reglab/statecodes huggingface dataset:
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 125 - HOSPITAL SERVICES › Section 410-125-2030 - Recovery of Payments

Current through Register Vol. 63, No. 7, July 1, 2024
(1) Payments
			 made by the Division of Medical Assistance Programs (Division) shall be
			 recovered for:
(a) Services identified by the
			 provider as emergent or urgent, but determined on retrospective review not to
			 have been emergent or urgent. Payment shall also be recovered from the
			 admitting and/or performing physician;
(b) Services determined by the Division that
			 the readmission to the same hospital was the result of a premature
			 discharge;
(c) Services were billed
			 but not provided;
(d) Services
			 provided at an inappropriate level of care, which includes the setting selected
			 for service delivery;
(e) The
			 Division non-covered services;
(f)
			 Services, which were covered by a third party payer or other resources;
			 or
(g) Services denied by a third
			 party payer as not medically necessary.
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 125 - HOSPITAL SERVICES › Section 410-125-2040 - Provider Appeals - Administrative Review

Current through Register Vol. 63, No. 7, July 1, 2024
(1) A provider may request an administrative
			 review regarding the decision(s) by the Division that affect the services they
			 provide or have provided. See General Rules (chapter 410 division
			 120).
(2) A requests for an
			 Administrative Review must be submitted in writing to the Medicaid
			 Administrator, 500 Summer Street NE, E49, Salem, OR 97301-1079.
(3) The request must be received within 30
			 days of the date of notification of the payment decision or notification of
			 change in reimbursement.
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 125 - HOSPITAL SERVICES › Section 410-125-2060 - Provider Appeals - Hearing Request

Current through Register Vol. 63, No. 7, July 1, 2024
If the hospital disagrees with the Division calculation of
				reasonable costs for outpatient services or inpatient services, the outpatient
				interim rate, DRG based prospective payment for inpatient services, the
				calculation of the hospital's unit value, or any other hospital reimbursement
				methodologies or payments, a written request for an appeal may be made to the
				Division in accordance with the General rules (chapter 410 division 120). A
				hearing request must be received not later than 30 days following the date of
				the notice of action. At the time of appeal, the hospital must submit any data
				the hospital wants DMAP to consider in support of the appeal. The appeal will
				be conducted as described in General rules.
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 125 - HOSPITAL SERVICES › Section 410-125-2080 - Administrative Errors

Current through Register Vol. 63, No. 7, July 1, 2024
(1) If a
			 hospital has been given incorrect information by Division of Medical Assistance
			 Programs, Children, Adults, and Families Programs, or Aging and People with
			 Disabilities/staff, and services were provided on the basis of this
			 information, and payment has been denied as a result, the hospital may submit a
			 request for payment as an Administrative Error.
(2) Include the following:
(a) An explanation of the problem;
(b) Any documents supporting the request for
			 payment;
(c) A copy of any paper
			 Remittance Advice or electronic 835 printouts received on this claim;
(d) A copy of the original claim.
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 127 - HOME HEALTH CARE SERVICES › Section 410-127-0020 - Definitions

Current through Register Vol. 63, No. 7, July 1, 2024
(1) "Acquisition
			 Cost" means the net invoice price of the item, supply, or equipment plus
			 shipping or postage for the item.
(2) "Assessment" means procedures by which a
			 client's health strengths, weaknesses, problems, and needs are
			 identified.
(3) "Custodial Care"
			 means provision of services and supplies that can safely be provided by
			 non-medical or unlicensed personnel.
(4) "Division " means the Health Systems
			 Division within the Oregon Health Authority (Authority). The Division is
			 responsible for coordinating medical assistance programs within the State of
			 Oregon including the Oregon Health Plan (OHP), the State Children's Health
			 Insurance Program (SCHIP-Title XXI), and several other programs.
(5) "Electronic Visit Verification (EVV)"
			 means a technological solution used to electronically verify home health
			 providers delivered or rendered home health services. EVV data to be collected
			 in real time for each visit includes:
(a)
			 Provider number of agency;
(b)
			 Individual name of provider rendering the service;
(c) Client prime number;
(d) Service date;
(e) Start and end time (to the
			 minute);
(f) Location (geo
			 location) of service delivery;
(g)
			 Type of service performed.
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 127 - HOME HEALTH CARE SERVICES › Section 410-127-0046 - Electronic Visit Verification (EVV)

