter 410, division 130);
(b) Dental (OAR 410-147-0125, and OAR chapter
			 410, division 123);
(c) Mental
			 Health - If a client is also seen for a medical office visit and receives a
			 mental health diagnosis, then the client contacts are a single encounter (Refer
			 to the Division of Addictions and Mental Health (AMH) for the appropriate
			 OARs);
(d) Addiction and Alcohol
			 and Chemical Dependency - If a client is also seen for a medical office visit
			 and receives an addiction diagnosis, then the client contacts area single
			 encounter (Refer to AMH's OARs);
(e) Ophthalmologic services - fitting and
			 dispensing of eyeglasses are included in the encounter when the practitioner
			 performs a vision examination. (OAR chapter 410, division 140);
(f) Maternity Case Management MCM (OAR
			 410-147-0200);
(g) Physical or
			 occupational therapy (PT/OT) - If this service is also performed on the same
			 date of service as the medical encounter that determined the need for PT/OT
			 (initial referral), then it is considered a single encounter (OAR chapter 410,
			 division 131);
(h) Immunizations -
			 if no other medical office visit occurs on the same date of service;
			 and
(i) Tobacco cessation - if no
			 other medical, dental, mental health or addiction service encounter occurs on
			 the same date of service (refer to OAR 410-130-0190).
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 147 - FQHC AND RHC SERVICES › Section 410-147-0160 - Modifiers

Current through Register Vol. 63, No. 7, July 1, 2024
(1) The Division of
			 Medical Assistance Programs (Division) uses HIPAA compliant modifiers for many
			 services.
(2) The following
			 conditions require the use of a modifier for all codes:
(a) Family Planning Service - FP, Refer to
			 OAR 410-130-0585  Family Planning Services
(b) Vaccine for Children - SL or 26, Refer to
			 OAR 410-130-0255(4)
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 147 - FQHC AND RHC SERVICES › Section 410-147-0180 - Vaccines for Children (VFC) Program

Current through Register Vol. 63, No. 7, July 1, 2024
(1) The Division of Medical Assistance
			 Programs will reimburse Federally Qualified Health Centers (FQHCs) and Rural
			 Health Clinics (RHCs) for the administration of vaccines to eligible
			 clients.
(2) The VFC program
			 supplies federally purchased free vaccines for immunizing eligible client's
			 ages 0 through 18 at no cost to participating health care providers. For more
			 information on how to enroll in the VFC program, contact the Oregon Health
			 Authority Immunization Program. Refer to the FQHC and RHC Supplemental
			 Information for instructions.
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 147 - FQHC AND RHC SERVICES › Section 410-147-0200 - Maternity Case Management Services

Current through Register Vol. 63, No. 7, July 1, 2024
(1) The Division of Medical Assistance
			 Programs (Division) will reimburse federally qualified health centers (FQHCs)
			 and rural health clinics (RHCs) for maternity case management (MCM)
			 services.
(2) MCM service is
			 optional coverage for Prepaid Health Plans (PHPs). Before providing MCM
			 services to a client enrolled in a PHP, determine if the PHP covers MCM
			 services:
(a) If the PHP does not cover MCM
			 services, the provider can bill the Division directly per the clinic's PPS
			 encounter rate. Prior authorization is not required if the PHP does not provide
			 coverage for MCM services;
(b) If
			 the PHP does cover MCM services, the provider needs to request the necessary
			 authorizations from the PHP.
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 147 - FQHC AND RHC SERVICES › Section 410-147-0240 - Administrative Medical Examinations and Reports

Current through Register Vol. 63, No. 7, July 1, 2024
(1) The Division of Medical Assistance
			 Programs (Division) does not reimburse Administrative Medical Examinations and
			 Reports at a clinic's encounter rate. DMAP reimburses providers for
			 Administrative Examinations and Reports on a fee-for-service basis.
(2) Refer to OAR 410 division 150,
			 Administrative Examination and Billing Services, for specific requirements. See
			 Administrative Exams Supplemental Information for more detailed information on
			 procedure codes and descriptions.
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 147 - FQHC AND RHC SERVICES › Section 410-147-0260 - Death With Dignity

