Oregon Administrative Code

410-130-0240 Medical Services (1) Coverage of medical and surgical services is subject to the Health Evidence Review Commission’s (HERC) Prioritized List of Health Services (Prioritized List). Medical and surgical services requiring prior authorization (PA) are listed in Oregon a…

410-130-0255 Immunizations, Vaccines for Children, and Immune Globulins (1) The Division covers immunizations as recommended by the Advisory Committee on Immunization Practices (ACIP) and approved by the Oregon Immunization Program. The approved ACIP recommendations are found in …

410-130-0365 Ambulatory Surgical Center and Birthing Center Services (1) Ambulatory Surgical Centers (ASC) and Birthing Centers (BC) must be licensed by the Oregon Health Division. ASC and BC services are items and services furnished by an ASC or BC in connection with a covered s…

410-130-0368 Anesthesia Services (1) Anesthesia is not covered for procedures that are below the funding line on the Health Services Commission’s Prioritized List of Health Services (see OAR 410-141-0520). (2) Effective January 1, 2012 all anesthesia claims submitted must be bill…

410-130-0380 Surgery Guidelines (1) The Division of Medical Assistance Programs (Division) reimburses all covered surgical procedures as global packages. Global payments do not include initial consultation or evaluation of the problem by the surgeon to determine the need for surg…

410-130-0562 Abortion For medically induced abortions by oral ingestion of medication use S0199 for all visits, counseling, lab tests, ultrasounds, and supplies. S0199 is a global package except for medication: (1) Bill medications with codes S0190-S0191 and appropriate HCPCS cod…

410-130-0580 Hysterectomies and Sterilization (1) Refer to OAR 410-130-0200 Prior Authorization, Table 130-0200-1 and 410-130-0220 Not Covered/Bundled Services, Table 130-0220-1. (2) Hysterectomies performed for the sole purpose of sterilization are not covered. (3) All hysterect…

410-130-0585 Family Planning Services (1) Family planning services are those intended to prevent or delay pregnancy, or otherwise control family size. (2) The Division of Medical Assistance Programs (Division) covers family planning services for clients of childbearing age (inclu…

410-130-0587 Family Planning Clinic Services (1) This rule pertains only to Family Planning Clinics. (2) To enroll with the Division of Medical Assistance Programs (Division) as a family planning clinic, a provider must also be enrolled with the Office of Family Health as an Oreg…

410-130-0595 Maternity Case Management (1) The primary purpose of the Maternity Case Management (MCM) program is to optimize pregnancy outcomes, including reducing the incidence of low birth weight babies. MCM services are tailored to the individual client needs. These services a…

410-130-0605 Newborn Nurse Home Visiting Services (1) Definitions. (a) “Comprehensive newborn nurse home visit” has the meaning described in OAR 333-006-0010 a 333-006-0120; (b) “HSD” means the Oregon Health Authority’s Health Systems Division; (c) “Public Health” means the Orego…

410-130-0670 Death With Dignity (1) All Death with Dignity services must be billed directly to the Division of Medical Assistance Programs (Division), even if the client is in a managed care plan. (2) Death with Dignity is a covered service, incorporated in the "comfort care" con…

410-130-0680 Laboratory and Radiology (1) The following tables list the medical and surgical services that: (a) Require prior authorization (PA) — OAR 410-130-0200 Table 130-0200-1 (PET scans require PA and are included in the table), and; (b) Are not covered/bundled — OAR 410-13…

410-130-0700 HCPCS Supplies and DME (1) Use appropriate HCPCS codes to bill all supplies and DME. (2) For items that do not have specific HCPCS codes: (a) Use unlisted HCPCS code; (b) Bill at acquisition cost, purchase price plus postage. (3) CPT code 99070 is no longer billable …

410-131-0040 Physical and Occupational Therapy (1) The Division's Physical and Occupational Therapy (PT/OT) Services rules are designed to assist licensed physical and occupational therapists deliver health care services and prepare health claims for clients with medical assistan…

410-131-0080 Therapy Plan of Care and Record Requirements (1) There must be a rehabilitative or habilitative therapy plan of care to receive payment. (2) The Division shall authorize for the level of care or type of service that meets the client’s medical need consistent with the…