Current through Register Vol. 63, No. 7, July 1, 2024
(1) The Home Health Care Agencies must comply
			 with Section 12006(a) of the 21st Century Cures Act by electronically verifying
			 Home Health services. Oregon Medicaid has selected the Provider Choice Model
			 for EVV. Home Health Care agencies must provide a method to capture EVV
			 information that meets the requirements of the 21st Century Cures
			 Act.
(2) The submission of EVV data
			 to the Authority by the Home Health Care agency provider is certification that
			 the foregoing information is true, accurate, and complete.
(a) Provider specific EVV solutions that do
			 not capture the start time and end time to the minute are not EVV
			 compliant;
(b) Provider specific
			 EVV solutions that do not capture geo location coordinates at the start time
			 and again at the end time of service provided are not EVV compliant;
(c) Provider alteration of one or more data
			 points in a provider specific EVV solution record, prior to sending that record
			 to the Department or Authority for payment is prohibited;
(d) Home health services that are not EVV
			 compliant are not eligible for payment and payments may be denied or recovered
			 from the Home Health Care agency provider;
(e) The Authority does not grant exceptions
			 to Home Health Care agency providers for provider specific EVV solutions. A
			 provider who is enrolled by the Authority shall comply with department guidance
			 to determine whether a limited exception for an individual or a rendering
			 provider employed by the provider may be permitted by the Authority. See
			 administrative rule chapter 411;
(f) The requirement to use EVV does not apply
			 to individuals enrolled and living in a residential service setting, including
			 24-hour group homes, foster care homes, supported living, or receiving On the
			 Job Attendant Care, or Day Support Activities. EVV does not include any
			 employment or community transportation services.
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 127 - HOME HEALTH CARE SERVICES › Section 410-127-0040 - Coverage

Current through Register Vol. 63, No. 7, July 1, 2024
(1) Medically
			 appropriate home health services may be covered on a visiting basis to eligible
			 clients as ordered by a physician and part of a written plan of care. Coverage
			 of home health services is not contingent on the client needing nursing,
			 nursing facility or therapy services.
(2) Home health services may be provided in
			 the client's home or any setting in which normal life activities take place
			 other than a hospital, nursing facility, intermediate care facility for
			 individuals with intellectual disabilities, any setting that exists primarily
			 for the purpose of providing medical/nursing care, or any setting in which
			 payment is or could be made under Medicaid for inpatient services that include
			 room and board.
(3) Home health
			 services require a face-to-face encounter as described in OAR 410-127-0045
			 consistent with federal Medicaid regulations at
			 42 CFR
			 440.70.
(4) Home health services must be prescribed
			 by a physician, and the signed order must be on file at the home health agency.
			 The prescription must include the ICD-10-CM diagnosis code indicating the
			 reason the home health services are requested. The orders on the plan of care
			 must specify the type of services to be provided to the client with respect to
			 the professional who will provide them, the nature of the individual services,
			 specific frequency, and specific duration. The orders must clearly indicate how
			 many times per day, each week or each month the services are to be provided.
			 The plan of care must include the client's condition, the rationale for the
			 care plan including justification for the required skill level of care, and the
			 summary of care for additional certification periods.
(5) The plan of care must be reviewed and
			 signed by the physician who established the plan of care at least every 60 days
			 to continue services.
(6) The
			 following services or items are covered, if diagnoses are on the portion of the
			 prioritized list above the line funded by the legislature:
(a) Skilled nursing services;
(b) Skilled nursing evaluation (includes
			 Outcome and Assessment Information Set (OASIS) assessment);
(c) Home health aide services;
(d) Occupational therapy services;
(e) Occupational therapy evaluation, which
			 may include OASIS assessment;
(f)
			 Physical therapy services;
(g)
			 Physical therapy evaluation, which may include OASIS assessment;
(h) Speech-language pathology services, which
			 may include OASIS assessment;
(i)
			 Speech-language pathology evaluation, which may include OASIS
			 assessment;
(j) Medical and
			 surgical supplies.
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 127 - HOME HEALTH CARE SERVICES › Section 410-127-0050 - Client Copayments

Current through Register Vol. 63, No. 7, July 1, 2024
Copayments may be required for certain services. See OAR
				410-120-1230  for specific details.
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 127 - HOME HEALTH CARE SERVICES › Section 410-127-0060 - Reimbursement and Limitations

Current through Register Vol. 63, No. 7, July 1, 2024
(1) The
			 Division reimburses home health services on a fee schedule by type of visit
			 (see home health rates on the Authority's website at:
http://www.oregon.gov/OHA/HSD/OHP/Pages/Policy-Home-Health.aspx
).
(2) The Division recalculates its home health
			 services rates every other year. The Division shall reimburse home health
			 services at a level of 74 percent of Medicare costs reported on the audited,
			 most recently accepted or submitted Medicare Cost Reports prior to the rebase
			 date and pending approval from the Centers for Medicare and Medicaid Services
			 (CMS), and, if indicated, legislative funding authority.
(3) The Division shall request the Medicare
			 Cost Reports from home health agencies with a due date and shall recalculate
			 potential rates based on the Medicare Cost Reports received by the requested
			 due date. The home health agency shall submit requested cost reports by the
			 date requested.
(4) The Division
			 reimburses only for services that are medically appropriate.
(5) Limitations:
(a) Limits of covered services:
(A) Skilled nursing visits are limited to two
			 visits per day with payment authorization;
(B) All therapy services are limited to one
			 visit or evaluation per day for physical therapy, occupational therapy, or
			 speech-language pathology services. Therapy visits require payment
			 authorization;
(C) Home health aide
			 services are limited to those ordered by a physician, included in the plan of
			 care, permitted to be performed under state law, consistent with home health
			 aide training, and under the direction of a registered nurse or licensed
			 therapist familiar with the client and the client's plan of care. These
			 services must not duplicate other Medicaid-paid personal care
			 services.
(D) The Division shall
			 authorize home health visits for clients with uterine monitoring only for
			 medical problems that could adversely affect the pregnancy and are not related
			 to the uterine monitoring;
(E)
			 Medical supplies must be billed at acquisition cost, and the total of all
			 medical supply revenue codes may not exceed $50 per day. Only supplies that are
			 used during the visit or the specified additional supplies used for current
			 client/caregiver teaching or training purposes as medically appropriate are
			 billable. Client visit notes must include documentation of supplies used during
			 the visit or supplies provided according to the current plan of care;
(F) Durable medical equipment must be
			 obtained by the client by prescription through a durable medical equipment
			 provider.
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 127 - HOME HEALTH CARE SERVICES › Section 410-127-0065 - Signature Requirements

