Or. Admin. Code § 410-122-0080 - Conditions of Coverage, Limitations, and Restrictions
(1) For clients
under the age of 21: The EPSDT program covers all medically necessary and
medically appropriate services needed to correct or ameliorate health
conditions, or to improve the client's ability to grow, develop, or participate
in school, regardless of placement on or inclusion in the Prioritized List of
Health Services. Coverage for medical equipment and supplies shall not be
denied without an individual review for medical necessity and medical
appropriateness, as defined in OAR
410-151-0001.
(2) For clients age 21 and older: The
Division may pay for durable medical equipment, prosthetics, orthotics, and
medical supplies (DMEPOS) when the item meets all criteria in these rules,
including all of the following conditions. The item:
(a) Is approved for marketing and registered
or listed as a medical device by the Food and Drug Administration (FDA), when
FDA approval is required for the item, and is otherwise generally considered to
be safe and effective for the intended purpose. In the event of delay in FDA
approval and registration, the Division shall review purchase options on a
case-by-case basis;
(b) Is
medically appropriate and medically necessary for the client, as defined in OAR
410-120-0000;
(c) Is primarily and customarily used to
serve a medical purpose;
(d) Is
generally not useful to an individual in the absence of medical disability,
illness, or injury;
(e) Is suitable
for use in a client's home or any non-institutional setting in which normal
life activities take place;
(f)
Specifically for durable medical equipment, the item can withstand repeated use
and can be reusable or removable;
(g) Meets the coverage criteria as specified
in this division and subject to service limitations of the Division
rules;
(h) Is requested in relation
to a diagnosis and treatment pair that is above the funding line and consistent
with treatment guidelines on the Health Evidence Review Commission's (HERC)
Prioritized List of Health Services (Prioritized List of Health Services or
List);
(i) Is included in the
Oregon Health Plan (OHP) client's benefit package of covered
services;
(j) Is the least costly,
medically appropriate item that meets the medical needs of the
client;
(k) Coverage is not
restricted to items covered by the Medicare program.
(3) Conditions for Medicare-Medicaid
Services:
(a) If Medicare is the primary payer
and Medicare denies payment, an appeal to Medicare must be filed timely prior
to submitting the claim to the Division for payment. If Medicare denies payment
based on failure to submit a timely appeal, the Division may reduce any amount
the Division determines could have been paid by Medicare;
(b) If Medicare denies payment on appeal, the
Division shall apply DMEPOS coverage criteria in this rule to determine whether
the item or service is covered under the OHP;
(c) Providers are not required to bill
Medicare for items that are statutorily excluded and therefore not recognized
as part of a covered Medicare benefit (e.g., incontinence supplies, bath
equipment, adaptive car seats, standing frames). Prior authorization criteria
for these services/items must still be met.
(4) The Division may not cover DMEPOS items
when the item or the use of the item is:
(a)
Not primarily medical in nature (e.g., personal hygiene items, sporting and
fitness equipment, equipment used with the primary intent to physically
restrain an individual);
(b) For
personal comfort or convenience of the client or caregiver;
(c) A self-help device;
(d) Not therapeutic or diagnostic in
nature;
(e) Used for precautionary
reasons (e.g., pressure-reducing support surface for prevention of decubitus
ulcers);
(f) Inappropriate for
client use in the home or non-institutional setting (e.g., institutional
equipment like an oscillating bed);
(g) For a purpose where the medical
effectiveness is not supported by evidence-based clinical practice guidelines;
or
(h) Reimbursed as part of the
bundled rate in a nursing facility as described in OAR
411-070-0085 or as part of a
home and community-based care waiver service or by any other public, community,
or third-party resource.
(5) Codes that are identified in these rules
or in fee schedules are provided as a mechanism to facilitate payment for
covered items and supplies consistent with OAR
410-122-0186, but codes do not
determine coverage. If prior authorization is required, the request for
reimbursement shall document that prior authorization was obtained in
compliance with the rules in this division.
(6) DMEPOS providers shall have documentation
on file that supports coverage criteria are met.
(7) Billing records shall demonstrate that
the provider has not exceeded any limitations and restrictions in the DMEPOS
rules. The Division may require additional claim information from the provider
consistent with program integrity review processes.
(8) Documentation described in sections (4),
(5), and (6) above shall be made available to the Division upon
request.
