Oregon Administrative Code

410-150-0005 Purpose The Administrative Examination and Report rules are provided for use in conjunction with the General Rules of the Division of Medical Assistance Programs (DMAP) to assist providers in completing examinations requested and in preparing claims for administrativ…

410-150-0010 Definitions (1) Administrative Examination – A medical or psychological evaluation required by the Department of Human Services (DHS), Oregon Health Authority (OHA), or Oregon Youth Authority (OYA) to assist in determining eligibility and for casework planning for va…

410-150-0040 Request Requirements (1) A completed OHP 729 Administrative Medical Examination/Report Authorization is the prior authorization needed to perform an administrative examination, complete supplemental forms, or send copies of records. (a) Only the version of the OHP 72…

410-150-0070 Billing Instructions for Administrative Examinations (1) When an examination is needed, administrative examination codes are authorized by the branch office. (2) Medical and ancillary services providers must bill using the Provider Web Portal at https://www.or-medica…

410-150-0090 Billing Instructions - Licensed Polygraphist (1) Billing for licensed polygrapher services must be submitted using the Provider Web Portal at https://www.or-medicaid.gov or on a CMS-1500, mailed to the address listed on the OHP 729. (2) A polygraph does not qualify a…

410-151-0000 Early and Periodic Screening, Diagnostic and Treatment Program (1) The Early and Periodic Screening, Diagnostic and Treatment (EPSDT) program offers comprehensive and preventive health care services to EPSDT Beneficiaries in accordance with 42 CFR § 441 Subpart B. EP…

410-151-0001 Definitions. The definitions in this rule apply to the Early and Periodic Screening, Diagnostic and Treatment (EPSDT) program only. (1) “EPSDT Dentally Appropriate” (a) Means dental services, items, or dental supplies that are: (A) Recommended by a licensed health pr…

410-151-0002 Coverage Requirements (1) The coverage requirements for services to EPSDT Beneficiaries set forth in this Rule supersede any other coverage standards or requirements set forth in any other Medical Assistance rules that are applicable to non-EPSDT Beneficiaries, regar…

410-151-0003 Utilization Management Requirements (1) The Oregon Health Authority (Authority) and Managed Care Entities (MCEs) do not have the right to pre-establish limits or caps on the amount of services or number of visits covered for EPSDT Beneficiaries. Instead, coverage dec…

410-151-0004 Screening Exams (1) Periodic EPSDT screening exams shall be provided in accordance with the Bright Futures Periodicity Schedule (https://downloads.aap.org/AAP/PDF/periodicity_schedule.pdf) and must include: (a) A comprehensive health and developmental history includi…

410-151-0005 Referrals (1) When a medical, behavioral health, nutritional, or dental condition is discovered during the EPSDT screening process, the EPSDT Beneficiary shall be referred to an appropriate provider for further diagnosis and, when EPSDT Medically Necessary and EPSDT …

410-151-0006 Transportation and scheduling assistance In accordance with the responsibilities in OAR 410-136-3000 Medical Transportation Services, the Authority or the MCE must offer and provide, when requested by the EPSDT Beneficiary or their parent or guardian: (1) Transportat…

410-151-0007 Notice and hearing requirements. If the Authority or an MCE takes action to deny, suspend, reduce or terminate services for an EPSDT Beneficiary, it must provide the EPSDT Beneficiary, and, as applicable, the EPSDT Beneficiary’s parent or guardian, with a written not…

410-151-0008 EPSDT Beneficiary communication requirements The Authority and MCEs must notify EPSDT Beneficiaries and, as applicable, the EPSDT Beneficiary’s parent or guardian, about services covered under EPSDT and how to access them, in accordance with a guidance document which…

410-151-0040 Lead Screening (1) All children enrolled in the Oregon Health Plan, including Fee-for-Service and MCEs, must have blood lead screening tests. Children with Medical Assistance Program coverage must have blood lead screening tests at age 12 months and 24 months. Any ch…

410-152-0000 Purpose (1) Community Violence Prevention services are evidence-based, trauma-informed, supportive, and non-psychotherapeutic services provided by a certified Violence Prevention Professional. (2) Services are provided within or outside of a clinical setting for the …

410-152-0005 Violence Prevention Professional Certification Requirements. To be certified as a Violence Prevention Professional, an individual shall: (1) Be employed by a community-based organization who is enrolled with the Oregon Health Authority as a Medicaid billing provider.…

