Or. Admin. R. 410-148-0100 - Reimbursement
(1) Drug
ingredients (medications) shall be reimbursed as defined in the Division of
Medical Assistance Programs (Division) Pharmaceutical Services administrative
rules (chapter 410, division 121).
(2) The following service/goods shall be
reimbursed on a fee-for-service basis according to the Division EPIV Fee
Schedule found in the Home Enteral/Parenteral Nutrition and IV Services on the
Division website:
(a) Enteral
formula;
(b) Oral nutritional
supplements which are medically appropriate and meet the criteria specified in
410-148-0260;
(c) Parenteral
nutrition solutions;
(3)
Reimbursement for services shall be based on the lesser of the amount billed,
or the Division maximum allowable rate. When the service is covered by
Medicare, reimbursement shall be based on the lesser of the amount billed,
Medicare's allowed amount, or the Division maximum allowable rate.
(4) Reimbursement for supplies that require
authorization or services/supplies that are listed as Not Otherwise Classified
(NOC) or By Report (BR) must be billed to the Division at the providers'
acquisition cost, and shall be reimbursed at such rate.
(a) For purposes of this rule, Acquisition
Cost is defined as the actual dollar amount paid by the provider to purchase
the item directly from the manufacturer (or supplier) plus any shipping and/or
postage for the item. Submit documentation identifying acquisition cost with
your authorization request;
(b) Per
diem, as it relates to reimbursement, represents each day that a given patient
is provided access to a prescribed therapy. This definition is valid for per
diem therapies of up to and including every 72 hours.
(c) Per diem reimbursement includes, but is
not limited to:
(A) Professional pharmacy
services:
(i) Initial and ongoing
assessment/clinical monitoring;
(ii) Coordination with medical professionals,
family and other caregivers;
(iii)
Sterile procedures, including IV admixtures, clean room upkeep and all
biomedical procedures necessary for a safe environment;
(iv) Compounding of medication/medication
set-up.
(B) Infusion
therapy related supplies:
(i) Durable,
reusable or elastomeric disposable infusion pumps;
(ii) All infusion or other administration
devices;
(iii) Short peripheral
vascular access devices;
(iv)
Needles, gauze, sterile tubing, catheters, dressing kits, and other supplies
necessary for the safe and effective administration of infusion
therapy.
(C)
Comprehensive, 24-hour per day, seven (7) days per week delivery and pickup
services (includes mileage).
(5) Reimbursement shall not be made for the
following:
(a) Central catheter insertion or
transfusion of blood/blood products in the client's home;
(b) Central catheter insertion in the nursing
facility;
(c) Intradialytic
parenteral nutrition in the client's home or Nursing Facility;
(d) Oral formula that is not covered by the
Oregon Health Plan (OHP) and available through the Women's, Infant and Children
(WIC) program. For covered formulas, OHP is the first payer before
WIC;
(e) Oral nutritional
supplements that are in addition to consumption of food items or
meals.
(f) Tocolytic pumps for
pre-term labor management;
(g) Home
enteral/parenteral nutrition or IV services outside of the client's place of
residence (i.e. home, nursing facility or AIS).
Notes
Statutory/Other Authority: ORS 413.042
Statutes/Other Implemented: ORS 414.065
State regulations are updated quarterly; we currently have two versions available. Below is a comparison between our most recent version and the prior quarterly release. More comparison features will be added as we have more versions to compare.
(1) Drug ingredients (medications) shall be reimbursed as defined in the Division of Medical Assistance Programs (Division) Pharmaceutical Services administrative rules (chapter 410, division 121).
(2) The following service/goods shall be reimbursed on a fee-for-service basis according to the Division EPIV Fee Schedule found in the Home Enteral/Parenteral Nutrition and IV Services on the Division website:
(a) Enteral formula;
(b) Oral nutritional supplements which are medically appropriate and meet the criteria specified in 410-148-0260;
(c) Parenteral nutrition solutions;
(3) Reimbursement for services shall be based on the lesser of the amount billed, or the Division maximum allowable rate. When the service is covered by Medicare, reimbursement shall be based on the lesser of the amount billed, Medicare's allowed amount, or the Division maximum allowable rate.
(4) Reimbursement for supplies that require authorization or services/supplies that are listed as Not Otherwise Classified (NOC) or By Report (BR) must be billed to the Division at the providers' acquisition cost, and shall be reimbursed at such rate.
(a) For purposes of this rule, Acquisition Cost is defined as the actual dollar amount paid by the provider to purchase the item directly from the manufacturer (or supplier) plus any shipping and/or postage for the item. Submit documentation identifying acquisition cost with your authorization request;
(b) Per diem, as it relates to reimbursement, represents each day that a given patient is provided access to a prescribed therapy. This definition is valid for per diem therapies of up to and including every 72 hours.
(c) Per diem reimbursement includes, but is not limited to:
(A) Professional pharmacy services:
(i) Initial and ongoing assessment/clinical monitoring;
(ii) Coordination with medical professionals, family and other caregivers;
(iii) Sterile procedures, including IV admixtures, clean room upkeep and all biomedical procedures necessary for a safe environment;
(iv) Compounding of medication/medication set-up.
(B) Infusion therapy related supplies:
(i) Durable, reusable or elastomeric disposable infusion pumps;
(ii) All infusion or other administration devices;
(iii) Short peripheral vascular access devices;
(iv) Needles, gauze, sterile tubing, catheters, dressing kits, and other supplies necessary for the safe and effective administration of infusion therapy.
(C) Comprehensive, 24-hour per day, seven (7) days per week delivery and pickup services (includes mileage).
(5) Reimbursement shall not be made for the following:
(a) Central catheter insertion or transfusion of blood/blood products in the client's home;
(b) Central catheter insertion in the nursing facility;
(c) Intradialytic parenteral nutrition in the client's home or Nursing Facility;
(d) Oral formula that is not covered by the Oregon Health Plan (OHP) and available through the Women's, Infant and Children (WIC) program. For covered formulas, OHP is the first payer before WIC;
(e) Oral nutritional supplements that are in addition to consumption of food items or meals.
(f) Tocolytic pumps for pre-term labor management;
(g) Home enteral/parenteral nutrition or IV services outside of the client's place of residence (i.e. home, nursing facility or AIS).
Notes
Statutory/Other Authority: ORS 413.042
Statutes/Other Implemented: ORS 414.065