(9) The Division fee
schedule provides a list of HCPCS codes that may be covered when criteria are
met. Coverage may be provided for HCPCS codes that do not appear on the fee
schedule with an individual medical appropriateness review as outlined in this
rule.
(10) Some benefit packages do
not cover equipment and supplies (see OAR
410-120-1210, Medical Assistance
Benefit Packages and Delivery System).
(11) Buy-ups are prohibited. Advanced
Beneficiary Notices (ABN) constitute a buy-up and is prohibited. Refer to the
Division General Rules (chapter 410, division 120) for specific rules on buying
up.
(12) Equipment purchased by the
Division for a client becomes the property of the client.
(13) Rental charges starting with the initial
date of service, regardless of payer, apply to the purchase price.
(14) A provider who supplies rented equipment
shall continue furnishing the same item throughout the entire rental period,
except under documented reasonable circumstances.
(15) Before renting, providers must consider
purchase for long-term requirements.
(16) The Division may not pay DMEPOS
providers for medical supplies separately while a client is under a home health
plan of care and covered home health care services.
(17) The Division may not pay DMEPOS
providers for medical supplies separately while a client is under a hospice
plan of care where the supplies are included as part of the written plan of
care and for which payment may otherwise be made by Medicare, the Division, or
other carrier.
(18) Separate
payment may not be made to DMEPOS providers for equipment and medical supplies
provided to a client when the cost of the items is already included in the
capitated (per diem) rate paid to a facility or organization.
(19) Certain specified medical equipment and
supplies require a face-to-face examination as described in these rules
consistent with federal regulations at
42 CFR
440.70. See OAR
410-122-0090 for the
face-to-face requirements.
(20)
Non-contiguous out-of-state DMEPOS providers may seek Medicaid payment only
under the following circumstances:
(a)
Medicare/Medicaid clients:
(A) For Medicare
covered services and then only Medicaid payment of a client's Medicare
cost-sharing expenses for DMEPOS services when all of the following criteria
are met:
(i) Client is a qualified Medicare
beneficiary (QMB);
(ii) Service is
covered by Medicare;
(iii) Medicare
has paid on the specific code. Prior authorization is not required.
(B) Services not covered by
Medicare:
(i) Only when the service or item is
not available in the State of Oregon, and this is clearly substantiated by
supporting documentation from the prescribing practitioner and maintained in
the DMEPOS provider's records;
(ii)
Some examples of services not reimbursable to a non-contiguous out-of-state
provider include but are not limited to incontinence supplies, grab
bars;
(iii) Services billed must be
covered under the OHP;
(iv)
Services provided and billed to the Division shall be in accordance with all
applicable Division rules.
(b) Medicaid-only clients:
(A) For a specific Oregon Medicaid client who
is temporarily outside Oregon and only when the prescribing practitioner has
documented that a delay in service may cause client harm;
(B) For foster care or subsidized adoption
children placed out of state;
(C)
Only when the service or item is not available in the State of Oregon, and this
is clearly substantiated by supporting documentation from the prescribing
practitioner and maintained in the DMEPOS provider's records;
(D) Services billed must be covered under the
OHP;
(E) Services provided and
billed to the Division shall be in accordance with all applicable Division
rules.
(21)
An individual medical appropriateness review shall be conducted by the Division
or CCO on requests for any DMEPOS item, related supplies, or services that are
not already identified as covered by the Division in these rules or the
Division fee schedule:
(a) The DME supplier
must submit clinical documentation from the prescribing practitioner that is
client-specific and demonstrates there is no equally effective, less costly
covered item or service that meets the client's medical needs;
(b) The client's prescribing practitioner
must certify that the less costly alternatives have been tried and failed or
could be reasonably expected to fail or is inappropriate for the
client;
(c) Documentation must
support that the requested item or service is medically appropriate and
medically necessary as defined in OAR
410-120-0000 for clients age 21
and older and 410-151-0001 for clients under
the age of 21;
(d) Requests under
this section for clients enrolled in CCOs shall be directed to the CCO in which
the client is enrolled, in accordance with OAR
410-122-0040(2).
(22) See General Rules OAR
410-120-1200 Excluded Services
and Limitations for more information on general scope of coverage and
limitations.
Notes
Tables referenced are not included in rule text. Click here for PDF copy of example(s).
Statutory/Other Authority: ORS 413.042 & 414.065
Statutes/Other Implemented: 414.065
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