Or. Admin. Code § 410-133-0040 - Definitions
In addition to the definitions in OAR 410-120-0000 and OAR 410-141-0001, the following definitions apply to these rules:
(1) "Adapted vehicle" means a specially
adapted vehicle that has been physically adjusted or designed to meet the needs
of the individual student under IDEA (e.g., special harnesses, wheelchair
lifts, ramps, specialized environmental controls, etc.) to accommodate students
with disabilities in the school-based setting. Special physical adaptations may
also include air conditioning and specialized suspension systems. In all cases,
the medical need for physical or environmental adaptations during transport
from home to school and back home must be identified in the IEP/IFSP.
(2) "Agent" has the same meaning as defined
in OAR 410-120-0000.
(3) "Assessment" means a process of obtaining
information to determine if a child or young adult qualifies for or continues
to qualify for SBHS, including but not limited to assessing the child or young
adult's need for health services, which services are needed, whether provided
services are leading to improved outcomes, or if services need to be
adjusted.
(4) "Assistive technology
service" means a service provided by a medically-qualified individual within
the scope of practice under state law with training and expertise in the use of
assistive technology.
(5)
"Behavioral health supports" means a broad range of mental health wellness
supports for students with social and/or relational health needs. Supports may
include social skills training or groups, regular check-ins with school staff,
development of behavior intervention plans, substance use prevention groups,
supporting essential health and well-being needs (such as food insecurity or
housing), referral to treatment, and/or coordination with community
providers.
(6) "Behavioral health
treatment" means intensive services for children or young adults with
identified mental health or substance use needs. Treatment may include
therapeutic interventions such as individual or family therapy sessions,
intensive treatment groups related to specific mental health or substance use
needs, or risk assessments and safety planning for students experiencing
suicidal ideation or other acute behavioral health crises.
(7) "Care coordination" has the same meaning
as defined in OAR 410-120-0000. For SBHS, care
coordination is performed by or under the supervision of medically-qualified
individuals and involves organizing care activities, sharing information, and
consultation to ensure and deliver safe, medically-necessary,
medically-appropriate, and effective care aligned with the child or young
adult's needs. Care coordination includes but is not limited to training and
supervision provided by medically-qualified individuals and communicating and
sharing information per the Individual Plan of Care (IPOC) with the child or
young adult's parent/guardian, physician, community practitioner(s), community
organization(s), coordinated care organization (CCO), and staff.
(8) "Case Management Services" means services
provided to ensure a child or young adult obtains health services necessary to
maintain physical, mental, and emotional development and oral health. Case
management services include a comprehensive, ongoing assessment of medical,
mental health, substance use disorder, or dental needs plus the development and
implementation of a plan to obtain or make referrals for needed medical,
mental, chemical dependency, or dental services, referring members to community
services and supports.
(9) "Centers
for Medicare and Medicaid Services (CMS)" means the federal regulatory agency
for Medical Assistance Programs, including Medicaid.
(10) "Child or young adult" means an
individual from birth through the school year in which they turn 21.
(11) "Children's Health Insurance Program
(CHIP)" means a federal and state funded portion of the Oregon Health Plan
(OHP) established by Title XXI of the Social Security Act and administered by
the Authority.
(12) "Delegated
health care" means a specific nursing procedure delegated by a registered nurse
(RN) per the Nurse Practice Act. Delegation process means the formal process
used by a RN to authorize an unregulated assistive person (UAP) to perform a
nursing procedure for a client, the outcome of which the RN retains
accountability for.
(13) "Diagnosis
code" means a code as identified in the International Classification of
Diseases, 10th revision, Clinical Modification (ICD-10-CM).
(14) "Early and Periodic Screening,
Diagnostic and Treatment (EPSDT)" means the program requiring specific coverage
for children and young adults, as described in OAR Chapter 410, Division
151.
(15) "Early Intervention/Early
Childhood Special Education" means a seamless system to support the
developmental and educational needs of children ages birth to five (5) years of
age and their families. Early Intervention/Early Childhood Special Education
(EI/ECSE) programs ensure that children who qualify for special education
receive a Free and Appropriate Public Education (FAPE), as required in the
Individuals with Disabilities Act (IDEA).
