Oregon Administrative Code

410-136-3040 Vehicle Equipment and Subcontractor Standards (1) Brokerages shall require all subcontractors, providers, and drivers to maintain their vehicles for the comfort and safety of the clients. The vehicles shall meet the following requirements: (a) The interior of the veh…

410-136-3060 Insurance Requirements (1) Brokerages must obtain and maintain general and automobile liability coverage for personal injury and death in accordance with ORS 30.271, Limitations on Liability of State for Personal Injury and Death. (2) Brokerages must obtain and maint…

410-136-3080 Out-of-State Transportation (1) “Out-of-state transportation” means transportation to or from any location outside Oregon, with the exception of contiguous areas up to 75 miles outside the Oregon border. (2) The brokerage shall arrange rides and pay for out-of-state …

410-136-3100 Attendants for Child Transports (1) This rule applies to non-emergent medical transportation (NEMT) for children twelve (12) years of age and under who are eligible for NEMT services to and from Oregon Health Plan (OHP) and RHAF covered medical services. The rule als…

410-136-3120 Secured Transports (1) Secured transport NEMT services are for the involuntary transport of clients who are in danger of harming themselves or other individuals. Secured transports are allowable when: (a) The brokerage verified that the subcontractor has met the requ…

410-136-3140 Transports of Clients Changing Hospitals or Other Facilities (1) Brokerages shall arrange and pay for transporting an eligible client who has had a change in condition, noted in the client’s Oregon Department of Human Services (ODHS) care plan, resulting in a need fo…

410-136-3160 Ground and Air Ambulance Transports (1) Transporting a client via ambulance is required when a medical facility or provider states the client’s medical condition requires the presence of a health care professional during the emergency or non-emergency transport. This…

410-136-3180 Reimbursement for Ground and Air Ambulance Transports (1) The following applies to how the Oregon Health Authority (Authority) shall reimburse providers of NEMT ground and air ambulance services that brokerages arrange for eligible clients. This applies to clients re…

410-136-3200 Reimbursement and Accounting for all Modes of Transports (1) The following applies to the rate the Oregon Health Authority (Authority) pays brokerages: (a) The Authority shall calculate and pay a brokerage a fixed rate for rides based on the following formula: Direct…

410-136-3220 Brokerage Reimbursements to Subcontractors (1) Brokerages shall reimburse their non-emergent medical transportation (NEMT) subcontractors for the most cost-effective route from point of origin to point of destination that most benefits the client’s condition. (2) Bro…

410-136-3240 Client Reimbursed Mileage, Meals and Lodging (1) The brokerage must prior authorize a client’s mileage, meals, and lodging to an Oregon Health Plan (OHP) or RHAF covered medical service in order for the client to qualify for reimbursement. If the brokerage prior auth…

410-136-3260 Modifications Based on Client Circumstances (1) A client may request modification of non-emergent medical transportation (NEMT) services when the NEMT driver: (a) Threatens to harm the client or others in the vehicle; (b) Drives or engages in other behavior that plac…

410-136-3280 Client Rights and Confidentiality (1) Brokerages shall treat all information gathered on the client as privileged and confidential communications. The brokerage shall apply confidentiality policies to all requests for information from outside sources. Nothing prohibi…

410-136-3300 Reports and Documentation (1) Brokerages shall maintain documentation of rides denied and rides provided to clients. This documentation shall include, but is not limited, to: (a) The name of the client and the person requesting the ride on behalf of the client, if ap…

410-136-3320 Audits (1) The Oregon Health Authority (Authority), the Oregon Secretary of State Audits Division, the Oregon Department of Justice, Medicaid Fraud Control Unit (MFCU) and the federal government may audit the brokerage’s and its subcontractor’s records at least annua…

410-136-3340 Brokerage Service Areas (1) Brokerages enrolled with the Oregon Health Authority (Authority) shall arrange and pay for NEMT services to all eligible clients in the counties shown in Table 136-3340. (2) Oregon Health Plan (OHP) clients and RHAF clients residing in Ore…

410-136-3360 Discontinuation of Brokerage as Enrolled Provider (1) A brokerage may discontinue being an enrolled provider for NEMT services only with notice to the Oregon Health Authority (Authority). The following establishes the requirements for notice: (a) If the reason is for…