410-131-0120 Limitations of Coverage and Payment (1) The provision of PT/OT evaluations and therapy services require a prescribing practitioner referral, and services shall be supported by a therapy plan of care signed and dated by the prescribing practitioner as specified in 42 …

410-131-0160 Prepayment Review (PPR) and Prior Authorization (PA) for Payment (1) Most OHP clients have prepaid health services contracted for by the Authority through enrollment in a Managed Care Entity (MCE). (2) The provider shall verify whether an MCE or the Division is respo…

410-132-0020 Private Duty Nursing Services (1) The practice of nursing is governed by the following: Oregon State Board of Nursing, ORS 678.010 to 678.410, and Oregon State Board of Nursing, chapter 851, divisions 031, 045, and 047. (2) Private duty nursing is considered supporti…

410-132-0030 Definitions (1) “Activities of daily living or ‘ADL’” means activities usually performed in the course of a normal day in an individual's life including: (a) Eating: Assisting the individual in feeding or fluid intake by any means from a receptacle into the body, inc…

410-132-0060 Private Duty Nursing Transition into Maintenance (1) Private duty nursing services become maintenance care when any one of the following situations occurs: (a) Medical and nursing documentation supports that the condition of the client is stable/predictable; (b) The …

410-132-0070 Documentation Requirements (1) Documentation of services provided shall be maintained in the client's place of residence by the private duty nurse until discharged from service. Payment may not be made for services where the documentation does not support the definit…

410-132-0080 Limitations (1) General pertains to both shift care and visits: (a) Private duty nursing is not covered if the client is: (A) Twenty-one years of age or older; (B) A resident of a nursing facility; (C) A resident of a licensed intermediate care facility for individua…

410-132-0100 Prior Authorization (1) Private duty nursing providers shall obtain prior authorization (PA) for all services. (2) Providers shall request PA as follows (see the Private Duty Nursing Services Supplemental Information booklet for contact information): (a) For individu…

410-132-0120 Billing Information (1) If the client has not enrolled in a CCO or PHP, bill with the appropriate Division unique procedure codes and follow the instructions on how to complete the CMS-1500. (2) Client copayments may be required for certain services. See OAR 410-120-…

410-132-0180 Procedure Codes (1) All private duty nursing services require prior authorization. (2) Private duty nursing visit: (a) T1030 — Nursing care in the home by registered nurse per diem; (b) T1031 — Nursing care in the home by licensed practical nurse per diem. (3) Privat…

410-132-0200 Provider Enrollment (1) Registered nurses and licensed practical nurses shall submit a copy of licensure every two years upon renewal by the Oregon State Board of Nursing to be enrolled or continue enrollment as a Division provider. (2) If the Division provider is a …

410-133-0000 Purpose (1) School-Based Health Services (SBHS) rules: (a) Define Oregon’s fee-for-service Medicaid program administered by the Oregon Health Authority (Authority) to reimburse publicly funded education agencies for health services provided in education settings to O…

410-133-0040 Definitions In addition to the definitions in OAR 410-120-0000 and OAR 410-141-0001, the following definitions apply to these rules: (1) “Adapted vehicle” means a vehicle that has been physically adjusted or designed to meet the needs of the individual student under …

410-133-0050 Individual Plan of Care (1) School-based health services, except unplanned services and screenings, must be provided pursuant to, in relation to, or in the development of a Medicaid-enrolled child or young adult’s Individual Plan of Care (IPOC). (2) The IPOC must con…

410-133-0060 School-Based Health Services (1) School-based health services are provided in education settings in support of a child or young adult’s education to address health-related service needs and devices that help the individual child or young adult keep, learn, or improve…

410-133-0070 Telehealth (1) The Authority may reimburse school medical providers for covered school-based health services delivered via telehealth that meet the following criteria: (a) The covered telehealth service is provided to a child or young adult to the same extent that th…

410-133-0080 Coverage (1) Services provided or supervised by Medicaid-enrolled SBHS-recognized providers are covered when EPSDT medical necessity and appropriateness are supported by: (a) For planned services: (A) The child or young adult’s IPOC; and (B) The rendering provider’s …