Current through Register Vol. 63, No. 7, July 1, 2024
(1) The
			 Division of Medical Assistance Programs (Division) requires practitioners to
			 sign for services they order. This signature shall be handwritten or
			 electronic, and it must be in the client's medical record.
(2) The ordering practitioner is responsible
			 for the authenticity of the signature.
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 127 - HOME HEALTH CARE SERVICES › Section 410-127-0080 - Prior Authorization

Current through Register Vol. 63, No. 7, July 1, 2024
(1) Home
			 health providers must obtain prior authorization (PA) for services as specified
			 in rule.
(2) Providers must
			 request PA as follows (see the Home Health Supplemental Information booklet for
			 contact information) and include the documentation requirements from the
			 Supplemental (e.g. plan of care, primary diagnosis, initial assessment,
			 evaluation, etc.):
(a) For clients enrolled
			 in a Coordinated Care Organization (CCO) or a Prepaid Health Plan (PHP), from
			 the CCO or the PHP;
(b) For all
			 other clients, from the Division of Medical Assistance Programs (Division).
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 127 - HOME HEALTH CARE SERVICES › Section 410-127-0200 - Home Health Revenue Center Codes

Current through Register Vol. 63, No. 7, July 1, 2024
Payment authorization is required for those services indicated
				by the Code PA. Following are the procedure codes to be used for
				billing:
(1) Medical/surgical supplies
			 and devices:
(a) 270 -- General
			 classification;
(b) 271 -
			 Non-sterile supply;
(c) 272 --
			 Sterile supply.
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 129 - SPEECH-LANGUAGE PATHOLOGY, AUDIOLOGY AND HEARING AID SERVICES › Section 410-129-0020 - Therapy Plan of Care, Goals, Outcomes, and Record Requirements

Current through Register Vol. 63, No. 7, July 1, 2024
(1) Therapy shall
			 be based on a prescribing practitioner's written order and therapy treatment
			 plan with goals and objectives developed from an evaluation or re-evaluation.
			 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 129 - SPEECH-LANGUAGE PATHOLOGY, AUDIOLOGY AND HEARING AID SERVICES › Section 410-129-0040

Current through Register Vol. 63, No. 7, July 1, 2024
Stat. Auth.: ORS
				  413.042
Stats. Implemented: ORS
				  414.065,
				  681.205 &
				  688.135
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 129 - SPEECH-LANGUAGE PATHOLOGY, AUDIOLOGY AND HEARING AID SERVICES › Section 410-129-0060 - Prescription Required

Current through Register Vol. 63, No. 7, July 1, 2024
(1) The
			 prescription is the written order by the prescribing practitioner pursuant to
			 state law governing SLP, audiology, and hearing aid services. Prescription
			 shall specify the ICD diagnosis code for all SLP, audiology, and hearing aid
			 services that require payment/prior authorization.
(2) The provision of speech therapy services
			 shall be supported by a written order and a therapy treatment plan signed by
			 the prescribing practitioner. A practitioner means an individual licensed
			 pursuant to state law to engage in the provision of health care services within
			 the scope of the practitioner's license or certification.
(3) A written order:
(a) Is required for the initial
			 evaluation;
(b) For therapy, shall
			 specify the ICD diagnosis code, service, amount, and duration
			 required.
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 129 - SPEECH-LANGUAGE PATHOLOGY, AUDIOLOGY AND HEARING AID SERVICES › Section 410-129-0065 - Licensing Requirements

Current through Register Vol. 63, No. 7, July 1, 2024
(1) The
			 Division enrolls only the following types of providers as performing providers
			 under the Speech-Language Pathology, Audiology and Hearing Aid Services
			 program:
(a) An individual licensed by the
			 relevant state licensing authority to practice speech-language pathology
			 (SLP);
(b) An individual licensed
			 by the relevant state licensing authority to practice audiology; and
(c) An individual licensed by the relevant
			 state licensing authority for "dealing in hearing aids" as defined in Oregon
			 Revised Statute 694.015.
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 129 - SPEECH-LANGUAGE PATHOLOGY, AUDIOLOGY AND HEARING AID SERVICES › Section 410-129-0070 - Limitations