(16) "Education agency" means, for the
purposes of these rules, a public school district, EI/ECSE contractor or
subcontractor, education service district, or a state institution providing
educational services or transition services (defined in OAR Chapter 581,
Division 15) to children and young adults, birth through age 21, that receives
state or federal funds either directly or by contract or subcontract with the
Oregon Department of Education (ODE), that is also considered a local unit of
government pursuant to 42
CFR 433.51.
(17) "Education service district (ESD)" means
a district created under ORS
334.010 that provides regional
educational services to component school districts.
(18) "Electronic Data Interchange (EDI)"
means the exchange of business documents from application to application in a
federally mandated format or, if no federal standard has been promulgated,
using bulk transmission processes and other formats as the Authority designates
for EDI transactions. For purposes of rules OAR
943-120-0100 through OAR
943-120-0200, EDI does not
include electronic transmission via Medicaid Management Information System
(MMIS) Provider Web Portal.
(19)
"EDI submitter" means an individual or an entity authorized to establish an
electronic media connection with the Authority to conduct an EDI transaction.
An EDI submitter may be a trading partner or an agent of a trading
partner.
(20) "Evaluation services"
means procedures used to determine a health-related need, diagnosis, or
eligibility for an IPOC. See also re-evaluation services.
(21) "Federal Medical Assistance Percentage
(FMAP)" means the percentage of federal match funds for qualified state medical
assistance program (Medicaid) expenditures.
(22) "Healthcare Common Procedural Coding
System (HCPCS)" means a method for reporting health care professional services,
procedures, and supplies. The HCPCS consists of the Level l - American Medical
Association's Physician's Current Procedural Terminology (CPT), Level II -
National codes, and Level III - Local codes. The Authority uses HCPCS codes;
however, the Authority uses Current Dental Terminology (CDT) codes for the
reporting of dental care services and procedures.
(23) "Health care practitioner" or
"Practitioner of the healing arts" means a person licensed pursuant to state
law to engage in the provision of health care services within the scope of
their license and certification standards established by their health licensing
agency.
(24) "Health Evidence
Review Commission (HERC)" means the commission that develops and maintains a
list of health services ranked by priority from the most to the least important
representing the comparative benefits of each service to the population
served.
(25) "Health Insurance
Portability and Accountability Act (HIPAA)" means the federal law (Public Law
104-191, August 21, 1996) with the legislative objective to assure health
insurance portability, reduce health care fraud and abuse, enforce standards
for health information, and guarantee security and privacy of health
information.
(26) "Individual Plan
of Care (IPOC)" means a prescriptive document for billing Medicaid for each
school-based health service provided to a child or young adult in the school
setting. To serve as the prescriptive document the plan must include the
education agency's name, the specific child or young adult's first and last
name, and each necessary and appropriate health service category including the
nature, extent, or units of service and therapeutic value for each service. The
IPOC may be an Individualized Education Program (IEP) or Individualized Family
Service Plan (IFSP) or Section 504 Accommodation Plan or any other established
and documented individualized health or behavioral health plan if such document
contains the necessary, prescriptive elements required to serve as the
prescriptive document for billing Medicaid.
(27) "Individuals with Disabilities Education
Act (IDEA)" means the federal law ensuring the rights of children with
disabilities to a free and appropriate public education (FAPE).
(28) "Individualized Education Program (IEP)"
means a written statement of an educational program for a child or young adult
with a disability that is developed, reviewed, or revised in a meeting in
accordance with OAR Chapter 581, Division 15.
(29) "Individualized Family Service Plan
(IFSP)" means a written plan of early childhood special education (ECSE)
services, early intervention (EI) services, and other services developed in
accordance with criteria established by the Oregon Department of Education
(ODE) for each child aged from birth through five (5) years of age that is
eligible for Individuals with Disabilities Education Act (IDEA) services. The
plan is developed to meet the needs of a child with disabilities in accordance
with requirements and definitions in OAR Chapter 581, Division 15.
(30) "IEP/IFSP Team" means a group of
teachers, specialists, and parents responsible for developing, reviewing, and
revising an Individualized Education Program (IEP) or Individualized Family
Service Plan (IFSP) in compliance with the OAR Chapter 581, Division
15.
