Or. Admin. Code § 410-146-0085 - Encounter and Recognized Practitioners
Encounter and Recognized Practitioners
(1) The Division shall reimburse enrolled
AI/AN providers as follows:
(a) For services,
items, and supplies that meet the criteria of a valid encounter in sections (5)
through (7) of this rule;
(b)
Reimbursement is limited to the Division's Medicaid-covered services according
to a client's OHP benefit package. These services may include any services
included in the State Plan under Title XIX or Title XXI of the Social Security
Act and provided pursuant to the determinations, conditions, and requirements
of the Prioritized List of Health Services found in the Health Evidence Review
Commission's Prioritized List of Health Services (see OAR
410-141-0520).
(2) IHCPs reimbursed according to
a cost-based rate under the Prospective Payment System (PPS) shall use OAR
410-147-0120, Encounter and
Recognized Practitioners, in the Division's FQHC and RHC program.
(3) IHCPs reimbursed according to the IHS
rate are subject to the requirements of this rule.
(4) Services provided to Citizenship Waived
Medical (CWM) and Qualified Medicare Beneficiary (QMB) only clients are not
billed according to encounter criteria and not reimbursed at the IHS encounter
rate (refer to OAR 410-120-1210, Medical Assistance
Benefit Packages and Delivery System).
(5) For the provision of services defined in
Titles XIX and XXI and provided through an IHS or Tribal 638 facility, an
"encounter" is defined as a face-to-face, telephone contact, or a prescription
fill as defined in OAR
410-146-0085(8)
between a health care professional and an eligible OHP client within a 24-hour
period ending at midnight, as documented in the client's medical record.
Section (7) of this rule outlines limitations for telephone contacts that
qualify as encounters. For purposes of this rule, face-to-face "encounter"
includes services provided via a synchronous two-way audiovisual link between a
patient and a provider per
410-130-0610.
(6) An encounter includes all services,
items, and supplies provided to a client during the course of an office visit
and "incident-to" services (except as excluded in section (17) of this rule).
The following services are inclusive of the visit with the core provider
meeting the criteria of a reimbursable valid encounter and are not reimbursed
separately:
(a) Drugs or medication treatments
provided during the clinic visit, with the exception of contraception supplies
and medications as costs for these items are excluded from the IHS encounter
rate calculation (refer to OAR
410-146-0200,
Pharmacy);
(b) Medical supplies,
equipment, or other disposable products (e.g. gauze, Band-Aids, wrist brace);
and
(c) Venipuncture for laboratory
tests.
(7) An IHS or
Tribal 638 Pharmacy encounter is a separate encounter and not made in
conjunction with a medical, behavioral health, substance use disorder, or
dental visit or with any other non-pharmacy visit related to a covered
benefit.
(8) A single pharmacy
encounter includes one prescription dispensed by one IHS or Tribal 638 Pharmacy
to a Medicaid-eligible individual in a single 24-hour period ending at
midnight. There is no limit on the number of encounters that may occur in the
24-hour period. The encounter rate is inclusive of dispensing
services.
(9) Telephone encounters
qualify as a valid encounter for services provided in accordance with OAR
410-130-0595, Maternity Case
Management; OAR 410-146-0200, Tribal Pharmacy;
and OAR 410-130-0190, Tobacco Cessation
(OAR 410-120-1200). Except as set
forth below, Providers may not make telephone contacts at the exclusion of
face-to-face visits.
(a) Telephone encounters
must include all the same components of the service as if provided
face-to-face.
(b) During a state of
emergency of an epidemic outbreak of an infectious disease impacting the safety
of public health, in accordance with the Health Evidence Review Commission's
Prioritized List, guideline notes, and OAR
410-130-0610 (for dates of
service on or before December 31, 2020) and OAR
410-120-1990 (for dates of
service on or after January 1, 2021), telephonic evaluation management
services, assessment and management services, and psychotherapy are appropriate
to ensure access to care while avoiding and preventing unnecessary potential
infectious exposure, and may be made in place of a face-to-face
visit.
(10) The
following services may be Medicaid-covered services according to an OHP
client's benefit package as a stand-alone service; however, when furnished as a
stand-alone service, they are not reimbursable:
(a) Case management services for coordinating
care for a client;
(b) Sign
language and oral interpreter services;
(c) Supportive rehabilitation services
including, but not limited to, environmental intervention, supported
employment, or skills training and activity therapy to promote community
integration and job readiness.
(11) IHCPs may provide certain services,
items, and supplies that are prohibited from being billed under the health
centers provider enrollment and that require separate enrollment (see OAR
410-146-0021, AI/AN Provider
Enrollment). These services include:
(a)
Durable medical equipment, prosthetics, orthotics, or medical supplies (DMEPOS)
(e.g., diabetic supplies) not generally provided during the course of a clinic
visit (refer to OAR chapter 410, division 122, DMEPOS);
(b) Prescription pharmaceuticals and
biologicals not generally provided during the clinic visit that are dispensed
by an IHS or Tribal 638 Pharmacy may be billed to and shall be reimbursed by
the Division through the pharmacy program (refer to OAR chapter 410, division
121, Pharmaceutical Services) or at the All-Inclusive Rate (AIR) as established
annually by the Indian Health Service (IHS); and
(c) Targeted case management (TCM) services.