Current through Register Vol. 63, No. 7, July 1, 2024
(1) Death
			 With Dignity is a covered service, except for those facilities limited by the
			 Assisted Suicide Funding Restriction Act of 1997 (ASFRA), and is incorporated
			 in the "comfort care" condition/treatment line on the Health Services
			 Commission's Prioritized List of Health Services.
(2) All claims for Death With Dignity
			 services must be billed directly to the Division of Medical Assistance Programs
			 (DMAP), even if the client is in a managed care plan. Death With Dignity
			 services are not part of the Federally Qualified Health Center (FQHC) or Rural
			 Health Clinic (RHC) encounter rate.
(3) Follow criteria outlined in OAR
			 410-130-0670.
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 147 - FQHC AND RHC SERVICES › Section 410-147-0280 - Drugs

Current through Register Vol. 63, No. 7, July 1, 2024
(1) As defined by
			 the Division of Medical Assistance Programs (DMAP), a valid FQHC or RHC
			 encounter excludes pharmaceutical or biologicals not generally provided during
			 a clinic visit. Refer to OAR 41-147-0120 DMAP Encounter and Recognized
			 Practitioners.
(a) Because DMAP includes the
			 costs of drugs or medication treatments administered by a clinic to treat a
			 client during an office visit in the PPS all-inclusive encounter rate for the
			 office visit, providers cannot bill separately for the costs of the drugs or
			 treatments;
(b) Prescriptions are
			 not included in the PPS encounter rate. To bill for filled prescriptions, the
			 FQHC or RHC's qualified enrolled pharmacy must bill DMAP using its pharmacy
			 provider number.
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 147 - FQHC AND RHC SERVICES › Section 410-147-0320 - Federally Qualified Health Center Rural Health Clinics Enrollment

Current through Register Vol. 63, No. 7, July 1, 2024
(1) This rule
			 outlines the Division of Medical Assistance Programs (Division) enrollment
			 requirements for Federally Qualified Health Centers (FQHC) and Rural Health
			 Clinics (RHC) (Refer also to OARs 410-120-1260  and 407-120-0320, Provider
			 Enrollment).
(a) For outpatient health
			 programs or facilities operated by an American Indian tribe under the Indian
			 Self-Determination Act ( Public Law 93-638), providers
			 should refer to the program rules for American Indian/Alaska Native (AI/AN)
			 Services, OAR chapter 410, division 146, for enrollment details;
(b) An FQHC or RHC that operates a retail
			 pharmacy; provides durable medical equipment, prosthetics, orthotics, and
			 supplies (DMEPOS); or provides targeted case management (TCM) services, must
			 enroll separately as a pharmacy, DMEPOS and/or TCM provider. For specific
			 information, refer to OAR chapter 410, division 121, Pharmaceutical; OAR
			 chapter 410, division 122, DMEPOS; and OAR chapter 410, division 138,
			 TCM.
(c) A county Community Mental
			 Health Program (CMHP) furnishing extended care services under contract with the
			 Oregon Health Authority Addictions and Mental Health Division (AMH) should
			 refer to AMH for licensure and reimbursement requirements.
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 147 - FQHC AND RHC SERVICES › Section 410-147-0340 - Federally Qualified Health Centers and Rural Health Clinics Provider Numbers

Current through Register Vol. 63, No. 7, July 1, 2024
(1) Pursuant to
			 National Provider Identifier (NPI) requirements in  45 CFR Part 162  providers
			 must use a NPI, and in specific situations associated taxonomy code(s), when
			 billing the Division of Medical Assistance Programs (Division).
(2) A Federally Qualified Health Center
			 (FQHC) or Rural Health Clinic (RHC) shall register the NPI number and
			 associated taxonomy code, obtained for the FQHC or RHC at the time of
			 enrollment. Multiple sites are not separately enrolled, unless each site has a
			 different tax identification number.
(3) The Division may grant an exception to
			 section (2) of this rule upon written request to the Division of Medical
			 Assistance Programs - Attn: FQHC/RHC Program Manager. The request must include
			 a detailed explanation describing the:
(a)
			 Need for separate enrollment of an additional site; and
(b) Mechanisms in place to assure no
			 duplication of billings.
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 147 - FQHC AND RHC SERVICES › Section 410-147-0360 - Encounter Rate Determination