Current through Register Vol. 63, No. 7, July 1, 2024
(1) Speech Language
			 Pathology (SLP) services:
(a) Shall be
			 provided by a practitioner as described in OAR 410-129-0065;
(b) Requirements for rehabilitative and
			 habilitative therapy treatment:
(A) Require
			 Prior Authorization (PA) when it exceeds one hour per day each for a group or
			 individual;
(B) Shall be either
			 group or individual and may not be combined in the authorization period;
			 and
(C) Require PA after thirty
			 (30) habilitative and thirty (30) rehabilitative visits per calendar
			 year.
(c) The following
			 SLP services are not subject to prepayment review (PPR) and do not require PA
			 but are limited to:
(A) Two SLP evaluations
			 in a 12-month period;
(B) Two
			 evaluations for dysphagia in a 12-month period;
(C) Up to four re-evaluations in a 12-month
			 period;
(D) One evaluation for
			 speech-generating/augmentative communication system or device (SGD) shall be
			 reimbursed per recipient in a 12-month period;
(E) One evaluation for voice prosthesis or
			 artificial larynx shall be reimbursed in a 12-month period;
(F) Purchase, repair, or modification of
			 electrolarynx;
(G) Supplies for
			 speech therapy shall be reimbursed up to two times in a 12-month period, not to
			 exceed five dollars each.
(d) The purchase, rental, repair, or
			 modification of a SGD requires PA. Rental of a SGD is limited to one month. All
			 rental fees shall be applied to the purchase price.
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 129 - SPEECH-LANGUAGE PATHOLOGY, AUDIOLOGY AND HEARING AID SERVICES › Section 410-129-0075 - Face-to-Face Encounter Requirements for Fee-for-Service Clients

Current through Register Vol. 63, No. 7, July 1, 2024
(1) For initial
			 ordering of speech generating devices (SGD), an in-person, face-to-face
			 encounter that is related to the primary reason the client requires the medical
			 equipment or supplies must occur no more than six months prior to the start of
			 services:
(a) The face-to-face encounter
			 shall be conducted and documented by the treating physician (MD or DO) or an
			 authorized non-physician practitioner (NPP);
(b) Authorized NPPs for SGD are nurse
			 practitioners, clinical nurse specialists working in collaboration with a
			 physician, or physician assistants under the supervision of a
			 physician;
(c) The physician or NPP
			 conducting the face-to-face encounter shall document that the client is
			 evaluated or treated for a condition that supports the need for the SGD ordered
			 within six months prior to completing the written order for the
			 equipment;
(d) If the NPP
			 performing the face-to-face encounter does not have prescribing authority, the
			 NPP shall communicate the clinical findings to the ordering
			 physician;
(e) The ordering
			 physician shall incorporate the clinical findings into a written or electronic
			 document included in the client's medical record.
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 129 - SPEECH-LANGUAGE PATHOLOGY, AUDIOLOGY AND HEARING AID SERVICES › Section 410-129-0080 - Prepayment Review (PPR) and Prior Authorization (PA) for payment

Current through Register Vol. 63, No. 7, July 1, 2024
(1) Speech-language
			 pathology, audiology, and hearing aid providers are subject to PPR or shall
			 obtain PA for services exceeding 30 habilitative and 30 rehabilitative visits
			 in a calendar year.
(2) Providers
			 shall request PA as follows (see the SLP, Audiology and Hearing Aid Services
			 Program Supplemental Information booklet for contact information):
(a) For Medically Fragile Children's Unit
			 (MFCU) clients, from the Authority's MFCU;
(b) For clients enrolled in the
			 fee-for-service Medical Case Management program, from the Medical Case
			 Management contractor;
(c) For
			 clients enrolled in an MCE, from the MCE;
(d) For clients requiring visits in excess of
			 30 habilitative visits and 30 rehabilitative visits per calendar
			 year.
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 129 - SPEECH-LANGUAGE PATHOLOGY, AUDIOLOGY AND HEARING AID SERVICES › Section 410-129-0085 - Payment Methodology

Current through Register Vol. 63, No. 7, July 1, 2024
(1)
			 Speech-Language Pathology and Audiology outpatient services are priced based on
			 RVU (Refer to OAR 410-120-1340(6)) and flat fee rates:
(a) Surgical procedures such as cochlear
			 implants may be provided in a hospital or Ambulatory Surgical Center (ASC)
			 (Refer to OAR 410-120-1340 (6) and (8));
(b) The Division reimburses inpatient
			 hospital service under the DRG methodology, unless specified otherwise in the
			 Division's Hospital Services program administrative rules, chapter 410,
			 division 125.
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 129 - SPEECH-LANGUAGE PATHOLOGY, AUDIOLOGY AND HEARING AID SERVICES › Section 410-129-0100 - Medicare/Medicaid Claims

