Or. Admin. Code § 410-148-0100 - Reimbursement
(1) Drug
ingredients (medications) shall be reimbursed as defined in the Division of
Pharmaceutical Services administrative rules (chapter 410, division
121).
(2) The following
service/goods shall be reimbursed on a fee-for-service basis according to the
Division EPIV Fee Schedule found in the Home Enteral/Parenteral Nutrition and
IV Services on the Division website:
(a)
Enteral formula which is medically appropriate and meets the criteria specified
in Chapter 410, Division 148 administrative rules;
(b) Oral nutritional supplements which are
medically appropriate and meet the criteria specified in Chapter 410, Division
148 administrative rules;
(c)
Parenteral nutrition solutions which are medically appropriate and meet the
criteria specified in Chapter 410, Division 148 administrative
rules;
(3) Reimbursement
for services shall be based on the lesser of the amount billed, or the Division
maximum allowable rate. When the service is covered by Medicare, reimbursement
shall be based on the lesser of the amount billed, Medicare's allowed amount,
or the Division maximum allowable rate.
(4) Reimbursement for supplies that require
authorization or services/supplies that are listed as Not Otherwise Classified
(NOC) or By Report (BR) must be billed to the Division at the providers'
acquisition cost and shall be reimbursed at such rate.
(a) For purposes of this rule, Acquisition
Cost is defined as the actual dollar amount paid by the provider to purchase
the item directly from the manufacturer (or supplier) plus any shipping and/or
postage for the item. Submit documentation identifying acquisition cost with
your authorization request;
(b) Per
diem, as it relates to reimbursement, represents each day that a given patient
is provided access to a prescribed therapy. This definition is valid for per
diem therapies of up to and including every 72 hours.
(c) Per diem reimbursement includes, but is
not limited to:
(A) Professional pharmacy
services:
(i) Initial and ongoing
assessment/clinical monitoring;
(ii) Coordination with medical professionals,
family and other caregivers;
(iii)
Sterile procedures, including IV admixtures, clean room upkeep and all
biomedical procedures necessary for a safe environment;
(iv) Compounding of medication/medication
set-up.
(B) Infusion
therapy related supplies:
(i) Durable,
reusable or elastomeric disposable infusion pumps;
(ii) All infusion or other administration
devices;
(iii) Short peripheral
vascular access devices;
(iv)
Needles, gauze, sterile tubing, catheters, dressing kits, and other supplies
necessary for the safe and effective administration of infusion
therapy.
(C)
Comprehensive, 24-hour per day, seven (7) days per week delivery and pickup
services (includes mileage).
(5) Reimbursement shall not be made for the
following:
(a) Central catheter insertion or
transfusion of blood/blood products in the client's home;
(b) Central catheter insertion in the nursing
facility;
(c) Intradialytic
parenteral nutrition in the client's home or nursing facility;
(d) Oral nutritional supplements when the
client is able to meet recommended caloric/protein and micronutrient intake
through the consumption of food items or meals;
(e) Tocolytic pumps for pre-term labor
management;
(f) Home
enteral/parenteral nutrition or IV services outside of the client's place of
residence. A client's place of residence can be an assisted living facility,
24-hour residential care facility, adult foster home, child foster home, or a
private home.
(6) The
Oregon Health Plan (OHP) shall be primary payer, before the Women's, Infant and
Children (WIC) program, for all formula covered by OHP to treat those infants
and children who are enrolled in both OHP and participating in the WIC
program.
Notes
Statutory/Other Authority: ORS 413.042
Statutes/Other Implemented: ORS 414.065
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