OAR 410-120-1160
Medical Assistance Benefits and Provider Rules

(1)

Providers enrolled with and seeking reimbursement for services through the Division of Medical Assistance Programs (Division) are responsible for compliance with current federal and state laws and regulations governing Medicaid services and reimbursement, including familiarity with periodic law and rule changes. The Division’s administrative rules are posted on the Oregon Health Authority (Authority) website for the Division and its medical assistance programs. It is the provider’s responsibility to become familiar with and abide by these rules.

(2)

The following services are covered to the extent included in the Division client’s benefit package of health care services, when medically or dentally appropriate and within the limitations established by the Division and set forth in the Oregon Administrative Rules (OARs) for each category of Medical Services:

(a)

Acupuncture services as described in the Medical-Surgical Services program provider rules (OAR chapter 410, division 130);

(b)

Administrative examinations as described in the Administrative Examinations and Billing Services program provider rules (OAR chapter 410, division 150);

(c)

Substance Use Disorder treatment services:

(A)

The Division covers substance use disorder (SUD) inpatient treatment services for medically managed intensive inpatient detoxification when provided in an acute care hospital and when hospitalization is considered medically appropriate. The Division covers medically monitored detoxification and clinically managed detoxification provided in a free standing detoxification center or an appropriately licensed SUDs residential treatment facility when considered medically appropriate;

(B)

The Division covers non-hospital SUD treatment and recovery services on a residential or outpatient basis. For information to access these services, contact the client’s PHP or CCO if enrolled, the community mental health program (CMHP), an outpatient substance use disorder treatment provider, the residential treatment program, or the Addictions and Mental Health Division (AMH);

(C)

The Division does not cover residential level of care provided in an inpatient hospital setting for substance use disorder treatment and recovery;

(d)

Ambulatory surgical center services as described in the Medical-Surgical Services program provider rules (OAR 410, division 130);

(e)

Anesthesia services as described in the Medical-Surgical Services program provider rules (OAR chapter 410, division 130);

(f)

Audiology services as described in the Speech-Language Pathology, Audiology and Hearing Aid Services program provider rules (OAR chapter 410, division 129);

(g)

Chiropractic services as described in the Medical-Surgical Services program provider rules (OAR chapter 410, division 130);

(h)

Dental services as described in the Dental Services program provider rules (OAR chapter 410, division 123);

(i)

Early and periodic screening, diagnosis, and treatment services (EPSDT) are covered for individuals under 21 years of age as set forth in the individual program provider rules. The Division may authorize services in excess of limitations established in the OARs when it is medically appropriate to treat a condition that is identified as the result of an EPSDT screening;

(j)

Family planning services as described in the Medical-Surgical Services program provider rules (OAR chapter 410, division 130);

(k)

Federally qualified health centers and rural health clinics as described in the Federally Qualified Health Centers and Rural Health Clinics program provider rules (OAR chapter 410, division 147);

(l)

Home and community-based waiver services as described in the Authority and the Department’s OARs of Child Welfare (CW), Self-Sufficiency Program (SSP), Addictions and Mental Health Division (AMH), and Aging and People with Disabilities Division (APD);

(m)

Home enteral/parenteral nutrition and IV services as described in the Home Enteral/Parenteral Nutrition and IV Services program rules (OAR chapter 410, division 148) and related Durable Medical Equipment. Prosthetics, Orthotics and Supplies program rules (OAR chapter 410, division 122) and Pharmaceutical Services program rules (OAR chapter 410, division 121);

(n)

Home health services as described in the Home Health Services program rules (OAR chapter 410, division 127);

(o)

Hospice services as described in the Hospice Services program rules (OAR chapter 410, division 142);

(p)

Indian health services or tribal facility as described in The Indian Health Care Improvement Act and its amendments (Public Law 102-573), and the Division’s American Indian/Alaska Native program rules (OAR chapter 410, division 146);

(q)