410-133-0090 Payment (1) Payment shall be made for school-based health services in accordance with OARs: 410-120-1340, 943-120-0350, and 410-133-0245. (2) Evaluation, re-evaluation, and assessment reimbursable time may include: (a) The time for evaluating and assessing a child or…

410-133-0100 School Medical Provider Requirements The school medical provider is responsible to: (1) Enroll as a school medical provider with the Authority in compliance with OARs: 410-120-1260 and 943-120-0320. (2) Ensure school-based health services are provided by SBHS-recogni…

410-133-0120 Recognized Providers (1) School-based health services must be provided and documented by SBHS-recognized providers that provide services within their scope of practice and in compliance with their respective board rules and requirements. (2) Providers with the follow…

410-133-0140 Provider Enrollment (1) Enrollment with the Authority is subject to and in compliance with OAR 410-120-1260 and 943-120-0320. (2) Education agencies must be enrolled as a school medical provider with the Authority to bill and receive reimbursement for Medicaid-covere…

410-133-0200 Services Not Covered (1) Oregon’s School-Based Health Services (SBHS) program does not cover or reimburse for: (a) Services that are not provided and documented by SBHS-recognized providers within their respective scope of practice and in compliance with their respec…

410-133-0220 Billing (1) The enrolled school medical provider must: (a) Bill the Authority in compliance with OARs 410-120-1280 and 943-120-0330; (b) Bill services using a professional claim format (i.e., paper CMS-1500 or electronic equivalent to the CMS-1500 form). (c) Include …

410-133-0245 Cost-Based Rates and Payment (1) The Authority shall determine cost-based rates based upon annual costs submitted by education agencies. (2) Cost-based rates for each education agency shall: (a) Be based upon the prior year's annual audited costs and the Oregon Depar…

410-133-0320 Documentation and Recordkeeping (1) The school medical provider is responsible for recordkeeping and documentation in adherence to federal, state, and local laws and regulations including OAR 410-120-1360. (2) Documentation for school-based health services: (a) Is a …

410-133-0340 Client Rights and Record Confidentiality (1) School medical providers must provide access to records and documentation that support claims submitted to the Authority for school-based health services provided to Medicaid-enrolled children and young adults when request…

410-134-0000 Purpose (1) The purpose of this OAR Chapter 410, division 134 is to set forth the rules that are specific to the Healthier Oregon program. (2) The Healthier Oregon program is a medical assistance benefit package equal to OHP Plus defined and described in OAR 410-120-…

410-134-0001 Acronyms and Definitions (1) The following acronyms and definitions within this rule specifically apply to the Healthier Oregon program in its entirety. (a) The Authority incorporates acronyms and definitions in OAR 410-141-3500, OAR 410-120-0000 and OAR 410-200-0015…

410-134-0003 Healthier Oregon and Healthier Oregon Cover All Kids Coverage (1) The Healthier Oregon and Healthier Oregon Cover All Kids benefit package description, benefits package identifier, eligibility criteria, and coverage is described in this Rule. (2) Healthier Oregon and…

410-134-0004 Healthier Oregon Funding (1) The Healthier Oregon medical assistance benefit package is equal to the medical assistance benefits package defined and describe in OAR 410-120-1210 as OHP Plus but the funding for the benefits is different as set out in this rule. (2) Em…

410-134-0005 Coverage and Billing for Citizenship Waived Medical and Citizenship Waived Medical Plus (1) The Citizenship Waived Medical (CWM) and Citizenship Waived Medical Plus (CWM Plus) benefit package ended on June 30, 2023. Prior to July 1, 2023, CWM Plus was referred to as …

410-136-3000 Responsibility for Providing Non-emergent Medical Transportation (1) The Authority shall provide non-emergent medical transportation (NEMT) for eligible clients who receive their Oregon Health Plan (OHP) covered medical services on a fee-for-service basis or are clie…

410-136-3010 Coordinated Care Organizations (1) The Authority contracts with Coordinated Care Organizations (CCOs) to provide medical services for clients receiving Title XIX and Title XXI services for the purpose of providing integrated and coordinated care services across physi…

410-136-3020 General Requirements for NEMT (1) The Authority may enroll governmental transportation brokerages (local units of government) or other entities contracted with the Authority as a “contractor” to arrange rides. Transportation brokerages pay subcontractors for NEMT ser…