Current through Register Vol. 63, No. 7, July 1, 2024
(1)
			 The Division of Medical Assistance Programs (Division) will coincide enrollment
			 of a Federally Qualified Health Center (FQHC) or Rural Health Clinic (RHC) with
			 the calculation of a clinic's Prospective Payment System (PPS) encounter rate:
(a) DMAP will enroll a clinic as an FQHC or
			 RHC effective the date DMAP determines the clinic's PPS encounter rate. The
			 encounter rate may be used to bill for services provided on or after the
			 coinciding effective dates of enrollment as an FQHC or RHC with the Division
			 and determination of the clinic's encounter rate.
(b) Consistent with OAR 410-120-1260,
			 Provider Enrollment, only enrolled providers can submit claims to the Division
			 for providing specific care, item(s), or service(s) to Division clients. A
			 clinic or individual provider needs to bill fee-for-service for services
			 provided prior to enrollment as an FQHC or RHC with DMAP, according to
			 applicable service program's enrollment and billing Oregon Administrative Rules
			 (OARs).
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 147 - FQHC AND RHC SERVICES › Section 410-147-0362 - Change in Scope of Services

Current through Register Vol. 63, No. 7, July 1, 2024
(1)
			 As required by 42 USC | 1396a(bb)(3)(B), the Division of Medical Assistance
			 Programs (Division) must adjust Federally Qualified Health Centers (FQHCs) and
			 Rural Health Clinics (RHCs) Prospective Payment System (PPS) encounter rates
			 based on any increase or decrease in the scope of FQHC or RHC services, as
			 defined by 42 USC | 1396d(a)(2)(B)-(C).
(2) The Centers for Medicare and Medicaid
			 Services (CMS) defines a "change in scope of services" as one that affects the
			 type, intensity, duration, and/or amount of services provided by a health
			 center. CMS' broad definition of change in scope of services allows the
			 Division the flexibility to develop a more precise definition of what qualifies
			 as a change in scope as it relates to the elements "type," "intensity,"
			 "duration," and "amount" and procedures for implementing these adjustments.
			 This rule defines the Division's policy for implementing FQHC and RHC PPS rate
			 adjustments based on a change in scope of services.
(3) A change in the scope of FQHC or RHC
			 services may occur if the FQHC or RHC has added, dropped or expanded any
			 service that meets the definition of an FQHC or RHC service as defined by 42
			 USC | 1396d(a)(2)(B)-(C).
(4) A
			 change in the cost of a service is not considered in and of itself a change in
			 the scope of services. An FQHC or RHC must demonstrate how a change in the
			 scope of services impacts the overall picture of health center services rather
			 than focus on the specific change alone. For example, while health centers may
			 increase services to higher-need populations, this increase may be offset by
			 growth in the number of lower intensity visits. Health centers therefore need
			 to demonstrate an overall change to health centers' services.
(5) The following examples are offered as
			 guidance to FQHCs and RHCs to facilitate understanding the types of changes
			 that may be recognized as part of the definition of a change in scope of
			 services. These examples should not be interpreted as a definitive nor
			 comprehensive delineation of the definition of scope of service. Examples
			 include:
(a) A change in scope of services
			 from what was initially reported and incorporated in the baseline PPS rate.
			 Examples of eligible changes in scope of services include, but are not limited
			 to:
(A) Changes within medical, dental or
			 mental health (including addiction, alcohol and chemical dependency services)
			 service areas (e.g. vision, physical/occupation therapy, internal medicine,
			 oral surgery, podiatry, obstetrics, acupuncture, or chiropractic);
(B) Services that do not require a
			 face-to-face visit with an FQHC or RHC provider will be recognized (e.g.
			 laboratory, radiology, case-management, supportive rehabilitative services, and
			 enabling services.)
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 147 - FQHC AND RHC SERVICES › Section 410-147-0365 - Rural Health Clinic Obstetrics Care Delivery Procedures Reimbursement

Current through Register Vol. 63, No. 7, July 1, 2024
Reimbursement for obstetric delivery procedures by the Division
				of Medical Assistance Programs (Division) to eligible Medicare-certified
				Independent RHCs will be according to the physician fee schedule and outside of
				the Prospective Payment System (PPS).
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 147 - FQHC AND RHC SERVICES › Section 410-147-0380 - Accounting and Record Keeping

Current through Register Vol. 63, No. 7, July 1, 2024
(1)
			 General Requirements:
(a) The following rules
			 and regulations apply to clinics reimbursed under the Federally Qualified
			 Health Center (FQHC) and Rural Health Clinic Program;
(b) In cases of conflict between the rules
			 contained in section (2) and (3) of this rule, section (2) will prevail over
			 section (3);
(c) FQHCs and RHCs
			 must use the cost principles contained in OMB Circular A-87 or A-122 to
			 determine reasonable costs. Use the circular appropriate to your
			 clinic;
(d) Must adhere to
			 acceptable accounting standards.
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 147 - FQHC AND RHC SERVICES › Section 410-147-0400 - Compensation for Outstationed Outreach Activities