For specific information, refer to OAR chapter 410, division 138,
TCM.
(12) Client contact
with more than one health professional for the same diagnosis or multiple
encounters with the same health professional that take place on the same day
and at a single location constitute a single visit. For exceptions to this
rule, see OAR 410-146-0086 for reporting
multiple encounters.
(13) For
claims that require a procedure and diagnosis code, the provider must bill as
instructed in the appropriate Division program rules and must use the
appropriate HIPAA procedure Code Set established according to
45 CFR
162.1000 to
162.1011, which best describes the
specific service or item provided (refer to OARs
410-120-1280, Billing and OAR
410-146-0040, ICD-10-CM
Diagnosis Codes and CPT/HCPCs Procedure Codes).
(14) Services furnished by AI/AN enrolled
providers that may meet the criteria of a valid encounter (refer to individual
program administrative rules for service limitations):
(a) Medical (OAR chapter 410, division
130);
(b) The Division covers
reasonable services for diagnosing conditions, including the initial diagnosis
of a condition that is below the funding line on the HERC's Prioritized List of
Health Services. Once a diagnosis is established for a service, treatment, or
item that falls below the funding line, the Division may l not cover any other
services related to the diagnosis;
(c) Tobacco Cessation (OAR
410-130-0190);
(d) Dental (OAR
410-146-0380 and OAR chapter
410, division 123);
(e) Vision (OAR
chapter 410, division 140);
(f)
Physical Therapy (OAR chapter 410, division 131);
(g) Occupational Therapy (OAR chapter 410,
division 131);
(h) Podiatry (OAR
chapter 410, division 130);
(i)
Behavioral health OAR chapter 309;
(j) Substance Use Disorder services (OAR
410-146-0021) require a letter
or licensure of approval by the Division;
(k) Maternity Case Management (OAR
410-146-0120);
(l) Speech (OAR 410 Division 129);
(m) Hearing (OAR 410 Division 129);
(n) The Division considers a home visit for
assessment, diagnosis, treatment, or maternity case management (MCM) as an
encounter. The Division does not consider home visits for MCM as home health
services;
(o) Professional services
provided in a hospital setting;
(p)
Prescriptions dispensed by an IHS or Tribal 638 Pharmacy constitute a separate
encounter reimbursed at the annually published IHS
All-Inclusive-Rate;
(q) Other Title
XIX or XXI services as allowed under Oregon's Medicaid and CHIP State Plan
Amendments, Oregon's approved 1115 Medicaid Demonstration, and the Division's
administrative rules.
(15) The following practitioners are
recognized by the Division:
(a) Doctors of
medicine, osteopathy, and naturopathy;
(b) Licensed physician associates;
(c) Nurse practitioners;
(d) Registered nurses may accept and
implement orders within the scope of their license for client care and
treatment under the supervision of a licensed health care professional
recognized by the Division in this section and who is authorized to
independently diagnose and treat according to appropriate State of Oregon's
Board of Nursing OARs;
(e) Nurse
midwives;
(f) Dentists;
(g) Dental hygienists who hold a Limited
Access Permit (LAP) may provide dental hygiene services without the supervision
of a dentist in certain settings. For more information, refer to the section on
Limited Access Permits in ORS
680.200 and the appropriate
Oregon Board of Dentistry OARs;
(h)
Pharmacists;
(i)
Psychiatrists;
(j) Licensed
Clinical Social Workers;
(k)
Clinical psychologists;
(l)
Acupuncturists, refer to OAR chapter 410, division 130 for service coverage and
limitations;
(m) Licensed
professional counselor;
(n)
Licensed marriage and family therapist; and
(o) Other health care professionals providing
services within their scope of practice and working under the supervision
requirements of:
(A) Their individual provider
certification or license; or
(B) A
clinic's behavioral health certification or SUD program approval or licensure
by the Division.
(16) Encounters with a registered
professional nurse or a licensed practical nurse and related medical supplies,
including drugs and biologicals, furnished on a part-time or intermittent basis
to home-bound AI/AN clients residing on tribal land and any other ambulatory
services covered by the Division are also reimbursable as permitted within the
clinic's scope of services.
(17)
The Division shall reimburse the following services fee-for-service outside of
the IHS all-inclusive encounter rate and according to the physician fee
schedule:
(a) Laboratory and radiology
services;
(b) Contraception
supplies and medications;
(c)
Administrative medical examinations and report services (refer to OAR chapter
410, division 150);
(d) Death with
Dignity services (refer to OAR
410-130-0670); and
(e) Comprehensive environmental lead
investigation (refer to OAR
410-130-0245, Early and Periodic
Screening, Diagnostic and Treatment program).
(18) Federal law requires that state Medicaid
agencies take all reasonable measures to ensure that in most instances the
Division will be the payer of last resort. Providers must make reasonable
efforts to obtain payment first from other resources before billing the
Division (refer to OAR
410-120-1140, Verification of
Eligibility).
(19) When a provider
receives a payment from any source prior to the submission of a claim to the
Division, the amount of the payment must be shown as a credit on the claim in
the appropriate field (refer to OARs
410-120-1280, Billing and
410-120-1340,
Payment).
Notes
Statutory/Other Authority: ORS 413.042 & ORS 414.065
Statutes/Other Implemented: ORS 414.065
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