Or. Admin. Code § 410-147-0120 - Division Encounter and Recognized Practitioners
(1) The Division of Medical Assistance
Programs (Division) reimburses Federally Qualified Health Center (FQHC) and
Rural Health Clinic (RHC) services according to the Prospective Payment System
(PPS) as follows:
(a) When the service(s)
meet the criteria of a valid encounter as defined in Sections (2) through (4)
of this rule;
(b) Reimbursement is
limited to the Division's Medicaid-covered services according to a client's
Oregon Health Plan (OHP) benefit package. These services include ambulatory
services included in the State Plan under Title XIX or Title XXI of the Social
Security Act. Other services that are not defined in this rule or the State
Plan under Title XIX or Title XXI of the Social Security Act are not reimbursed
by the Division.
(2) For
the provision of services defined in Titles XIX and XXI and provided through an
FQHC or RHC, an "encounter" is defined as a face-to-face or telephone contact
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 (4) of this rule outlines limitations for telephone contacts that
qualify as encounters. For purposes of this rule, a face-to-face "encounter"
includes services provided via a synchronous two-way audiovisual link between a
patient and a provider per OAR
410-130-0610.
(3) An encounter includes all services, items
and supplies provided to a client during the course of an office visit (except
as excluded in Sections (6) and (12) of this rule) and those services
considered "incident-to." These services are inclusive of the visit with the
core provider meeting the criteria a valid encounter and reimbursed at the PPS
all-inclusive encounter rate. These services include:
(a) Drugs or medication treatments provided
during a clinic visit are inclusive of the encounter, with the exception of
contraception supplies and medications as costs for these items are excluded
from the PPS encounter rate calculation (see OAR
410-147-0280 Drugs and OAR
410-147-0480 Cost Statement
(DMAP 3027) Instructions);
(b)
Medical supplies, equipment, or other disposable products (e.g. gauze,
band-aids, wrist brace) are inclusive of an office visit;
(c) Laboratory and/or radiology services
(even if performed on another day);
(d) Venipuncture for lab tests. The Division
does not deem a visit for lab test only to be a clinic encounter;
(4) Telephone encounters qualify
as a valid encounter for services provided in accordance with OAR
410-130-0595, Maternity Case
Management (MCM) and 410-130-0190, Tobacco Cessation
(see also 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.
(5) Extended care
services furnished under a contract between a county Community Mental Health
Program (CMHP) of the FQHC and Addictions and Mental Health Division (AMH) are
reimbursed outside of the PPS. Extended care services are those services
provided under AMH's licensure requirements and reimbursed under AMH's terms
and conditions.
(6) Some Division
Medicaid-covered services are not reimbursable when furnished according to
Oregon Health Plan (OHP) client's benefit package as a stand alone service.
Although costs incurred for furnishing these services are inclusive of the PPS
all-inclusive rate calculation, visits where these services were furnished as a
stand-alone service were excluded from the denominator for the PPS rate
calculation (see OAR 410-147-0480, Cost Statement
(DMAP 3027) Instructions). The following services when furnished as a
stand-alone service are not reimbursable:
(a)
Sign language and oral interpreter services;
(b) Supportive rehabilitation services
including, but not limited to, environmental intervention, supported housing
and employment, or skills training and activity therapy to promote community
integration and job.
(7)
FQHCs and RHCs may provide certain services, items and supplies that are
prohibited from being billed under the health centers provider enrollment, and
requires separate enrollment (see OAR
410-147-0320(1)(b)
Federally Qualified Health Center (FQHC)/Rural Health Clinics (RHC)
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 pharmaceutical and/or
biologicals not generally provided during the clinic visit must be billed to
DMAP through the pharmacy program (refer to OAR chapter 410, division 121,
Pharmaceutical Services);
(c)
Targeted case management (TCM) services (refer to OAR chapter 410, division
138).
(8) 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 encounter. For exceptions to this
rule, see OAR 410-147-0140 for reporting
multiple encounters.
(9) Providers
are advised to include all services that can appropriately be reported using a
procedure code on the claim and bill as instructed in the appropriate Division
program rules and must use the appropriate HIPAA procedure code set such as
CPT, HCPCS, ICD-10-CM, ADA CDT, NDC, established according to
45 CFR
162.1000 to
162.1011, which best describes the
specific service or item provided. For claims that require the listing of a
diagnosis or procedure code as a condition of payment, the code listed on the
claim form must be the code that most accurately describes the client's
condition and the service(s) provided. Providers must use the ICD-10-CM
diagnosis coding system when a diagnosis is required unless otherwise specified
in the appropriate individual provider rules (refer to OAR
410-120-1280 Billing and see OAR
410-147-0040 ICD-10-CM Diagnosis
and CPT/HCPCs Procedure Codes).
