Or. Admin. Code § 410-120-1340 - Payment
(1) The Division
shall make payment only to the enrolled provider (see OAR
410-120-1260) who actually
performs the service or to the provider's enrolled billing provider for covered
services rendered to eligible clients.
(2) Division reimbursement for services may
be subject to review prior to reimbursement.
(3) The Division sets fee-for-service (FFS)
payment rates for the billed services or items. The FFS payment rates are the
Division's maximum allowable rates for billed services or items.
(4) The Division reimburses providers for
billed services or items at the lesser of:
(a) The amount billed;
(b) The Division's FFS payment rate in effect
on the date of service; or
(c) The
rate specified in the individual program provider rules.
(5) The amount billed may not exceed the
provider's "usual charge" (see definitions OAR
410-120-0000).
(6) The Division's maximum allowable rate
setting process uses the following methodology for:
(a) Relative Value Unit (RVU) weight-based
rates. The Division updates all CPT/HCPCS codes assigned an RVU weight
effective January 1 of each year, based on the annual RVU updates published in
the Federal Register:
(A) The Division applies
RVU weights as follows:
(i) The Non-Facility
Total RVU weight, to professional services not typically performed in a
facility;
(ii) The Facility Total
RVU weight, to professional services typically performed in a
facility.
(B) The
Division applies the following conversion factors:
(i) $40.79 for labor and delivery codes
(59400-59622);
(ii) $38.76 for
neonatal intensive care and pediatric intensive care professional service codes
(99468-99480);
(iii) $28.50 for
Oregon primary care providers. A current list of primary care CPT, HCPCs, and
provider types and specialties ("Oregon Primary Care Providers and Procedure
Codes") is available at
http://www.oregon.gov/OHA/HSD/OHP/Pages/Providers.aspx;
(iv) $27.11 for all remaining RVU
weight-based CPT/HCPCS codes.
(C) The Division calculates rates using
statewide Geographic Practice Cost Indices (GPCIs) as follows:
(i) (Work RVU) X (Work GPCI) + (Practice
Expense RVU) X (Practice GPCI) + (Malpractice RVU) X (Malpractice GPCI). The
formula used to create the statewide GPCI is (3*(Portland GPCI) + 33* (Rest of
State GPCI))/36 = GPCI.
(ii) The
sum in paragraph (C)(i) is multiplied by the applicable conversion factor in
section (B) to calculate the rate;
(b) Non-RVU-weight-based rates:
(A) $21.12 is the base rate for anesthesia
service codes 00100-01996. The rate is based on per unit of service;
(B) Clinical lab codes are 80 percent of the
Medicare clinical lab fee schedule effective on the date of service;
(C) All approved Ambulatory Surgical Center
procedures are 80 percent of the Medicare fee schedule effective on the date of
service;
(D) Physician-administered
drugs billed under a HCPCS code are 100 percent of the Medicare rate;
(i) When no Medicare rate is available, the
rate is based upon the Wholesale Acquisition Cost (WAC) provided by First Data
Bank;
(ii) If no WAC is available,
then the rate is the Acquisition Cost. These rates may change periodically
based on drug costs;
(c) All procedures used for vision materials
and supplies are contracted rates that include acquisition cost plus shipping
and handling;
(d) Individual
provider rules may specify rates for particular services or items.
(7) The Division reimburses
inpatient hospital services under the DRG methodology, unless specified
otherwise in the Hospital Services program administrative rules (chapter 410,
division 125). Reimbursement for services, including claims paid at DRG rates,
may not exceed any upper limits established by federal regulation.
(8) The Division reimburses all out-of-state
hospital services at Oregon DRG or FFS rates as published in the Hospital
Services program rules (chapter 410, division 125) unless the hospital has a
contract or service agreement with the Division to provide highly specialized
services.
(9) Payment rates for
in-home services provided through Oregon Department of Human Services
(Department) Aging and People with Disabilities (APD) may not exceed the costs
of nursing facility services unless the criteria in OAR
411-027-0020 have been
met.