Current through Register Vol. 63, No. 7, July 1, 2024
(1) When an
			 individual not in managed care has both Medicare and Medicaid coverage,
			 audiologists shall bill audiometry and all diagnostic testings to Medicare
			 first. Medicare will automatically forward these claims to Medicaid. Refer to
			 OAR 410-120-1210  (General Rules) for information on Division or CCO
			 reimbursement.
(2) Audiologists
			 shall bill all hearing aids and related services directly to the Division on an
			 OHP 505. Payment authorization is required on most of these services.
(3) If Medicare transmits
			 incorrect information to the Division, or if an out-of-state Medicare carrier
			 or intermediary was billed, providers shall bill the Division using an OHP 505
			 form. If any payment is made by the Division, an adjustment request shall be
			 submitted to correct payment, if necessary.
(4) Send all completed OHP 505 forms to the
			 Division.
(5) Hearing aid dealers
			 shall bill all services directly to the Division on a CMS-1500. Payment
			 authorization is required on most services.
(6) When a client not in managed care has
			 both Medicare and Medicaid coverage, speech-language pathologists shall bill
			 services to Medicare first. Medicare will automatically forward these claims to
			 Medicaid. Refer to OAR 410-120-1210  (General Rules) for information on Division
			 or CCO reimbursement.
Stat. Auth.: ORS
				  413.042
Stats. Implemented: ORS
				  414.025,
				  414.034,
				  414.065,
				  414.329,
				  414.706 &
				  414.710
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 129 - SPEECH-LANGUAGE PATHOLOGY, AUDIOLOGY AND HEARING AID SERVICES › Section 410-129-0180 - Procedure Codes

Current through Register Vol. 63, No. 7, July 1, 2024
(1) Procedure codes
			 listed in the Speech-Language Pathology, Audiology and Hearing Aid Services
			 Program rules are intended for use by licensed speech-language pathologists,
			 licensed audiologists, and certified hearing aid dealers.
(2) Physicians and nurse practitioners are
			 subject to the administrative rules contained in the Division Medical-Surgical
			 Services Program rules and shall bill the Division using the processes and
			 procedure codes identified in those rules.
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 129 - SPEECH-LANGUAGE PATHOLOGY, AUDIOLOGY AND HEARING AID SERVICES › Section 410-129-0190

Current through Register Vol. 63, No. 7, July 1, 2024
Stat. Auth.: ORS
				  413.042
Stats. Implemented: ORS
				  414.010 &
				  414.065
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 129 - SPEECH-LANGUAGE PATHOLOGY, AUDIOLOGY AND HEARING AID SERVICES › Section 410-129-0200 - Speech-Language Pathology Procedure Codes

Current through Register Vol. 63, No. 7, July 1, 2024
(1) Inclusion of a current procedural
			 terminology (CPT) or healthcare common procedure coding system (HCPCS) code in
			 sections (2), (3) and (4) does not mean a code is covered. Refer to OAR
			 410-141-0480, 410-141-0500, and 410-141-0520  for information on coverage.
(2) The following Speech therapy
			 services are subject to PPR when paired above the funding line on the HERC
			 prioritized list (see OAR 410-141-0520), when visits have not exceeded the
			 allowed 30 habilitative and 30 rehabilitative visits allowed in a calendar
			 year:
(a) 92507 Treatment of speech,
			 language, voice, communication and auditory processing disorder, individual;
			 and
(b) 92508 Group, two or more
			 individuals.
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 129 - SPEECH-LANGUAGE PATHOLOGY, AUDIOLOGY AND HEARING AID SERVICES › Section 410-129-0220 - Augmentative Communications System or Device

Current through Register Vol. 63, No. 7, July 1, 2024
(1) Augmentative Communications System or
			 Device and the necessary attachment equipment to bed or wheelchair are a
			 covered benefit of the Division.
(2) The requested system or device shall be
			 approved, registered, or listed as a medical device with the Food and Drug
			 Administration.
(3) Criteria for
			 coverage: Providers shall meet each of the following components and submit
			 documentation to the Division with claims subject to PPR and with PA request
			 for review:
(a) A physician's statement of
			 diagnosis and medical prognosis (not a prescription for an augmentative device)
			 documenting the inability to use speech for effective communication as a result
			 of the diagnosis;
(b) Reliable
			 cognitive ability and a consistent motor response to communicate that can be
			 measured by standardized or observational tools:
(A) Object permanence - ability to remember
			 objects and realize they exist when they are not seen; and
(B) Means end - ability to anticipate events
			 independent of those currently in progress - the ability to associate certain
			 behaviors with actions that will follow.
(c) The client shall be assessed by a SLP and
			 when appropriate an occupational therapist or physical therapist. The
			 evaluation report shall include:
(A) A
			 completed OHA 3047 form: Augmentative Communication Device Selection Report
			 Summary (page 1) and required elements of the Formal Augmentative/Alternative
			 Communication Evaluation (page 2). Attach additional pages required to complete
			 information requested;
(B) An
			 explanation of why this device is best suited for this client and why the
			 device is the lowest level that will meet basic functional communication
			 needs;
(C) Evidence of a documented
			 trial of the selected device and a report on the client's success in using this
			 device; and
(D) A therapy treatment
			 plan with the identification of the individual responsible to program the
			 device and monitor and reevaluate on a periodic basis.
(d) Providers send requests for augmentative
			 communications systems or devices to the Division; and
(e) The manufacturer's MSRP and the vendor's
			 acquisition cost quotations for the device shall accompany each request
			 including where the device is to be shipped.
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 129 - SPEECH-LANGUAGE PATHOLOGY, AUDIOLOGY AND HEARING AID SERVICES › Section 410-129-0240 - Audiologist and Hearing Aid Procedure Codes