410-136-3370 General Requirements for GEMT (1) The Ground Emergency Medical Transportation (GEMT) program is a voluntary program that makes supplemental payments to eligible GEMT providers who furnish qualifying emergency ambulance services to Oregon Health Authority (Authority) …

410-136-3371 Provider Requirements and Payment Processing for the CCO GEMT Supplemental Payments (1) Definitions: (a) “Coordinated Care Organization” has the meaning defined in OAR 410-141-3500. (b) "Ground Emergency Medical Transportation Provider" and "GEMT Provider" each means…

410-136-3372 General Requirements for Ground Emergency Medical Transportation Emergency Medical Services Transport Private Provider Program (1) The Ground Emergency Medical Transportation (GEMT) Emergency Medical Services Transport (EMST) private provider program makes supplement…

410-136-3373 Ground Emergency Medical Transportation - Emergency Medical Services Transport Private Provider Program - Quality Assurance Fee Requirements and Qualifications (1) Quality Assurance Fee (QAF) assessment for the Ground Emergency Medical Transportation (GEMT) Emergency…

410-136-3374 Ground Emergency Medical Transportation – Emergency Medical Services Transportation Private Provider Program - Coordinated Care Organizations Requirements and Payment Processing (1) Definitions: (a) “Coordinated Care Organization” has the meaning defined in OAR 410-1…

410-138-0000 Targeted Case Management Definitions The following definitions apply to OAR 410-138-0000 through 410-138-0390: (1) “Assessment” means the act of gathering information and reviewing historical and existing records of an eligible client in a target group to determine t…

410-138-0005 Payment for Targeted Case Management Services Eligible for Federal Financial Participation (1) This rule is to be used in conjunction with Targeted Case Management (TCM) rules OAR 410-138-0000 through 410-138-0009 and 410-138-0390 and the Division’s General Rules cha…

410-138-0007 Targeted Case Management — Covered Services (1) Targeted case management (TCM) services shall be furnished only to assist individuals eligible under the Medicaid State Plan in gaining access to and effectively using needed medical, social, educational, and other serv…

410-138-0009 Targeted Case Management — Services Not Covered Targeted Case Management (TCM) services do not cover: (1) Direct delivery of an underlying medical, educational, social, or other service to which the eligible client has been referred. (2) Providing transportation to a…

410-138-0020 Targeted Case Management Programs (1) This rule includes services in the State Plan for Targeted Case Management. (2) TCM programs include the following: (a) Human Immunodeficiency Virus (HIV); (b) Public Health Nurse Home Visiting programs including, Babies First!, …

410-138-0040 Targeted Case Management Babies First!, CaCoon, and Nurse-Family Partnership Program Risk Criteria (1) This rule is in effect for services approved by CMS effective for services rendered beginning January 1, 2017, and sets forth the criteria for risk factors for the …

410-138-0060 Targeted Case Management Program — Provider Requirements (1) TCM Public Health Nurse Home Visiting (Babies First!, CaCoon, and Nurse-Family Partnership) targeted case managers may be an employee of a Local Public Health Authority or other public or private agency con…

410-138-0080 Targeted Case Management Program Billing Policy (1) Reimbursement is based on cost-based rate methodology and subject to all rules and laws pertaining to federal financial participation. The Authority’s acceptance of cost data provided by provider organizations for t…

410-138-0390 Targeted Case Management Retroactive Payments (1) Providers may submit claims retroactively for services provided to the targeted populations described in OAR 410-138-0020(2) if the claims meet the following criteria: (a) Services were provided less than 12 months pr…

410-140-0010 Definitions and Acronyms (1) Aphakia is a condition in which the eye lens of one or both eyes are missing. (2) Comorbidity has the meaning provided in OAR 410-141-3820 (10 & 11). (3) Congenital aphakia is a congenital eye defect presenting at birth with no lens forma…

410-140-0140 Vision Coverage (1) The Division covers: (a) Ocular prosthesis (e.g., artificial eye) and related services (OAR 410-122-0640). (b) Reasonable services for diagnosing conditions, including the initial diagnosis of a condition that is below the funding line on the Prio…

