Oregon Administrative Code

410-146-0160 Administrative Medical Examinations and Reports (1) The Division may not reimburse administrative medical examinations and reports at an IHCP’s IHS encounter rate. Administrative medical examinations and reports are not eligible under the Memorandum of Agreement (MOA…

410-146-0200 Pharmacy (1) A valid encounter excludes pharmaceutical or biologicals not generally provided during a clinic visit: (a) An IHS or Tribal 638 Pharmacy may select whether to be reimbursed by the Division for prescriptions, including dispensing services, at the appropri…

410-146-0220 Death With Dignity (1) Death with Dignity is a covered service, except for those facilities limited by the Assisted Suicide Funding Restriction Act of 1997 (ASFRA), and is incorporated in the "comfort care" condition/treatment line on the HERC’s Prioritized List of H…

410-146-0240 Transportation (1) The Division may reimburse IHCP for medically appropriate sedan car or wheelchair van transportation services provided to OHP AI/AN clients who receive medical services through an IHCP. (Refer to OAR 410 Division 136, Medical Transportation.) (2) F…

410-146-0440 Prepaid Health Plan Supplemental Payments (1) Effective January 1, 2001, the Division is required by 42 USC 1396a(bb) to make supplemental payments to eligible Federally Qualified Health Centers (FQHC) and Rural Health Clinics (RHC) that contract with Prepaid Health …

410-146-0460 Compensation for Outstationed Eligibility Workers (1) The Division may provide reasonable compensation for activities directly related to the receipt and initial processing of applications for individuals to apply for Medicaid at outstationed locations other than sta…

410-146-0470 Traditional Health Care Practices (1) Definitions: (a) Indian Health Care Provider (IHCP) means a health care program operated by the Indian Health Service (IHS) or by an Indian Tribe, Tribal Organization, or Urban Indian Organization (otherwise known as an I/T/U) as…

410-146-5000 Indian Managed Care Entities (1) Definitions. The definitions in OAR 410-141-3500 apply to this rule unless context dictates otherwise. In addition, for purposes of this rule: (a) “The Authority” means the Oregon Health Authority; (b) “Contract” means an agreement be…

410-147-0000 Foreword (1) The Division of Medical Assistance Programs” (Division) Federally Qualified Health Center (FQHC) and Rural Health Clinic (RHC) rules are designed to assist FQHCs and RHCs to deliver health care services and prepare health claims for clients with Medical …

410-147-0020 Professional Ambulatory Services (1) Providers must use the following rules in conjunction with all individual program rules to determine service coverage and limitations for Oregon Health Plan (OHP) clients according to their benefit packages: Medical, EPSDT, Diagno…

410-147-0040 ICD-10-CM Diagnosis and CPT/HCPCs Procedure Codes (1) The appropriate ICD-10-CM diagnosis code or codes from 001.0 through V99.9 must be used to identify: (a) Diagnoses; (b) Symptoms; (c) Conditions; (d) Problems; (e) Complaints; or (f) Other reasons for the encounte…

410-147-0060 Prior Authorization (1) Most Oregon Health Plan (OHP) clients have prepaid health services, contracted for by the Oregon Health Authority (Authority) through enrollment in a prepaid health plan (PHP). client’s who are not enrolled in a PHP, receive services on an "op…

410-147-0080 Prepaid Health Plans (PHPs) (1) Most Oregon Health Plan (OHP) clients have prepaid health services, contracted for by the Oregon Health Authority (Authority) through enrollment in a prepaid health plan (PHP). Clinics serving eligible OHP clients who are enrolled in a…

410-147-0085 Client Copayments (1) The Division of Medical Assistance Programs (Division) Medical Care Identification will indicate which Oregon Health Plan (OHP) clients are responsible for copayments for services. (2) Division requires copayments from clients with certain benef…

410-147-0120 Division Encounter and Recognized Practitioners (1) The Division of Medical Assistance Programs (Division) reimburses Federally Qualified Health Center (FQHC) and Rural Health Clinic (RHC) services according to the Prospective Payment System (PPS) as follows: (a) Whe…

410-147-0140 Multiple Encounters (1) An encounter is defined in OAR 410-147-0120. (2) The following services may be considered as multiple encounters when two or more service encounters are provided on the same date of service with distinctly different diagnoses (see OAR 410-147-…

410-147-0160 Modifiers (1) The Division of Medical Assistance Programs (Division) uses HIPAA compliant modifiers for many services. (2) The following conditions require the use of a modifier for all codes: (a) Family Planning Service — FP, Refer to OAR 410-130-0585 Family Plannin…