Current through Register Vol. 63, No. 7, July 1, 2024
(1) Inclusion of a CPT/HCPCS code on the
			 following does not mean that a code is covered. Refer to OAR 410-120-1280  and
			 OAR 410-141-3565  for information on coverage.
(2) The following are Audiologist and hearing
			 aid procedure codes:
(a) 92553 - Pure tone
			 audiometry, air and bone, limited to one per calendar year;
(b) 92557 - Comprehensive audiometry
			 threshold evaluation and speech recognition includes pure tone, air and bone,
			 and speech threshold and discrimination. Also includes testing necessary to
			 determine feasibility of amplification;
(c) 92590 - Hearing aid examination and
			 selection, monaural may include sound field speech reception tests, speech
			 discrimination tests, determination of appropriate style of hearing aid and to
			 determine if the ear may receive amplification;
(d) 92591 - Hearing aid examination and
			 selection, binaural may include sound field speech reception tests, speech
			 discrimination tests, determination of appropriate style of hearing aid, and
			 which ear may receive amplification;
(e) 92592 - Monaural hearing aid inspection
			 and battery check. The aid is cleaned, and the power and clarity are checked
			 using a special stethoscope, which attaches to the hearing aid.
(f) 92593 - Binaural hearing aids inspection
			 and battery check. The aids are cleaned, and the power and clarity are checked
			 using a special stethoscope, which attaches to the hearing aids.
(g) V5261 - Hearing aid, digital, binaural
			 and behind the ear requires Prior Authorization (PA);
(h) V5011 - Fitting, orientation, checking of
			 hearing aid includes adjusting aid to the wearer, instructions to wearer, and
			 follow-up care, and requires PA prior to provision of services;
(i) V5275 - Ear impressions made to obtain a
			 hearing device specified for the individual, each.
(j) V5160 - Hearing aid dispensing fee,
			 binaural, requires PA prior to providing services;
(k) V5181 - Hearing aid, contralateral
			 routing device, monaural, behind the ear (bte);
(l) V5200 - Hearing aid dispensing fee,
			 contralateral, monaural, requires PA prior to providing services;
(m) V5240 - Hearing aid dispensing fee, two
			 devises, contralateral routing system, binaural, requires PA prior to providing
			 services;
(n) V5241 - Hearing aid
			 dispensing fee, monaural hearing aid, any type, requires PA prior to providing
			 services;
(o) V5110 - Body warn
			 hearing aid dispensing fee, bilateral.
(p) V5020 - The conformity evaluation is to
			 confirm that the hearing aid is meeting the needs of the patient.
(q) 95992 - Canalith repositioning, treatment
			 for vertigo, per day.
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 129 - SPEECH-LANGUAGE PATHOLOGY, AUDIOLOGY AND HEARING AID SERVICES › Section 410-129-0260 - Hearing Aids and Hearing Aid Technical Service and Repair

Current through Register Vol. 63, No. 7, July 1, 2024
(1) The provider
			 shall bill the Division for hearing aids at the provider's acquisition cost and
			 shall be reimbursed at that rate. For purposes of this rule, acquisition cost
			 is defined as the actual dollar amount paid by the provider to purchase the
			 item directly from the manufacturer or supplier plus any shipping or
			 postage.
(2) The provider shall
			 submit history of hearing aid use and an audiogram when requesting Prior
			 Authorization (PA) for hearing aids.
(3) Procedure codes are the following:
(a) 92594 - Electroacoustic evaluation for
			 hearing aid, monaural;
(b) 92595 -
			 Electroacoustic evaluation for hearing aid, binaural;
(c) 92596 - Ear protector eval, measurement
			 of adequacy of hearing protection device;
(d) V5014 - Repair/modification of hearing
			 aid, requires PA;
(e) V5266 -
			 Hearing aid batteries, limited to 60 individual batteries per calendar
			 year;
(f) V5264 - Ear mold/insert,
			 not disposable, any type, requires PA;
(g) V5274 - Assistive listening device, not
			 otherwise specified, requires PA;
(h) V5030 - Hearing aid, monaural, body worn,
			 air conduction, requires PA;
(i)
			 V5040 - Hearing aid, monaural, body worn, bone conduction, requires
			 PA;
(j) V5050 - Hearing aid,
			 monaural, in the ear, requires PA;
(k) V5060 - Hearing aid, monaural, behind the
			 ear, requires PA;
(l) V5130 -
			 Hearing aid, binaural, in the ear, requires PA;
(m) V5140 - Hearing aid, binaural, behind the
			 ear, requires PA;
(n) V5171 -
			 Hearing aid, contralateral routing device, monaural, ITE, requires
			 PA;
(o) V5180 - Hearing aid,
			 contralateral routing device, monaural, BTE, requires PA;
(p) V5211 - Hearing aid, contralateral
			 routing system, binaural, ITE- requires PA;
(q) V5221 - Hearing aid, contralateral
			 routing system, binaural, BTE- requires PA;
(r) V5246 - Hearing aid, digitally
			 programmable analog, monaural, ITE, requires PA;
(s) V5247 - Hearing aid, digitally
			 programmable analog, monaural, (BTE) requires PA;
(t) V5252 - Hearing aid, digital
			 programmable, binaural, ITE, requires PA;
(u) V5253 - Hearing aid, digital
			 programmable, binaural, BTE, requires PA;
(v) V5256 - Hearing aid, digital, monaural,
			 ITE, requires PA;
(w) V5257 -
			 Hearing aid, digital, monaural, BTE, requires PA.
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 130 - MEDICAL-SURGICAL SERVICES › Section 410-130-0000 - Foreword

