Oregon Administrative Code

410-123-1620 Coding and Documentation (1) Providers must use the standardized code sets adopted by the Health Insurance Portability and Accountability Act (HIPAA) and the Centers for Medicare and Medicaid Services (CMS), and by the Chapter 410 Division 120 rules. (2) Unless other…

410-124-0000 Transplant Services (1) The Health Systems Division (Division) shall make payment for transplant services identified in these rules as covered for eligible Medicaid clients defined in OAR 410-124-0010 that meet the transplant criteria outlined in OAR 410-124-0000 thr…

410-124-0005 Donor Services (1) Living and cadaver donor search and procurement services are covered for medically necessary transplants. (2) All living or cadaver donor services are payable under the recipient’s Medicaid identification number and not under the donor. (3) For Man…

410-124-0006 Transplant Hospital Requirements And Reimbursement Transplant services shall be reimbursed only when provided in a transplant hospital that meets the Division requirements. (1) Medicare certified transplant facility. (2) Must be an enrolled provider with Oregon Healt…

410-124-0010 Eligibility for Transplant Services (1) To be eligible for transplant services the client must be enrolled under the following Benefit Packages at the time the transplant services are provided: (a) Oregon Health Plan Plus benefit package (BMH) described in OAR 410-12…

410-124-0040 Emergency Transplants (1) An Emergency Transplant is one in which medical appropriateness requires that a transplant be performed less than five days after determination of the need for a transplant. (2) Emergency transplants are subject to post transplant review of …

410-125-0000 Determining When the Patient Has Medical Assistance (1) The Medical Card gives the client’s name as listed with the Oregon Health Plan (OHP) and their alpha-numeric prime number. (2) Eligibility may change on a monthly basis. In some instances, eligibility will chang…

410-125-0020 Retroactive Eligibility (1) The Division of Medical Assistance Programs (Division) may pay for services provided to an individual who does not have Medicaid coverage at the time services are provided if the individual is made retroactively eligible for medical assist…

410-125-0030 Hospital Hold (1) A hospital hold is a process which allows an in-state general hospital or an out-of-state contiguous general hospital to assist an individual who is admitted to the hospital for an inpatient hospital stay to secure a date of request when the individ…

410-125-0040 Title XIX/Title XXI Clients (1) Title XIX /Title XXI clients are eligible for medical assistance through programs established by the Federal government and for which the State receives federal assistance. Most Title XIX/Title XXI clients are eligible for the Plus or …

410-125-0041 Non-Title XIX/XXI Clients (1) State-funded clients are clients who have not qualified for medical assistance through a federal program but have access to medical benefits through state funded programs. There are two categories of clients who are in State-funded progr…

410-125-0045 Coverage and Limitations In general, most medically appropriate services are covered. There are, however, some restrictions and limitations. Please refer to the Division of Medical Assistance Programs’ (Division) General Rules Program for information on general scope…

410-125-0050 Client Copayments Copayments may be required for certain services and/or benefit package(s). See OAR 410-120-1230 for specific details. Statutory/Other Authority: ORS 413.042 Statutes/Other Implemented: ORS 414.065 History: OMAP 70-2004, f. 9-15-04, cert. ef. 10-1-04…

410-125-0080 Inpatient Services (1) Elective (not urgent or emergent) hospital admission: (a) Coordinated Care Organization (CCO) and Mental Health Organization (MHO) clients: Contact the client’s CCO, or MHO. The health plan may have different prior authorization (PA) requiremen…

410-125-0085 Outpatient Services (1) Outpatient services that may require prior authorization (PA) include (see the individual program in the Authority’s Health Systems Division (Division)) Oregon Administrative Rules: (a) Physical Therapy (chapter 410, division 131); (b) Occupat…

410-125-0086 Prior Authorization for FCHP/MHO Clients Most non-emergent inpatient and outpatient services require prior authorization by a Fully Capitated Health Plan (FCHP) or a Mental Health Organization (MHO). Emergency hospital services must be covered by an FCHP or MHO witho…

