Or. Admin. Code § 410-125-0045 - Coverage and Limitations
In general, most medically appropriate services are covered. There are, however, some restrictions and limitations. Please refer to the Division of Medical Assistance Programs' (Division) General Rules Program for information on general scope of coverage and limitations. Some of the limitations and restrictions that apply to hospital services are:
(1) Prior authorization (PA): Some services
require PA for the Oregon Health Plan (OHP) Plus Benefit Package check OAR
410-125-0080.
(2) Non-covered services:
(a) Services that are not medically
appropriate, unproven medical efficacy or services that are the responsibility
of another Department of Human Services (Department) or Oregon Health Authority
(Authority) Division are not covered by the Division of Medical Assistance
Programs;
(b) Service coverage is
based on the Health Evidence Review Commission's (HERC) Prioritized List of
Services and the client's benefit package;
(c) See the General Rules Program (chapter
410, division 120) and other program divisions in chapter 410 for a list of not
covered services. Further information on covered and non-covered services is
found in the Revenue Code section in the Hospital Services Supplemental
Information.
(3)
Limitations on hospital benefit days: Clients have no hospital benefit day
limitations for treatment of covered services.
(4) Dental services: Clients have
dental/denturist services identified as covered on the HERC Prioritized List
(OAR 410-141-520).
(5) Services
provided outside of the hospital's licensed facilities; for example, in the
client's home or in a nursing home, are not covered by Division as hospital
services. The only exceptions to this are Maternity Case Management services
and specific nursing or physician services provided during a ground or air
ambulance transport.
(6) Dialysis
services require a written physician prescription. The prescription must
indicate the ICD-10 diagnosis code and must be retained by the provider of
dialysis services for the period of time specified in the General Rules
Program.
Notes
Stat. Auth.: ORS 413.042
Stats. Implemented: ORS 414.065
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