Current through Register Vol. 63, No. 7, July 1, 2024
(1) The Division
			 Medical-Surgical Services rules are designed to assist medical-surgical
			 providers to deliver medical services and prepare health claims for clients
			 with Medical Assistance Program coverage. Providers must follow the Division
			 rules in effect on the date of service.
(2) The Division enrolls only the following
			 types of providers as performing providers under the Medical-Surgical program:
(a) Doctors of medicine, osteopathy and
			 naturopathy;
(b)
			 Podiatrists;
(c)
			 Acupuncturists;
(d) Licensed
			 Physician assistants;
(e) Nurse
			 practitioners;
(f)
			 Laboratories;
(g) Family planning
			 clinics;
(h) Social workers (for
			 specified services only);
(i)
			 Licensed Direct entry midwives;
(j)
			 Portable x-ray providers;
(k)
			 Ambulatory surgical centers;
(l)
			 Chiropractors;
(m) Licensed
			 Dieticians (for specified service only);
(n) Registered Nurse First
			 Assistants;
(o) Certified Nurse
			 Anesthetists;
(p) Clinical
			 Pharmacists;
(q) Birthing
			 Centers;
(r) Licensed Genetic
			 Counselor.
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 130 - MEDICAL-SURGICAL SERVICES › Section 410-130-0005 - Federally Qualified Primary Care Provider

Current through Register Vol. 63, No. 7, July 1, 2024
(1) Section 1202 of the Affordable Care Act
			 (ACA) amended sections 1902(a)(13), 1902(jj), 1905(dd) and 1932(f) of the
			 Social Security Act to require increased Medicaid payment for primary care
			 services to qualified providers for calendar years 2013 and 2014 as specified
			 in these rules.
(2) Federally
			 Qualified Primary Care Services are designated as:
(a) Evaluation and Management (E&M)
			 Current Procedural Terminology (CPT) codes 99201 through 99499; and
(b) Vaccine administration CPT codes 90460,
			 90461, 90471, 90472, 90473 and 90474, or their successor codes; and
(c) Administration of vaccines under Vaccines
			 for Children Program (refer to OAR 410-130-0255).
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 130 - MEDICAL-SURGICAL SERVICES › Section 410-130-0015 - Doula Services

Current through Register Vol. 63, No. 7, July 1, 2024
(1) The primary
			 purpose of providing birth doula services as a member of the birthing team is
			 to optimize birth outcomes, including prevention of preterm births, fewer
			 neonatal intensive care admissions, reduced Caesarean sections, reduced
			 epidural use, and improved member experience of birthing care. These services
			 are provided during the prenatal, labor and delivery, and postpartum phases of
			 the member's pregnancy. Pregnant women or pregnant persons experiencing health
			 disparities are expected to benefit most from birth doula services, including
			 the following:
(a) A pregnant woman or
			 pregnant person with a racially or ethnically diverse background including,
			 Black/African American, Asian, Native Hawaiian/Pacific Islander, Native
			 American, Latino/Latina/Latinxe, multicultural or multiracial;
(b) A pregnant woman or pregnant person
			 experiencing houselessness;
(c) A
			 pregnant woman or pregnant person who speaks limited to no English;
(d) A pregnant woman or pregnant person who
			 has limited to no family or partner support;
(e) A pregnant woman or pregnant person who
			 is under the age of 21.
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 130 - MEDICAL-SURGICAL SERVICES › Section 410-130-0160 - Codes

Current through Register Vol. 63, No. 7, July 1, 2024
(1) ICD-10-CM
			 Diagnosis Codes:
(a) Always use the principal
			 diagnosis code in the first position to the highest degree of specificity. List
			 additional diagnosis codes if the claim includes charges for services that
			 relate to the additional diagnoses. However, it is not necessary to include
			 more than one diagnosis code per procedure code;
(b) Diagnosis codes are required on all
			 billings including those from independent laboratories and portable radiology
			 including nuclear medicine and diagnostic ultrasound providers;
(c) Always supply the ICD-10-CM diagnosis
			 code to ancillary service providers when prescribing services, equipment, and
			 supplies.
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 130 - MEDICAL-SURGICAL SERVICES › Section 410-130-0180 - Drugs