(10) FQHC and RHC services that may meet the
criteria of a valid encounter are (refer to individual program administrative
rules for service limitations.):
(a) Medical
(OAR chapter 410, division 130);
(b) Diagnostic: The Division covers
reasonable services for diagnosing conditions, including the initial diagnosis
of a condition that is below the funding line on the Prioritized List of Health
Services. Once a diagnosis is established for a service, treatment or item that
falls below the funding line, the Division will not cover any other services
related to the diagnosis;
(c)
Tobacco Cessation (OAR
410-130-0190);
(d) Dental (see to OAR
410-147-0125, and refer to 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) Mental Health (Refer to
the Division of Addiction and Mental Health (AMH) for appropriate
OARs);
(j) Alcohol, Chemical
Dependency, and Addiction services (see also OAR
410-147-0320). Requires a letter
or licensure of approval by AMH (refer to AMH for appropriate OARs);
(k) Maternity Case Management (MCM) (OAR
410-147-0200);
(l) Speech (OAR chapter 410, division
129);
(m) Hearing (OAR chapter 410,
division 129);
(n) The Division
considers a home visit for assessment, diagnosis, treatment or 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; and
(p) Other Title XIX or XXI services as
allowed under Oregon's Medicaid and CHIP State Plan Amendments and the
Division's administrative rules.
(11) The following practitioners are
recognized by the Division:
(a) Doctors of
medicine, osteopathy and naturopathy;
(b) Licensed Physician Associates;
(c) Dentists;
(d) 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, ORS
680.200 and the appropriate
Oregon Board of Dentistry OARs;
(e)
Pharmacists;
(f) Nurse
Practitioners;
(g) Nurse
Midwives;
(h) Other specialized
nurse practitioners;
(i) 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;
(j)
Psychiatrists;
(k) Licensed
Clinical Social Workers;
(l)
Clinical psychologists;
(m)
Acupuncturists - Refer to OAR chapter 410, division 130 for service coverage
and limitations;
(n) Licensed
professional counselor;
(o)
Licensed marriage and family therapist; or
(p) Other health care professionals providing
services within their scope of practice and working under the supervision
requirements of:
(A) Their individual
provider's certification or license; or
(B) A clinic's mental health certification or
alcohol and other drug program approval or licensure by the Addictions and
Mental Health Division (AMH) (see OAR
410-147-0320).
(12) Encounters with a
registered professional nurse or a licensed practical nurse and related medical
supplies (other than drugs and biologicals) furnished on a part-time or
intermittent basis to home-bound clients (limited to areas in which the
Secretary has determined that there is a shortage of home health agencies -
Code of Federal Regulations 42 | 405.2417), and any other ambulatory services
covered by the Division are also reimbursable as permitted within the clinic's
scope of services (see OAR
410-147-0020).
(13) FQHCs and RHCs may furnish services that
are reimbursed outside of the PPS all-inclusive encounter rate and according to
the physician fee schedule. These services include:
(a) Administrative medical examinations and
report services (refer to OAR chapter 410, division 150);
(b) Death with Dignity services (refer to OAR
410-130-0670);
(c) Services provided to Citizenship Waived
Medical (CWM) clients (refer to OARs
410-120-1210,
461-135-1070 and
410-130-0240);
(d) Services provided to Qualified Medicare
Beneficiary (QMB) only clients (refer to OAR
410-120-1210, Medical Assistance
Benefit Packages and Delivery System). Specific billing information is located
in the FQHC and RHC Supplemental Information billing guide; and
(e) Comprehensive environmental lead
investigation (refer to OAR
410-130-0245, Early and Periodic
Screening, Diagnostic and Treatment Program).
(14) OHP benefit packages and delivery system
are described in OAR 410-120-1210. Most OHP clients
have prepaid health services, contracted for by the Authority through
enrollment in a Prepaid Health Plan (PHP). Non-PHP-enrolled clients, receive
services on an "open card" or "fee-for-service" (FFS) basis.
(a) The Division is responsible for making
payment for services provided to open card clients. The provider will bill the
Division the clinic's encounter rate for Medicaid-covered services provided to
these clients according to their OHP benefit package (see OAR
410-147-0360, Encounter Rate
Determination).
(b) A PHP is
responsible to provide, arrange and make reimbursement arrangements for covered
services for their Division members (refer to OAR
410-120-0250, and OAR chapter
410, division 141, OHP administrative rules governing PHPs). The provider must
bill the PHP directly for services provided to an enrolled client (See also
OARs 410-147-0080, Prepaid Health
Plans, and 410-147-0460, PHP Supplemental
Payment). Clinics must not bill the Division for PHP-covered services provided
to eligible OHP clients enrolled in PHPs. Exceptions include:
(A) Family planning services provided to a
PHP-enrolled client when the clinic does not have a contract with the PHP, and
if the PHP denies payment (see OAR
410-147-0060); and
(B) HIV/AIDS prevention provided to a
PHP-enrolled client when the clinic does not have a contract with the PHP, and
if the PHP denies payment (see OAR
410-147-0060).
(15) 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).
(16) 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
State regulations are updated quarterly; we currently have two versions available. Below is a comparison between our most recent version and the prior quarterly release. More comparison features will be added as we have more versions to compare.
No prior version found.