410-140-0160 Contact Lens Services and Supplies (1) The following is general information regarding the Division’s contact lens services and supplies coverage for members who receive services on an FFS basis: (a) The prescription of optical and physical characteristics of and fitt…

410-140-0200 Glasses (1) The Division covers the fitting of glasses and the refitting and repair of glasses only when glasses and replacement parts are purchased from: (a) The Division’s contractor; (b) Any visual materials supplier when the member has primary Medicare coverage o…

410-140-0400 Contractor Services (1) The Division of Medical Assistance Programs (Division) contracts with SWEEP Optical Laboratories (also referred to herein as contractor) to provide vision materials and supplies. Providers needing materials and supplies must order those direct…

410-140-0410 Provider Responsibility (1) The Oregon Health Authority (Authority) uses several approaches to promote program integrity and prevent fraud, waste and abuse in the Medicaid program (Refer to OAR 410-120-1395) (2) The Division enrolls the following as providers of visi…

410-140-0415 Codes (1) Providers shall use an International Classification of Diseases, 10th revision, Clinical Modification (ICD-10-CM) diagnosis code on all claims. (2) Providers shall provide the member's diagnosis to ancillary service providers (e.g., SWEEP Optical Laboratori…

410-140-0420 Prior Authorizations (1) If a member has FFS the Division may require a Prior Authorization (PA) for certain covered services or items before the service may be provided and before payment is made; and (2) Prior Authorization (PA) is defined in OAR 410-120-0000, OAR …

410-140-0425 Meaningful Language Access (1) Providers shall take reasonable steps to ensure that persons with Limited English Proficiency (LEP) have meaningful access and an equal opportunity to participate in program services at all visual service care visits: (a) The size or ty…

410-140-0430 Limitations and Exclusions (1) Buying up, as defined in OAR 410-120-1350 is prohibited. (2) Vision therapy is not covered except under EPSDT when medically necessary and medically appropriate (Refer to Chapter 410, Division 151). (3) The following ophthalmic material…

410-141-3500 Definitions (1) The following definitions apply with respect to OAR chapter 410, division 141. The Oregon Health Authority (Authority) also incorporates the definitions in OAR 410-120-0000, 309-032-0860 for any terms not defined in this rule. (2) “Adjudication” means…

410-141-3501 Administration of Oregon Integrated and Coordinated Health Care Delivery System Regulation; Rule Precedence (1) The Authority may adopt reasonable and lawful policies, procedures, rules and interpretations to promote the orderly and efficient administration of the Or…

410-141-3505 Use of Subcontractors (1) MCEs may delegate their activities or obligations to subcontractors except as otherwise provided by law or in the MCE contract: (a) MCEs remain fully accountable for the performance of all subcontracted work, including that of all downstream…

410-141-3510 Provider Contracting and Credentialing (1) Managed Care Entity’s (MCEs) shall develop policies and procedures for credentialing providers to include quality standards and a process to remove providers from their provider network if they fail to meet the objective qua…

410-141-3515 Network Adequacy (1) Managed Care Entities (MCEs) shall maintain and monitor a network of participating providers that is sufficient in number, provider type, and geographic distribution to ensure adequate service capacity and availability to provide available and ti…

410-141-3520 Record Keeping and Use of Health Information Technology (1) MCEs shall have written policies and procedures that ensure maintenance of a record keeping system that includes maintaining the security of records as required by the Health Insurance Portability and Accoun…

410-141-3525 Outcome and Quality Measures (1) Managed Care Entities (MCEs) shall report to the Authority its health promotion and disease prevention activities, national accreditation organization results, and Healthcare Effectiveness Data and Information Set (HEDIS) measures as …

410-141-3530 Sanctions (1) The Authority may establish and impose sanctions on Managed Care Entities (MCEs), pursuant to 42 CFR § 438.700, if the Authority makes a determination specified in paragraph (3) of this rule. (2) The Authority may base its determinations on findings fro…

410-141-3531 Sanctions for Failure to Comply with State or Federal Information Security or Privacy Laws (1) Pursuant to 42 CFR §438.700, the Authority may impose sanctions on an MCE if the Authority makes a determination that an MCE failed to comply with any one or more of the fo…