Current through Register Vol. 63, No. 7, July 1, 2024
(1) The Division of
			 Medical Assistance Programs' (Division) Medical-Surgical Services Program
			 reimburses practitioners for drugs only when administered by the practitioner
			 in the office, clinic or home settings. The Division does not reimburse
			 practitioners for drugs that are self-administered by the client, except for
			 contraceptives such as birth control pills, spermicides and patches:
(a) Use an appropriate Current Procedural
			 Terminology (CPT) therapeutic injection code for administration of
			 injectables;
(b) Use an appropriate
			 Healthcare Common Procedure Coding System (HCPCS) code for the specific drug.
			 Do not bill for drugs under code 99070; The Division requires both the NDC
			 number and HCPCS codes on all claim forms.
(c) When there is no specific HCPCS code for
			 a drug or biological, use an appropriate unlisted code from the list below and
			 bill at acquisition cost (purchase price plus postage):
(A) J3490;
(B) J3590;
(C) J7599;
(D) J7699;
(E) J7799;
(F) J8499;
(G) J8999;
(H) J9999;
(I) Include the name of the drug, National
			 Drug Code (NDC) number and dosage.
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 130 - MEDICAL-SURGICAL SERVICES › Section 410-130-0190 - Tobacco Cessation

Current through Register Vol. 63, No. 7, July 1, 2024
(1) Tobacco
			 treatment interventions may include one or more of these services: basic,
			 intensive, and telephone calls.
(2) Basic tobacco cessation treatment
			 includes the following services:
(a) Ask -
			 systematically identify all tobacco users - usually done at each visit;
(b) Advise - strongly urge all
			 tobacco users to quit using;
(c)
			 Assess - the tobacco user's willingness to attempt to quit using tobacco within
			 30 days;
(d) Assist - with brief
			 behavioral counseling, treatment materials and the recommendation/prescription
			 of tobacco cessation therapy products (e.g., nicotine patches, oral medications
			 intended for tobacco cessation treatment and gum);
(e) Arrange - follow-up support and/or
			 referral to more intensive treatments, if needed.
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 130 - MEDICAL-SURGICAL SERVICES › Section 410-130-0200 - Prior Authorization

Current through Register Vol. 63, No. 7, July 1, 2024
(1) For
			 fee-for-service (FFS) clients, Prior Authorization (PA) is required for all
			 procedure codes listed in Table 130-0200-1. PA is required in all settings
			 unless otherwise indicated. See indicators in table heading. For details on
			 where to obtain PA, download a copy of the Prior Authorization Handbook at:
http://www.oregon.gov/oha/HSD/OHP/Tools/Prior%20Authorization%20Handbook.pdf
.
(2) Providers must obtain PA from the OHP
			 payer, either FFS or CCO; that shall be responsible for payment at the time the
			 service is delivered.
(3) 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, as referenced in OAR 410-141-3830.
(4) Codes for which medical need has not been
			 specified by the HERC shall be authorized based on medical appropriateness as
			 the term is defined in OAR 410-120-0000.
(5) PA requests for coverage of planned
			 births taking place in a clinic, birth center or home setting will be referred
			 to as community births or as out-of-hospital births. To obtain PA for coverage
			 of these services, providers must meet the requirements and submit the forms
			 and required supporting documentation as described in the Planned Community
			 Births (Out-of-Hospital Births) Prior Authorization and Billing Guide,
			 effective September 2021 available at:
https://www.oregon.gov/oha/HSD/OHP/Tools/Planned-Community-Birth-Guide.pdf
.
(a) Due to the current COVID-19 public health
			 emergency and surge in Oregon cases impacting hospital capacities, initial
			 documentation to assess pregnancy risk per OAR 410-130-0240  must be received by
			 the Division no later than 38 weeks, 0 days gestation, through the COVID health
			 emergency or until rescinded or revised by the Division;
(b) Documentation requirements reflecting
			 prior prenatal care must be met. Requests for ongoing documentation to continue
			 the support of assessment of pregnancy risk must also be met per OAR
			 410-120-1320(2)(3).
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 130 - MEDICAL-SURGICAL SERVICES › Section 410-130-0220 - Not Covered/Bundled Services/Not Valid

Current through Register Vol. 63, No. 7, July 1, 2024
(1) Under the Division's Fee-for-Service
			 Medical-Surgical program, no payment shall be made for (a) and (b) of this
			 section except in accordance with applicable exceptions as defined in
			 administrative rule:
(a) For the purposes of
			 this rule, the billing codes that are not covered shall be:
(A) Services below the funding line or
			 otherwise specified as not covered on the Health Evidence Review Commission
			 (HERC) Prioritized List of Health Services as referenced in OAR
			 410-141-3830;
(B) Services
			 specified in OAR 410-120-1200;
(C)
			 For Ambulatory Surgical Centers, services listed on Medicare's ASC Covered
			 Surgical Procedures file addendum EE, Surgical Procedures to Be Excluded from
			 Payment in ASCs as referenced in OAR 410-120-1340.
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 130 - MEDICAL-SURGICAL SERVICES › Section 410-130-0225 - Teaching Physicians

Current through Register Vol. 63, No. 7, July 1, 2024
(1)
			 Supervising faculty physicians in a teaching hospital may not bill the Division
			 of Medical Assistance Programs (Division) on a CMS-1500 or 837P when serving as
			 an employee of the hospital during the time the service was provided or when
			 the hospital reports the service as a direct medical education cost on the
			 Medicare and Division cost report.
(2) For requirements for the provision of
			 services, including documentation requirements, follow Medicare guidelines for
			 Teaching Physician Services.
Stat. Auth.: ORS
				  413.042
Stats. Implemented: ORS
				  414.025 &
				  414.065