410-152-0010 Definitions. (1) “Authority” means the Oregon Health Authority. (2) “Certification” means the national training and program credentials to be certified as a Violence Prevention Professional. (3) “Certified Violence Prevention Professionals” mean mentors, violence int…

410-152-0015 Community Violence Prevention Services. (1) All Community Violence Prevention services provided by a community violence prevention program shall be performed by a certified Violence Prevention Professional. (2) Community Violence Prevention services performed by a ce…

410-152-0020 Documentation Requirements. (1) The Plan of Care shall include the individuals need for: safety planning, interest in employment, housing, education, mental health and substance abuse treatment services, gang affiliation, legal needs and history of injury within the …

410-152-0025 Eligibility Requirements. (1) To be eligible to receive Community Violence Prevention services performed by a certified Violence Prevention Professional the individual shall: (a) be enrolled in the Oregon Health Plan; (b) have a history of injury sustained because of…

410-152-0030 Limitations. (1) Community Violence Prevention Services are not covered for individuals: (a) Solely treated for intimate partner violence; (b) Identified as a family member, friend, or associate of the individual receiving the service, and does not meet eligibility r…

410-153-0000 Purpose and Scope These rules define the requirements for Certified Community Behavioral Health Clinic (CCBHC) reimbursement through a bundled daily rate, cost reporting, rebasing, change in scope, and oversight for services provided to Oregon Health Plan members by …

410-153-0005 Definitions (1) “Access facility” means an outpatient setting owned and operated by a CCBHC and subject to approval by the Authority that provides low barrier services that facilitate engagement and access to care within the scope of CCBHC. Access facilities offer un…

410-153-0010 Provider Requirements (1) To qualify for payment under these rules, a provider must: (a) Be certified by Oregon Health Authority (Authority) as a Certified Community Behavioral Health Clinic (CCBHC), Oregon Administrative Rule (OAR) chapter 309, division 009; (b) Mai…

410-153-0015 Eligibility and Enrollment Requirements (1) Certified Community Behavioral Health Clinics (CCBHC) must: (a) Be enrolled and have a signed provider enrollment agreement as a Medicaid provider prior to CCBHC certification; (b) Obtain and maintain certification by Orego…

410-153-0020 Required Services (1) Certified Community Behavioral Health Clinics (CCBHC) must follow the Oregon Administrative Rules (OAR) chapter 410, division 120 and division 141 coverage rules applicable to each service in section (2) below. (2) CCBHCs are reimbursed by the A…

410-153-0025 Designated Collaborating Organization (1) Designated Collaborating Organization are entities that are not under the direct supervision of a CCBHC but engage in a contractual agreement with a Certified Community Behavioral Health Clinic (CCBHC) to provide CCBHC servic…

410-153-0030 Eligibility for Payment (1) Certified Community Behavioral Health Clinics (CCBHC) must bill the clinic-specific bundled daily rate when at least one qualifying CCBHC service, as these services are described in Oregon Administrative Rules (OAR) 410-153-0020, is provid…

410-153-0035 Bundled Daily Rate Establishment (1) Oregon Health Authority (Authority) establishes an initial interim bundled daily rate for each Certified Community Behavioral Health Clinic (CCBHC) based on projected allowable costs and projected CCBHC daily encounters or based o…

410-153-0040 Cost Reporting Requirements (1) Each Certified Community Behavioral Health Clinic (CCBHC) must submit a cost report on forms prescribed by Oregon Health Authority (Authority), identifying: (a) Total allowable direct and indirect costs; and (b) Total number of Medicai…

410-153-0045 Cost Reconciliation and Settlement (1) Oregon Health Authority (Authority) performs reconciliation following the establishment of a new bundled daily rate by comparing payments made under previous bundled daily rate to newly established bundled daily rate. (2) If the…

410-153-0050 Scope of Service Changes (1) A Certified Community Behavioral Health Clinic (CCBHC) may submit a written request to the Oregon Health Authority (Authority) for an adjustment to its bundled daily rate if there is a documented scope of service change that results in at…

410-153-0055 Rebasing Requirements (1) Oregon Health Authority (Authority) must rebase each Certified Community Behavioral Health Clinic’s (CCBHC) bundled daily rate no less frequently than once every two (2) years based on finalized cost reports and actual encounter data. (2) Th…

