Oregon Administrative Code

410-125-0450 Provider Preventable Conditions (1) Health Care-Acquired Conditions (HCAC): (a) Formally known as Medicare’s list of “hospital acquired conditions” (HAC) that apply to inpatient hospital settings with dates of admission on or after January 1, 2011 except those hospit…

410-125-0550 X-Ray or EKG Procedures Furnished in Emergency Room The Division pays for only one interpretation of an x-ray or EKG procedure furnished to an emergency room patient, and that is for the interpretation and report that directly contributed to the diagnosis and treatme…

410-125-0600 Non-Contiguous Out-of-State Hospital Services (1) Non-contiguous out-of-state hospitals are those hospitals located more than 75 miles from the Oregon border. (2) The hospital must be enrolled as a provider with Oregon Medical Assistance Programs to receive payment. …

410-125-0620 Special Reports and Exams and Medical Records Refer to the Division’s Administrative Exams and Reports Billing rules (chapter 410 division 150) for information and instructions on billing for administrative exams and reports. Statutory/Other Authority: ORS 413.042 St…

410-125-0640 Third Party Payers — Other Resources, Client Responsibility and Liability (1) Medicare: Do not send claims to the Division of Medical Assistance Programs (Division) until they have been billed to and adjudicated by Medicare: (a) Exception: Take home drugs and other s…

410-125-0641 Medicare (1) A Medicare/Medicaid claim can automatically be sent to the Division after adjudicated by Medicare. This saves the effort of a second submission, as well as ensuring a more accurate and speedier payment by the Division. Medicare will automatically transmi…

410-125-0720 Adjustment Requests (1) Most overpayment and under-payments are resolved through the adjustment process. Only paid claims can be adjusted. If no payment was made, the claim must be submitted using a CMS 1450 (UB-04) for processing. All overpayments must be reported. …

410-125-1020 Filing of Cost Statement (1) The hospital must file an annual Calculation of Reasonable Cost (DMAP 42), covering the latest fiscal period of operation of the hospital with Division of Medical Assistance Programs (Division): (a) A Calculation of Reasonable Cost statem…

410-125-1040 Accounting and Record Keeping (1) All records for a given fiscal period must be kept for three years after the Medicare audit for that period has been finalized. (2) Each hospital is required to make its financial records available for auditing within the state of Or…

410-125-1060 Fiscal Audits (1) Year-end fiscal audits will include retrospective examination and verification of claims and the determination of allowable charges and costs of hospital services provided to Division clients. (2) The principal source document for the fiscal audit o…

410-125-1070 Type A and Type B Hospitals (1) Type A and Type B hospitals must submit the following information to the Division: (a) The aggregate percent increase in patient charges and the effective date of the increase within 30 days following the end of their fiscal year for i…

410-125-1080 Documentation (1) Federal regulations require Medicaid providers to maintain records that fully support the extent of services for which payment has been requested, and that such records be furnished to the Division upon request (42 CFR 431.107). (2) When requested b…

410-125-2000 Access to Records (1) Providers must furnish requested medical and financial documentation within 30 calendar days from the date of request. Failure to comply within 30 calendar days shall result in recovery of payment(s) made by the Division for services being revie…

410-125-2020 Post Payment Review (1) All services provided by a hospital in the inpatient or outpatient setting are subject to post-payment review by the Division. Both emergency and non-emergency services may be reviewed. Claims for services may be reviewed to determine: (a) The…

410-125-2030 Recovery of Payments (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…

410-125-2040 Provider Appeals — Administrative Review (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 administ…

410-125-2060 Provider Appeals — Hearing Request If the hospital disagrees with the Division calculation of reasonable costs for outpatient services or inpatient services, the outpatient interim rate, Diagnosis-Related Groups based prospective payment for inpatient services, the c…

410-125-2080 Administrative Errors (1) If a hospital has been given incorrect information by the Division of Medical Assistance Programs, or Children, Adults, and Families Programs, or Aging and People with Disabilities/staff, and services were provided on the basis of this infor…

410-127-0020 Definitions (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) “Custod…

410-127-0040 Coverage (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 faci…

410-127-0045 Face-to-Face Encounter Requirements for Home Health Services (1) The Division requires that for the initial ordering of home health services, an in-person face-to-face encounter that is related to the primary reason the client requires the home health services must o…

410-127-0046 Electronic Visit Verification (EVV) (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 ag…

410-127-0060 Reimbursement and Limitations (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…

410-127-0065 Signature Requirements (1) Physicians shall 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 physician shall ensure the authenticity of the signature. Statutory/Other Auth…

410-127-0080 Prior Authorization (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…

410-127-0200 Home Health Revenue Center Codes 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-steri…

410-129-0020 Therapy Plan of Care, Goals, Outcomes, and Record Requirements (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 …

410-129-0060 Prescription Required (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 service…

410-129-0065 Licensing Requirements (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 prac…

410-129-0070 Limitations (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 p…

410-129-0075 Face-to-Face Encounter Requirements for Fee-for-Service Clients (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…

410-129-0080 Prepayment Review (PPR) and Prior Authorization (PA) for payment (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) Prov…

410-129-0085 Payment Methodology (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 Cente…

410-129-0100 Medicare/Medicaid Claims (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 4…

410-129-0180 Procedure Codes (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 n…

410-129-0200 Speech-Language Pathology Procedure Codes (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-…

410-129-0220 Augmentative Communications System or Device (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 liste…

410-129-0240 Audiologist and Hearing Aid Procedure Codes (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 procedur…

410-129-0260 Hearing Aids and Hearing Aid Technical Service and Repair (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 am…

410-129-0280 Hearing Testing for Diagnostic Purposes on Physician’s Referral Only (1) A physician's referral is required for the tests shown in this rule. The tests may only be performed and billed by a licensed audiologist or a licensed physician. (2) Procedure codes are the fol…

410-130-0000 Foreword (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 …

410-130-0005 Federally Qualified Primary Care Provider (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 …

410-130-0015 Doula Services (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…

410-130-0160 Codes (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, i…

410-130-0180 Drugs (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…

410-130-0190 Tobacco Cessation (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 — usuall…

410-130-0200 Prior Authorization (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 obt…

410-130-0220 Not Covered/Bundled Services/Not Valid (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 …

410-130-0225 Teaching Physicians (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 ho…

410-130-0230 Administrative Medical Examinations and Reports (1) This rule does not apply to Managed Health Care plans. (2) These services are covered only when requested by an CAF, APD, AMH, OYA, Child Welfare branch office or approved by the Division of Medical Assistance Progr…