(31) "Medicaid" means a federal
program that is administered and partially funded by the state for medical
assistance established by Title XIX of the Social Security Act as amended and
administered by the Authority.
(32)
"Medicaid-enrolled" means an individual is eligible and enrolled in Oregon's
Medicaid Program.
(33) "Medicaid
Management Information System (MMIS)" means a statewide system that houses
Medicaid data necessary for the business operations of Medicaid administration
including, but not limited to, eligible member information, enrolled provider
information, procedure and diagnosis codes, prior authorizations, claims data,
and reimbursement rules.
(34)
"Medical Assistance Programs" means a program for payment of health services
provided to eligible Oregonians, including Medicaid and CHIP services under the
OHP Medicaid Demonstration Project and Medicaid and CHIP services under the
State Plan, or Healthier Oregon, or Bridge Program, or any other programs that
may be prescribed by the Authority from time to time, in accordance with ORS
414.025(17).
(35) "Medically Appropriate" has the same
meaning as "EPSDT Medically Appropriate" in OAR
410-151-0001.
(36) "Medically Necessary" has the same
meaning as "EPSDT Medically Necessary" in OAR
410-151-0001.
(37) "Medically-qualified Individual" means
an individual possessing a qualification identified in OAR
410-133-0120 who provides
Medicaid-covered health services in an education setting.
(38) "MMIS Provider Web Portal" means an
electronic portal that allows Oregon Medicaid enrolled providers to log in and
access relevant information to provide and be reimbursed for services provided
to Oregon Medicaid members. Oregon Medicaid enrolled providers can use the
portal to verify member eligibility and managed care assignment, access and
query Oregon's HERC Prioritized List of Health Services, submit and adjust
claims for services provided, download claim remittance advices, and more.
Non-enrolled individuals cannot log in to the portal, but they can apply
through the portal to enroll as an Oregon Medicaid provider.
(39) "National Provider Identifier (NPI)"
means a federally administered provider number mandated for use on
HIPAA-covered transactions. Individuals, provider organizations, and subparts
of provider organizations that meet the definition of health care provider
under 45 CFR
160.103 and who conduct HIPAA-covered
transactions electronically are eligible to apply for a NPI. Medicare and
Medicaid covered entities are required to apply for an NPI.
(40) "Non-Billing Provider" also referred to
as non-payable, means a provider who is issued a provider number for purposes
of rendering, ordering, referring, prescribing, data collection, encounters, or
non-claims-use of the Provider Web Portal (e.g., eligibility
verification).
(41) "Oregon
Department of Education (ODE)" means the state agency that provides oversight
to public educational agencies for ensuring compliance with federal and state
laws relating to education.
(42)
"Oregon Health Authority (the Authority)" means the agency established in ORS
Chapter 413 that administers the funds for Titles XIX and XXI of the Social
Security Act. It is the single state agency for the administration of the
medical assistance program under ORS Chapter 414.
(43) "Oregon Health Plan (OHP)" means the
Medicaid and CHIP as administered in Oregon by the Authority and under Oregon's
Medicaid State Plan.
(44)
"Prioritized List of Health Services" means the listing of conditions and
treatment pairs developed by the HERC for the purpose of administering the
OHP.
(45) "Procedure code" means a
code or codes used in the Healthcare Common Procedural Coding System
(HCPCS).
(46) "Re-evaluation
services" means procedures used to measure a child or young adult's health
status compared to an initial or previous evaluation that are focused on
evaluation of progress toward current goals, modifying goals or treatment, or
making a professional judgment to determine whether or not the child or young
adult shall continue to receive one or more school-based health service(s)
pursuant to the child or young adult's IPOC. Continuous monitoring of the child
or young adult's progress as a component of ongoing therapy services is not
billable as a re-evaluation.
(47)
"Referral" means the transfer of total or specified care of a client from one
provider to another. As used by the Authority, the term referral also includes
a request for a consultation or evaluation or a request or approval of specific
services.
(48) "School medical
provider" means an enrolled provider type that is established by the Authority
to designate the provider eligible to receive Medicaid reimbursement for
Medicaid-covered SBHS. Authority-enrolled education agencies, as defined in
this rule, are school medical providers.