Current through Register Vol. 63, No. 7, July 1, 2024
(1) This rule provides reasonable
			 compensation for activities directly related to the receipt and initial
			 processing of applications for individuals, including low-income pregnant women
			 and children, to apply for Medicaid at outstation locations other than state
			 offices.
(2) A federally qualified
			 health center (FQHC) eligible in accordance with OAR 410-120-0045, will be
			 eligible for compensation under this rule.
(3) "Initial processing'' includes the
			 following activities:
(a) Taking
			 applications;
(b) Assisting
			 applicants in completing the application;
(c) Providing information as outlined in OAR
			 410-120-0045;
(d) Obtaining
			 required documentation to complete processing of the application;
(e) Ensuring that the information contained
			 on the application form is complete; and
(f) Conducting any necessary interviews.
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 147 - FQHC AND RHC SERVICES › Section 410-147-0420 - Rebasing

Current through Register Vol. 63, No. 7, July 1, 2024
(1) Determination
			 of encounter rates effective January 1, 2001 as directed by the Balanced Budget
			 Act (BBA) of 1997 and the Budget Refinement Act of 1999 Prospective Payment
			 System (PPS) was changed for Federally Qualified Health Center (FQHC) and Rural
			 Health Clinic (RHC) clinics. PPS eliminates annual cost reports and
			 retrospective settlements except for managed care organization (MCO)
			 Supplemental Payments.
(2) As
			 directed by the BBA and PPS, the federal government will notify states when
			 clinics can re-base clinic rates. No specific date has been determined by the
			 federal government at this time.
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 147 - FQHC AND RHC SERVICES › Section 410-147-0440 - Medicare Economic Index (MEI)

Current through Register Vol. 63, No. 7, July 1, 2024
Effective January 1, 2001, as directed by the Balanced Budget
				Act of 1997, the Budget Refinement Act of 1999 Prospective Payment System
				(PPS), and BIPA all encounter rates must be adjusted annually by the Medicare
				Economic Index (MEI) for the current year. The encounter rate will be adjusted
				by the MEI effective January 1st of the current year.
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 147 - FQHC AND RHC SERVICES › Section 410-147-0460 - Prepaid Health Plan Supplemental Payments

Current through Register Vol. 63, No. 7, July 1, 2024
(1) Effective January 1, 2001, the Division
			 of Medical Assistance Programs (Division) is required by
			 42 USC
			 1396 a(bb), to make supplemental payments to
			 eligible Federally Qualified Health Centers (FQHC) and Rural Health Clinics
			 (RHC) that contract with Prepaid Health Plans (PHP).
(2) The PHP Supplemental Payment represents
			 the difference, if any, between the payment received by the FQHC/RHC from the
			 PHP(s) for treating the PHP enrollee and the payment to which the FQHC/RHC
			 would be entitled if they had billed the Division directly for these encounters
			 according to the clinic's Medicaid Prospective Payment System (PPS) encounter
			 rate. Refer to OAR 410-147-0360.
(3) In accordance with federal regulations
			 the Provider must take all reasonable measures to ensure that in most instances
			 Medicaid will be the payer of last resort. Providers must make reasonable
			 efforts to obtain payment first from other resources before submitting claims
			 to the PHP. Refer to OAR 410-147-0120(14).
(4) When any other coverage is known to the
			 provider, the provider must bill the other resource(s) prior to billing the
			 PHP. When a Provider receives a payment from any source prior to the submission
			 of a claim to the PHP, the amount of the payment must be shown as a credit on
			 the claim in the appropriate field. See also OAR 410-120-1280  Billing and
			 410-120-1340  Payment.
(5)
			 Supplemental payment by the Division for encounters submitted by FQHC/RHCs for
			 purposes of this rule is reduced by any and all payments received by the
			 FQHC/RHC from outside resources, including Medicare, private insurance or any
			 other coverage. Therefore, FQHC/RHCs are required to report all payments
			 received on the Managed Care Data Submission Worksheet, including:
(a) Medicaid PHPs;
(b) Medicare Advantage Managed Care
			 Organizations (MCO);
(c) Medicare,
			 including Medicare MCO supplemental payments; and
(d) Any Third Party Resource(s)
			 (TPR).