Or. Admin. Code § 410-134-0004 - Billing

(1) For information about fraud and abuse refer to OAR 410-120-1510. For information about audits refer to OAR 410-120-1396. For information about provider sanctions refer to OAR 410-120-1397 through 1460.

(2) The Authority will reimburse providers, when all billing requirements are met pursuant to OAR 410-120-1280.

(3) There is a list of conditions, always considered an emergency found at: https://data.oregon.gov/Health-Human-Services/Oregon-Medicaid-CWM-Emergency-Diagnosis-Codes/4ppf-rfju/data.

(a) CWM emergency claims, must use the appropriate emergency admit type 1 for inpatient and outpatient claims;

(b) or check the appropriate emergency indicator on a professional claim.

(4) Behavioral Health Crisis as defined in OAR chapter 309 division 19.

(a) Professional claims must pair behavioral health diagnosis from group 6179 with the crisis CPT codes 90839 or 90840;

(b) Inpatient and Outpatient claims must pair a behavioral health diagnosis from group 6179 with the emergency admit type;

(c) behavioral health crisis medication coverage:

(A) Requires prior authorization;

(B) Medication per crisis is limited to 30 days plus 1 refill.

(5) Emergency and outpatient Dialysis as defined in OAR 410-134-0003.

(6) Cancer treatment shall include a diagnosis from Group 6149. Cancer diagnosis codes from Group 6149 do not require an emergency indicator or admit type, the cancer diagnosis is the emergency. Cancer coverage includes:

(a) Surgery;

(b) Radiation;

(c) Lab tests and radiology to measure and track treatment;

(d) Side effects of cancer treatment, when if left untreated would place the patient's health in serious jeopardy, cause serious impairment to bodily functions or serious dysfunction to any bodily organ or part;

(e) Co-morbid conditions as a result of cancer treatment, when if left untreated would place the patient's health in serious jeopardy, cause serious impairment to bodily functions or serious dysfunction to any bodily organ or part;

(f) Complications because of and/or impairing the treatment of cancer, when if left untreated would place the patient's health in serious jeopardy, cause serious impairment to bodily functions or serious dysfunction to any bodily organ or part;

(g) Oncology office visits; and

(h) Inpatient treatment and recovery;

(i) Medications that treat cancer, side effects of cancer treatment, comorbid conditions and complications, when if left untreated would place the patient's health in serious jeopardy, cause serious impairment to bodily functions or serious dysfunction to any bodily organ or part; pursuant to OAR 410-121-0147(i).

(7) Claims with diagnosis codes from Group 6149 for office visits and labs to prescribe and monitor immunosuppressant medications post kidney transplant, do not require an emergency indictor. The need for immunosuppressant medications post kidney transplant is the emergency.

(8) Emergency Dental Services defined in OAR 410-120-0000 and pursuant to OAR 410-123-1540 and 410-123-1160(2).

(9) For CWM eligible clients receiving RHEA services, find full coverage and criteria at OAR Chapter 333, Division 004 (for modifiers required for FQHC or RHC clients, see OAR 410-147-0160).

(10) Prior Authorization (PA) must be appropriately obtained for services requiring PA pursuant to OAR 410-120-1320.

(11) Medication coverage limited to emergency medical conditions pursuant to OAR 410-134-0004(4) behavioral health, and 410-134-0004(6) for cancer; prior authorization required.

Notes

Or. Admin. Code § 410-134-0004

DMAP 65-2022, adopt filed 06/30/2022, effective 7/1/2022; DMAP 94-2022, amend filed 12/27/2022, effective 1/1/2023; DMAP 13-2023, minor correction filed 03/30/2023, effective 3/30/2023; DMAP 55-2023, temporary amend filed 06/30/2023, effective 7/1/2023through 12/27/2023; DMAP 89-2023, amend filed 12/19/2023, effective 12/20/2023

Statutory/Other Authority: ORS 413.042 & 414.065

Statutes/Other Implemented: ORS 413.042, 414.065, 414.025, 414.231, 414.312, 414.430, 414.432 & 414.706