(49) "Section 504 of The Rehabilitation Act
of 1973" means a federal civil rights law, guided by the Americans with
Disabilities Act (ADA), that protects qualified individuals from discrimination
based on their disability. Under Section 504, free and appropriate public
education (FAPE) means providing regular or special education and related aids
and services designed to meet individual needs of children and young
adults.
(50) "Section 504
Accommodation Plan" means a formal plan that provides children and young adults
with disabilities specific supports and accommodations needed to access the
general education setting.
(51)
"Special education services" means specially designed instruction to meet the
unique needs of a child or young adult with a disability including regular
classroom instruction, instruction in physical education, home instruction, and
instruction in hospitals, institutions, special schools, and other
settings.
(52) "Specialized
transportation" means transportation to a medically necessary service (as
outlined in the IEP/IFSP of a Medicaid-enrolled child) provided in a specially
adapted vehicle that has been physically adjusted or designed to meet the needs
of the individual student under IDEA (e.g., special harnesses, wheelchair
lifts, ramps, specialized environmental controls, etc.) to accommodate students
with disabilities in the school-based setting. Special physical adaptations may
also include air conditioning and specialized suspension systems. In all cases,
the medical need for physical or environmental adaptations during transport
from home to school and back home must be identified in the IEP/IFSP.
(53) "Synchronous" means an interaction
between a provider and a client or member that occurs at the same time using an
interactive technology. This may include audio only, video only, or audio with
video and may include remote monitoring.
(54) "Supervisory-level" means the
medically-qualified individual is licensed or certified to practice
independently and may supervise other medically-qualified individuals providing
services within their scope of practice and in compliance with their respective
board rules.
(55) "Teacher
Standards and Practices Commission (TSPC)" means the commission that governs
licensing of teachers, personnel, service specialists, and administrators as
set forth in OAR Chapter 584.
(56)
"Telecommunication technologies" means the use of devices and services for
telemedicine or telehealth delivered services. These technologies include, but
are not limited to, videoconferencing, store-and-forward imaging, streaming
media including services with information transmitted using landlines, and
wireless communications, including the Internet and telephone
networks.
(57) "Telehealth" means
the use of electronic information and telecommunications technologies,
including telemedicine, to support remote clinical healthcare, client or member
and professional health-related education, public health, and health
administration.
(58) "Telemedicine"
means the mode of delivering remote clinical health services using information
and telecommunication technologies to provide consultation and education or to
facilitate diagnosis, treatment, care management or self-management of a client
or member's healthcare.
(59)
"Transportation vehicle trip log" means a record or log kept specifically for
tracking each transportation trip to or from a covered health service a
Medicaid-eligible child or young adult receives.
(60) "Treatment Plan" means a practitioner's
written plan of health services, including treatment with proposed location,
frequency, and duration of treatment. A treatment plan must be written by a
practitioner within the scope of the practitioner's license or certification
and in compliance with the practitioner's respective Oregon board. Treatment
plans may include but are not limited to behavioral health service plans (see
OAR 309-019-0140), nurse treatment
plans of care (see Oregon's Nurse Practice Act, OARs Chapter 851), occupational
therapy service plans (See OARs Chapter 339, Division 10), and physical therapy
plans of care (see OARs Chapter 848, Division 40).
(61) "Unit" means a service measurement of
time for billing and reimbursement efficiency. One unit equals 15 minutes
unless otherwise stated.
(62)
"Unregulated Assistive Person (UAP)" means an unlicensed, unregulated
individual who performs a nursing procedure for a patient when the specific
procedure has been delegated and authorized by a licensed registered nurse (RN)
or nurse practitioner (NP) acting within the scope of their license. The
delegating nurse retains accountability for the nursing procedure.
(63) "Visit" means a service measurement of
time for billing and reimbursement efficiency. For billing purposes, a visit is
always presented as one (1) visit.
(64) "Written recommendation" means a
physician or a licensed health care practitioner has documented a specific
service or treatment, within their scope of practice, that is medically
necessary and appropriate for the individual child or young adult. The written
recommendation must be written by a practitioner other than the performing
provider, except when the performing provider may self-refer within their scope
of practice. The written recommendation must be current, within twelve (12)
months of the date of service, to allow for Medicaid reimbursement.
Notes
Statutory/Other Authority: ORS 413.042
Statutes/Other Implemented: 414.065
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