Or. Admin. Code § 410-122-0010 - Definitions
In addition to the definitions in OAR 410-120-0000, the following definitions in these rules apply:
(1)
"Activities of Daily Living (ADL's)" means activities related to personal care
including, but not limited to, tasks such as eating, toileting, grooming,
dressing, and bathing that are necessary to maintain or improve the client's
health.
(2) "Buy-up" means a
situation in which a client wants to upgrade to a higher level of service than
he or she is eligible for; e.g., a heavy-duty walker instead of a standard
walker.
(3) "Consecutive Months"
means any period of continuous use where no more than a 60-day break
occurs.
(4) "Durable Medical
Equipment" means equipment and appliances that are primarily and customarily
used to serve a medical purpose, generally are not useful to an individual in
the absence of a disability, illness or injury, can withstand repeated use, can
be reusable or removable, and is appropriate for use in any non-institutional
setting in which normal life activities take place. Some examples include
wheelchairs, crutches, and hospital beds.
(5) "Division" means the Health Systems
Division within the Authority. The Division is responsible for coordinating the
medical assistance programs within the State of Oregon including the Oregon
Health Plan (OHP) Medicaid demonstration, the State Children's Health Insurance
Program (SCHIP-Title XXI), and several other programs.
(6) "EPSDT" means the Early and Periodic
Screening, Diagnostic and Treatment program which provides comprehensive and
preventive health care services to OHP clients under the age of 21 in
accordance with federal regulations and as defined in OAR 410, Division
151.
(7) "Home" for purposes of
purchase, rental, and repair of durable medical equipment (DME) means a place
of permanent residence such as an assisted living facility, 24-hour residential
care facility, adult foster home, child foster home, or a private home. This
does not include hospitals, nursing facilities, intermediate care facilities
for individuals with intellectual disabilities, any setting that exists
primarily for the purpose of providing medical/nursing care, or any setting in
which payment is or could be made under Medicaid for inpatient services that
include room and board. Separate payment may not be made to DME providers for
equipment and medical supplies provided to a client when the cost of such items
is already included in the capitated (per diem) rate paid to a facility or
organization.
(8) "Lifetime Need"
means 99 months or more.
(9)
"Manufacturer Part Number (MPN)" means:
(a)
Each manufacturer provides an MPN to identify that manufacturer's part. It is a
specification used by the manufacturer to store a part in an illustrated part
catalog (graphics and text).
(b) An
MPN uniquely identifies a part when used together with manufacturer code
(external manufacturer), which is the own name used by the manufacturer and not
the manufacturer name provided by other.
(10) "Medical Records" means the
practitioner's office records, hospital records, nursing facility records, home
health agency records, records from other healthcare professionals, and
diagnostic and test reports. This documentation must be made available to the
Health Systems Division (Division) upon request.
(11) "Medical Supplies" means health care
related items that are consumable or disposable or cannot withstand repeated
use by more than one individual, that are required to address an individual
medical disability, illness, or injury. Examples of medical supplies include
diapers, syringes, gauze bandages, and tubing.
(12) "Medically Appropriate" has the meaning
given that term in OAR
410-120-0000 for clients age 21
and older and OAR 410-151-0001 for clients under
age 21.
(13) "Medically Necessary"
has the meaning given that term in OAR
410-120-0000 for clients over
the age of 21 and OARR
410-151-0001 for clients under
age 21.
(14) "Mobility-related
Activities of Daily Living (MRADL's)" means personal care activities including,
but not limited to, tasks such as toileting, eating, dressing, grooming, and
bathing.
(15) "Morbidity" means a
diseased state, often used in the context of a "morbidity rate" (i.e., the rate
of disease or proportion of diseased people in a population). In common
clinical usage, any disease state including diagnosis and complications is
referred to as morbidity.
(16)
"Morbidity Rate" means the rate of illness in a population. The number of
people ill during a time period is divided by the number of people in the total
population.
(17) "The Division
Maximum Allowable Rate" means the maximum amount paid by the Division for a
service.
(18) "Practitioner" means
an individual licensed pursuant to federal and state law to engage in the
provision of health care services within the scope of the practitioner's
license and certification. For ordering and provision of durable medical
equipment, prosthetics, orthotics and medical suppliers this includes both
physicians and non-physician practitioners (i.e., physician associate, nurse
practitioners, and certified nurse specialists) as defined in section 1861 of
the Social Security Act).
(19)
"Prosthetic and Orthotic Devices" means devices that replace all or part of an
internal body organ, including ostomy bags and supplies directly related to
ostomy care and replacement of such devices and supplies. Prosthetic and
orthotic devices also include leg, arm, back, and neck braces, and artificial
legs, arms, and eyes, including replacements if required because of a change in
the client's physical condition.
(20) "Purchase price" means:
(a) Delivery;
(b) Assembly;
(c) Adjustments, if needed; and
(d) Training in the use of the equipment or
supply.
(21) "Rental
fees" means:
(a) Delivery;
(b) Training in the use of the
equipment;
(c) Pick-up;
(d) Routine service, maintenance, and repair;
and
(e) Moving equipment to a new
residence, if coverage is to continue.
(22) "Technician" means a DMEPOS provider
staff professionally trained through product or vendor-based training,
technical school training (e.g., electronics), or through apprenticeship
programs with on-the-job training.
(23) "Licensed Practitioner of the Healing
Arts (LPHA)" means a physician or other practitioner licensed in the State of
Oregon who is authorized within the scope of the LPHA's practice, as defined
under state law, to diagnose and treat individuals with physical or mental
disabilities or psychosocial, emotional, and behavioral disorders.
Notes
Statutory/Other Authority: ORS 413.042 & 414.065
Statutes/Other Implemented: 414.065
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