410-125-0090 Inpatient Rate Calculations — Type A, Type B, and Critical Access Oregon Hospitals (1) The Office of Rural Health designates Type A, Type B, and Critical Access Oregon Hospitals. (2) Reimbursement to Type A, Type B, and Critical Access Oregon Hospitals for covered in…

410-125-0095 Hospitals Providing Specialized Inpatient Services (1) Some hospitals provide specific highly specialized in patient services by arrangement with the Division. (2) Reimbursement is made according to the terms of a contract between the Division and the hospital. Statu…

410-125-0101 Hospital-Based Nursing Facilities and Medicaid Swing Beds To be eligible to receive reimbursement for hospital-based long-term care nursing facility services or Medicaid swing beds, the hospital must: (1) Have approval from the Centers for Medicare and Medicaid Servi…

410-125-0102 Medically Needy Clients (1) The QIO can give prior authorization for non-emergency inpatient services for clients who are in the Medically Needy Program but have not yet met their spend-down. Only Medically Needy Program clients under age 21 and pregnant women have c…

410-125-0103 Medicare Clients When Medicare is the primary payer, services provided in the inpatient or out-patient setting do not require prior authorization. However, if the Division is the primary payer because the service is not covered by Medicare; the prior authorization re…

410-125-0115 Non-Contiguous Area Out-of-State Hospitals — Effective for services rendered on or after October 1, 2003 Non-contiguous area hospitals are out-of-state hospitals located more than 75 miles outside the Oregon border. Unless such hospitals have an agreement or contract…

410-125-0120 Transportation To and From Medical Services (1) Transportation to and from medical services, including hospital services, is a covered service. However, all non-emergency transports require prior authorization in order for the transportation provider to be paid. (2) …

410-125-0121 Contiguous Area Out-of-State Hospitals Contiguous area hospitals are out-of-state hospitals located less than 75 miles outside the Oregon border. Unless such hospitals have an agreement or contract with the Agency for specialized services, contiguous area out-of-stat…

410-125-0124 Retroactive Authorization Retroactive authorization for payment can be granted after the service is provided only in the following circumstances: (1) The person was not yet eligible for Medicaid/CHIP at the time the services were provided. Payment can be made if the …

410-125-0125 Free-Standing Inpatient Psychiatric Facilities Free-standing inpatient psychiatric facilities (institutions for mental diseases), including Oregon's state-operated psychiatric and training facilities, are reimbursed according to the terms of an agreement between the …

410-125-0140 Prior Authorization Does Not Guarantee Payment (1) Prior authorization (PA) is valid for the date range approved only as long as the client remains eligible for services. For example, a client may become ineligible after the PA has been granted but before the actual …

410-125-0141 DRG Rate Methodology (1) Diagnosis Related Groups, (DRG): (a) The DRG is a system of classification of diagnoses and procedures based on the International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM); (b) The DRG classification methodo…

410-125-0142 Graduate Medical Education Reimbursement for Public Teaching Hospitals (1) Graduate medical education payment is reimbursement made to an institution for the costs of an approved medical training program. The State makes GME payments to any in-state public acute care…

410-125-0146 Supplemental Reimbursement for Public Academic Teaching University Medical Practitioners (1) Effective for dates of service on or after November 17, 2005, physician and other practitioner services provided by practitioners affiliated with a public academic medical ce…

410-125-0150 Disproportionate Share (1) The Disproportionate-share hospital (DSH) payment is an additional reimbursement made to hospitals that serve a disproportionate share of low-income patients with special needs. (a) To receive DSH payments, a hospital must have at least two…

410-125-0155 Upper Limits on Payment of Hospital Claims (1) Supplemental payments: (a) Private Hospital Supplemental Payments: (A) From the private Upper Payment Limit (UPL) gap, payments shall be made to all private Diagnosis Related Groups (DRG) hospitals in the form of a per d…

410-125-0162 Hospital Transformation Performance Program (1) The Hospital Transformation Performance Program (HTPP) is established by the Oregon Health Authority (Authority) to allow hospitals to earn incentive payments by meeting specific performance standards that advance healt…

410-125-0165 Transfers and Reimbursement (1) When a patient is transferred between hospitals, the transferring hospital is paid on the basis of the number of inpatient days spent at the transferring hospital multiplied by the per diem inter-hospital transfer payment rate. (2) The…