(10) For services provided by
out-of-state institutions and facilities such as skilled nursing care
facilities, psychiatric facilities and rehabilitative care facilities, the
Division sets rates that are:
(a) Consistent
with the rate for similar services provided in Oregon; and
(b) The lesser of the rate paid to the most
similar licensed Oregon facility or the rate paid by the other state's Medicaid
program; or
(c) Consistent with the
rate established by APD for out-of-state nursing facilities.
(11) The Division may not make
payment on the following claims:
(a) Assigned,
sold or otherwise transferred claims; or
(b) Claims where the billing provider,
billing agent, or billing service receives a percentage of the amount billed,
amount collected or payment authorized. This includes, but is not limited to,
claims transferred to a collection agency or individual who advances money to a
provider for accounts receivable.
(12) Nursing facility payments:
(a) The Division may not make a separate
payment to a nursing facility or other provider for services included in the
nursing facility's all-inclusive rate (OAR
411-070-0085).
(b) The following services are not in the
all-inclusive rate and may be reimbursed separately:
(A) Legend drugs, biologicals and
hyperalimentation drugs and supplies, and enteral nutritional formula as
addressed in the Pharmaceutical Services program administrative rules (chapter
410, division 121) and Home Enteral/Parenteral Nutrition and IV Services
program administrative rules (chapter 410, division 148);
(B) Physical therapy, speech therapy, and
occupational therapy provided by a non-employee of the nursing facility within
the appropriate program administrative rules (chapter 410, division 129 and
131);
(C) Continuous oxygen that
exceeds 1,000 liters per day by lease of a concentrator or concentrators as
addressed in the Durable Medical Equipment, Prosthetics, Orthotics and Supplies
program administrative rules (chapter 410, division 122);
(D) Influenza immunization serum as described
in the Pharmaceutical Services program administrative rules (chapter 410,
division 121);
(E) Podiatry
services provided under the rules in the Medical-Surgical Services program
administrative rules (chapter 410, division 130);
(F) Medical services provided by a physician
or other provider of medical services, such as radiology and laboratory, as
outlined in the Medical-Surgical Services program rules (chapter 410, division
130);
(G) Certain custom fitted or
specialized equipment as specified in the Durable Medical Equipment,
Prosthetics, Orthotics and Supplies program administrative rules (chapter 410,
division 122).
(13) The Division reimburses hospice services
based on CMS Core-Based Statistical Areas (CBSAs). A separate payment may not
be made for services included in the core package of services as outlined in
chapter 410, division 142.
(14) For
payment for Division clients with Medicare and full Medicaid:
(a) The Division limits payment to the
Medicaid allowed amount, less the Medicare payment, up to the Medicare
co-insurance and deductible, whichever is less. The Division's payment may not
exceed the co-insurance and deductible amounts due;
(b) The Division pays the allowable rate for
covered services that are not covered by Medicare.
(15) For clients with third-party resources
(TPR), the Division pays the allowed rate less the TPR payment but not to
exceed the billed amount.
(16) The
Division payments including contracted Managed Care Entity (MCE) payments,
unless in error, constitute payment in full, except in limited instances
involving allowable spend-down. For the Division, payment in full includes:
(a) Zero payments for claims when a third
party or other resource has paid an amount equivalent to or exceeding Division
allowable payment; and
(b) Denials
of payment for failure to submit a claim in a timely manner, failure to obtain
payment authorization in a timely and appropriate manner, or failure to follow
other required procedures identified in the individual provider
rules.
(17) Payment by
the Division does not restrict or limit the Authority or any state or federal
oversight entity's right to review or audit a claim before or after the
payment. Claim payment may be denied or subject to recovery if medical review,
audit, or other post-payment review determines the service was not provided in
accordance with applicable rules or does not meet the criteria for quality of
care or medical appropriateness of the care or payment.
Notes
Statutory/Other Authority: ORS 413.042
Statutes/Other Implemented: ORS 414.025, 414.033, 414.065, 414.095, 414.727, 414.728, 414.742 & 414.743
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