410-153-0060 Annual Inflation Adjustment Using MEI The Authority will adjust for inflation annually, trending each clinic-specific from the mid-point of the previous calendar year to the midpoint of the following year using the Medicare Economic Index (MEI). Statutory/Other Autho…

410-153-0065 Coordinated Care Organization (CCO) Payments and Supplemental (Wraparound) Payments (1) Certified Community Behavioral Health Clinics (CCBHCs) must bill the applicable CCO for services provided to members enrolled in a CCO. CCOs are not required to pay CCBHCs at thei…

410-153-0070 Fee-for-Service Payments Certified Community Behavioral Health Clinics (CCBHC) must bill the Oregon Health Authority directly for CCBHC daily encounters with fee-for-service Oregon Health Plan members using the clinic's bundled daily rate. Statutory/Other Authority: …

410-153-0075 CCBHC Daily Encounter Definitions and Billing (1) A Certified Community Behavioral Health Clinic (CCBHC) submitting a claim or other request for payment to Oregon Health Authority (Authority) or a Coordinated Care Organization (CCO) must meet the requirements in Oreg…

410-153-0080 Program Integrity and Audit Compliance (1) Certified Community Behavioral Health Clinics (CCBHC) are subject to audits and other reviews by the Oregon Health Authority (Authority) under Oregon Administrative Rules (OAR) chapter 410, division 120. (2) The CCBHC must s…

410-153-0085 Appeals (1) Certified Community Behavioral Health Clinics (CCBHC) may appeal Oregon Health Authority (Authority) adverse actions relating to bundled daily rate setting, cost reconciliation, scope of service adjustments, or supplemental payment determinations. (2) CCB…

410-155-0000 Acronyms and Definitions (1) “Adjudication” is when a court process has determined that the eligible individual committed the charged act and the court ordered the eligible individual be held in custody as part of the disposition of the charges. (2) “Correctional Fac…

410-155-0010 Eligibility Criteria and Service Requirements The purpose of this rule is to establish the processes, standards, and obligations required to be followed or met in administering and delivering Reentry FCAA Services, identified below. (1) Reentry FCAA Services must be …

410-160-0000 Definitions For the purposes of OAR 410-160-0000 through 410-160-0100, the following definitions shall apply: (1) LEMLA means the Law Enforcement Medical Liability Account. (2) LEMLA Patient means a person who has suffered injuries related to law enforcement activity…

410-160-0100 Process and Procedure (1) The purpose of the Law Enforcement Medical Liability Account (LEMLA) is to provide a fund to reimburse a claimant for emergency medical services provided to a LEMLA patient. (2) The time limit for submitting claims to LEMLA is one year after…

410-165-0000 Basis and Purpose (1) These rules (OAR chapter 410, division 165) govern the Oregon Health Authority (Authority), Health Systems Division (Division), Medicaid Electronic Health Record (EHR) Incentive Program. The Medicaid EHR Incentive Program provides incentive paym…

410-165-0020 Definitions The following definitions apply to OAR 410-165-0010 through 410-165-0140: (1) “Acceptance Documents” means written evidence supplied by a provider demonstrating that the provider met Medicaid EHR Incentive Program eligibility criteria or participation req…

410-165-0040 Application (1) An eligible provider shall apply to the program each program year that the eligible provider seeks an incentive payment. To apply, an eligible provider or preparer shall: (a) Register with CMS; (b) After registering with CMS, follow the steps as outli…

410-165-0060 Eligibility (1) There are three categories of eligibility criteria: (a) Eligible professionals; (b) Eligible professionals practicing predominately in a FQHC or RHC; and (c) Eligible hospitals. (2) To be eligible for a Medicaid EHR incentive payment for the program y…

410-165-0080 Meaningful Use (1) An eligible provider shall demonstrate being a meaningful EHR user as prescribed by 42 CFR 495.4 (2010, 2012, 2015, 2016, 2017, and 2018), 42 CFR 495.6 (2010, 2012, and 2014), 42 CFR 495.8 (2010, 2012, and 2014), 42 CFR 495.20 (2015), 42 CFR 495.22…

410-165-0100 Participation and Incentive Payments (1) To qualify for an incentive payment, an eligible provider shall meet the Program eligibility criteria and participation requirements for each year the eligible provider applies: (a) An eligible provider shall meet the eligibil…