410-125-0170 Death Occurring on Day of Admission A hospital receiving DRG reimbursements will receive the DRG reimbursement for the inpatient stay when death occurs on the day of admission as long as at least one hospital benefit day is available. Statutory/Other Authority: ORS 4…

410-125-0175 Hospitals Providing Specialized Outpatient Services Some hospitals provide specific highly specialized outpatient services by arrangement with the Division. Reimbursement is made according to the terms of a written agreement or contract. Statutory/Other Authority: OR…

410-125-0180 Public Rates Rates billed to Division of Medical Assistance Programs cannot exceed the facility’s public billing rate. Statutory/Other Authority: ORS 413.042 Statutes/Other Implemented: ORS 414.065 History: HR 42-1991, f. & cert. ef. 10-1-91 HR 21-1990, f. & cert. ef…

410-125-0181 Non-Contiguous and Contiguous Area Out-of-State Hospitals — Outpatient Services Non-contiguous area hospitals are out-of-state hospitals located more than 75 miles outside the Oregon border. Contiguous area hospitals are out-of-state hospitals located less than 75 mi…

410-125-0190 Outpatient Rate Calculations — Type A, Type B, and Critical Access Oregon Hospitals (1) The Office of Rural Health designates Type A, Type B, and Critical Access Oregon Hospitals. (2) Reimbursement to Type A, Type B, and Critical Access Oregon Hospitals for covered o…

410-125-0195 Outpatient Services In-State DRG Hospitals (1) The National Drug Code (NDC) must be included on all claim formats for physician administered drug codes required by the Deficit Reduction Act of 2005. (2) For discharges prior to January 1, 2012, In-State Diagnostic Rel…

410-125-0200 Time Limitation for Submission of Claims Division of Medical Assistance Programs (Division) will accept a claim up to 12 months after the date of service. The date of discharge is the date of service for an inpatient hospital claim. Statutory/Other Authority: ORS 413…

410-125-0201 Independent ESRD Facilities (1) Independent End Stage Renal Dialysis (ESRD) Facilities: (a) ESRD facilities are reimbursed for Continuous Ambulatory Peritoneal Dialysis. (b) (CAPD), Continuous Cycling Peritoneal Dialysis (CCPD), and Hemodialysis: (A) Composite at 80%…

410-125-0210 Third Party Resources and Reimbursement (1) The Division of Medical Assistance Programs (Division) establishes maximum allowable reimbursements for all services. When clients have other third party payers, the payment made by that payer is deducted from the Division’…

410-125-0220 Services Billed on the Electronic 837I or on the Paper UB-04 and Other Claim Forms (1) All inpatient and outpatient services provided by the hospital or hospital employees, unless otherwise specified below, are billed on the electronic 837I (837 Institutional) or on …

410-125-0221 Payment in Full The payment made by Medicaid towards any inpatient or outpatient services, including cost outlier, disproportionate share, and capital payments, constitutes payment in full for the service. Statutory/Other Authority: ORS 413.042 Statutes/Other Impleme…

410-125-0230 Qualified Directed Payments Qualified Directed Payments (QDP) are payments made by the Oregon Health Authority (Authority) to Coordinated Care Organizations (CCOs) from three Quality and Access pools for distinct provider classes as follows: (i) Rural Type A and Type…

410-125-0360 Definitions and Billing Requirements (1) Total days on an inpatient claim must equal the number of accommodation days. Do not count the day of discharge when calculating the number of accommodation days. (2) Inpatient services are reimbursed based on the admission da…

410-125-0400 Discharge (1) A discharge from a hospital is the formal release of a patient to home, to another facility such as an intermediate care facility or nursing home, to a home health care agency, or to another provider of health care services. (2) For services beginning J…

410-125-0401 Definitions: Emergent, Urgent, and Elective Admissions (1) EMERGENT ADMISSION — an admission which occurs after the sudden onset of a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that a prudent layperson, …

410-125-0410 Readmission (1) A patient whose readmission for surgery or follow-up care is planned at the time of discharge must be placed on leave of absence status, and both admissions must be combined into a single billing. The Division of Medical Assistance Programs (Division)…