410-147-0180 Vaccines for Children (VFC) Program (1) The Division of Medical Assistance Programs (Division) will reimburse Federally Qualified Health Centers (FQHCs) and Rural Health Clinics (RHCs) for the administration of vaccines to eligible clients. (2) The VFC program suppli…

410-147-0200 Maternity Case Management Services (1) The Division of Medical Assistance Programs (Division) will reimburse federally qualified health centers (FQHCs) and rural health clinics (RHCs) for maternity case management (MCM) services. (2) MCM service is optional coverage …

410-147-0240 Administrative Medical Examinations and Reports (1) The Division of Medical Assistance Programs (Division) does not reimburse Administrative Medical Examinations and Reports at a clinic’s encounter rate. Division reimburses providers for Administrative Examinations a…

410-147-0260 Death With Dignity (1) Death With Dignity is a covered service, except for those facilities limited by the Assisted Suicide Funding Restriction Act of 1997 (ASFRA), and is incorporated in the “comfort care” condition/treatment line on the Health Services Commission’s…

410-147-0280 Drugs (1) As defined by the Division of Medical Assistance Programs (Division), a valid Federally Qualified Health Center (FQHC) or Rural Health Clinic (RHC) encounter excludes pharmaceutical or biologicals not generally provided during a clinic visit. Refer to OAR 4…

410-147-0320 Federally Qualified Health Center Rural Health Clinics Enrollment (1) This rule outlines the Division of Medical Assistance Programs (Division) enrollment requirements for Federally Qualified Health Centers (FQHC) and Rural Health Clinics (RHC) (Refer also to OAR 410…

410-147-0340 Federally Qualified Health Centers and Rural Health Clinics Provider Numbers (1) Pursuant to National Provider Identifier (NPI) requirements in 45 CFR Part 162 providers must use a NPI, and in specific situations associated taxonomy code(s), when billing the Division…

410-147-0360 Encounter Rate Determination (1) The Division of Medical Assistance Programs (Division) will coincide enrollment of a Federally Qualified Health Center (FQHC) or Rural Health Clinic (RHC) with the calculation of a clinic’s Prospective Payment System (PPS) encounter r…

410-147-0362 Change in Scope of Services (1) As required by 42 USC § 1396a(bb)(3)(B), the Division of Medical Assistance Programs (Division) must adjust Federally Qualified Health Centers (FQHCs) and Rural Health Clinics (RHCs) Prospective Payment System (PPS) encounter rates bas…

410-147-0365 Rural Health Clinic Obstetrics Care Delivery Procedures Reimbursement Reimbursement for obstetric delivery procedures by the Division of Medical Assistance Programs (Division) to eligible Medicare-certified Independent RHCs will be according to the physician fee sche…

410-147-0380 Accounting and Record Keeping (1) General Requirements: (a) The following rules and regulations apply to clinics reimbursed under the Federally Qualified Health Center (FQHC) and Rural Health Clinic Program; (b) In cases of conflict between the rules contained in sec…

410-147-0400 Compensation for Outstationed Outreach Activities (1) This rule provides reasonable compensation for activities directly related to the receipt and initial processing of applications for individuals, including low-income pregnant women and children, to apply for Medi…

410-147-0420 Rebasing (1) Determination of encounter rates effective January 1, 2001 as directed by the Balanced Budget Act (BBA) of 1997 and the Budget Refinement Act of 1999 Prospective Payment System (PPS) was changed for Federally Qualified Health Center (FQHC) and Rural Heal…

410-147-0440 Medicare Economic Index (MEI) Effective January 1, 2001, as directed by the Balanced Budget Act of 1997, the Budget Refinement Act of 1999 Prospective Payment System (PPS), and BIPA all encounter rates must be adjusted annually by the Medicare Economic Index (MEI) fo…

410-147-0460 Prepaid Health Plan Supplemental Payments (1) Effective January 1, 2001, the Division of Medical Assistance Programs (Division) is required by 42 USC 1396a(bb), to make supplemental payments to eligible federally qualified health centers (FQHC) and rural health clini…

410-147-0480 Cost Statement Instructions (1) The Division of Medical Assistance Programs (Division) requires federally qualified health centers (FQHC) to submit Cost Statements (DMAP 3027). (2) Rural health clinics (RHCs) can choose to submit either their Medicare Cost Report or …

410-147-0500 Total Encounters for Cost Reports (1) Federally Qualified Health Centers and Rural Health Clinics (FQHC/RHCs) are required to report the total number of encounters for furnishing services outlined in 42 USC 1396d(a)(2)(C) and 1396d(a)(2)(B), respectively. (2) In gene…

410-147-0520 Depreciation Office of Management and Budget (OMB) Circular A-87 and A-122, Section 13 is applicable with the following exception: depreciation and amortization must be calculated on a straight line basis less the estimated salvage value. The clinic must use the Amer…

410-147-0540 Related Party Transactions (1) A “related party” is an individual or organization that is associated or affiliated with, or has control of, or is controlled by the federally qualified health center (FQHC) or rural health clinic (RHC) furnishing the services, faciliti…

410-147-0560 Sanctions (1) Providers are directed to Division of Medical Assistance Programs' General Rules OARs 410-120-1400 Provider Sanctions and 410-120-1460 Type and Conditions of Sanctions and Oregon Health Authority OAR 943-120-0360 Consequences of Non-Compliance and Provi…

410-148-0000 Foreword (1) The Home Enteral/Parenteral Nutrition and IV Services rules are a user's manual designed to assist providers in preparing health claims for medical assistance program clients. The Home Enteral/Parenteral Nutrition and IV Services provider rules are to be…

410-148-0020 Home Enteral/Parenteral Nutrition and IV Services (1) The Division shall make payment for medically appropriate and medically necessary goods, supplies, and services for home enteral/parenteral nutrition and IV therapy on written order or prescription. (a) The order …

410-148-0040 Requirements for Home Enteral/Parenteral Nutrition and IV Services (1) Home Enteral/Parenteral Nutrition and IV Services: (a) Home enteral/parenteral nutrition and IV services must include training and/or education of client or support person on nutritional supplemen…

410-148-0060 Authorization (1) The Division requires authorization of payment for the following items or services: (a) All nursing service visits, except the assessment nursing visit, associated with home enteral/parenteral nutrition or IV services; (b) All oral formula and nutri…

410-148-0080 Equipment Rental/Purchase/Repair (1) The following equipment shall be covered, if medically appropriate and when cost effective, on a rental basis only: (a) IV/Parenteral nutrition infusion pumps; (b) Enteral nutrition infusion pumps; (2) The equipment provider is re…

410-148-0100 Reimbursement (1) Drug ingredients (medications) shall be reimbursed as defined in the Division of Pharmaceutical Services administrative rules (chapter 410, division 121). (2) The following service/goods shall be reimbursed on a fee-for-service basis according to th…

410-148-0120 Reimbursement Limitations for Clients in a Nursing Facility (1) The Division of Medical Assistance Programs (Division) will not reimburse for the following services/supplies for clients residing in a nursing facility: (a) Nursing service visits (including assessment …

410-148-0140 Billing Information (1) For medications: (a) Pharmacies billing electronically bill through the Division of Medical Assistance Program (Division) pharmacy benefit manager, point of sale. For more information on point of sale, contact the Division’s pharmacy benefit m…

410-148-0160 Billing for Clients Who Have Both Medicare and Basic Health Care Coverage (1) The Division of Medical Assistance Programs (Division) may be billed directly for services provided to a client when the provider has established and clearly documented in the client's reco…

410-148-0260 Home Enteral Nutrition (1) Indications and limitations of coverage and medical appropriateness: The Division may cover home enteral formula, oral nutritional supplements, equipment, supplies, and services for clients of any age. Refer to Table 148-0260-1 and the foll…

410-148-0280 Home Parenteral Nutrition (1) Codes that have "PA" indicated require prior authorization. Codes with "BR" indicated are covered by report. (2) Standard Total Parenteral Nutrition (TPN): (a) Bill using Healthcare Common Procedure Coding System (HCPCS) codes S9365 thro…

410-148-0300 Other Home IV and Enteral/Parenteral Administration Services (1) Codes that have "PA" indicated require prior authorization. Codes with "BR" indicated are covered by report. (2) Catheter Care Kits. All catheter care kit allowable amounts are determined on a per diem …

410-148-0320 Billing Quantities, Metric Quantities and Package Sizes (1) Use the following metric conversions when billing; (a) Fluid Ounce — 30 ml; (b) Pint — 480 ml; (c) Quart — 960 ml; (d) Gallon — 3,840 ml; (e) Ounce (solids) — 30 gm; (f) Pound (solids) — 454 gm. (2) Use the …