Inpatient hospital services as described in the Hospital Services program rules (OAR chapter 410, division 125);

(r)

Laboratory services as described in the Hospital Services program rules (OAR chapter 410, division 125) and the Medical-Surgical Services program rules (OAR chapter 410, division 130);

(s)

Licensed direct-entry midwife services as described in the Medical-Surgical Services program rules (OAR chapter 410, division 130);

(t)

Maternity case management as described in the Medical-Surgical Services program rules (OAR chapter 410, division 130);

(u)

Medical equipment and supplies as described in the Hospital Services program, Medical-Surgical Services program, DMEPOS program, Home Health Services program, Home Enteral/Parenteral Nutrition and IV Services program, and other rules;
(v)
When a client’s benefit package includes mental health, the mental health services provided will be based on the Health Evidence Review Commission (HERC) Prioritized List of Health Services;

(w)

Naturopathic services as described in the Medical-Surgical Services program rules (OAR chapter 410, division 130);
(x)
Nutritional counseling as described in the Medical-Surgical Services program rules (OAR chapter 410, division 130);

(y)

Occupational therapy as described in the Physical and Occupational Therapy Services program rules (OAR chapter 410, division 131);

(z)

Organ transplant services as described in the Transplant Services program rules (OAR chapter 410, division 124);

(aa)

Outpatient hospital services including clinic services, emergency department services, physical and occupational therapy services, and any other outpatient hospital services provided by and in a hospital as described in the Hospital Services program rules (OAR chapter 410, division 125);

(bb)

Physician, podiatrist, nurse practitioner and licensed physician assistant services as described in the Medical-Surgical Services program rules (OAR chapter 410, division 130);

(cc)

Physical therapy as described in the Physical and Occupational Therapy and the Hospital Services program rules (OAR chapter 410, division 131 and 125);

(dd)

Post-hospital extended care benefit as described in OAR chapter 410, division 120 and 141 and Aging and People with Disabilities (APD) program rules;

(ee)

Prescription drugs including home enteral and parenteral nutritional services and home intravenous services as described in the Pharmaceutical Services program (OAR chapter 410, division 121), the Home Enteral/Parenteral Nutrition and IV Services program (OAR chapter 410, division 148), and the Hospital Services program rules (OAR chapter 410, division 125);

(ff)

Preventive services as described in the Medical-Surgical Services program (OAR chapter 410, division 130), the Dental Services program rules (OAR chapter 410, division 123), and prevention guidelines associated with the Health Evidence Review Commission’s Prioritized List of Health Services (OAR 410-141-0520);

(gg)

Private duty nursing as described in the Private Duty Nursing Services program rules (OAR chapter 410, division 132);

(hh)

Radiology and imaging services as described in the Medical-Surgical Services program rules (OAR chapter 410, division 130), the Hospital Services program rules (OAR chapter 410, division 125), and Dental Services program rules (OAR chapter 410, division 123);
(ii)
Rural health clinic services as described in the Federally Qualified Health Center and Rural Health Clinic Program rules (OAR chapter 410, division 147);

(jj)

School-based health services as described in the School-Based Health Services Program rules (OAR chapter 410, division 133);

(kk)

Speech and language therapy as described in the Speech-Language Pathology, Audiology and Hearing Aid Services program rules (OAR chapter 410, division 129) and Hospital Services program rules (OAR chapter 410, division 125);

(LL)

Transportation necessary to access a covered medical service or item as described in the Medical Transportation program rules (OAR chapter 410, division 136);

(mm)

Vision services as described in the Visual Services program rules (OAR chapter 410, division 140).

(3)

Other Authority or Department, divisions, units, or offices, including Vocational Rehabilitation, AMH, and APD may offer services to Medicaid eligible clients, that are not reimbursed by or available through the Division of Medical Assistance Programs.
[Publications: Publications referenced are available from the agency.]

Source: Rule 410-120-1160 — Medical Assistance Benefits and Provider Rules, https://secure.­sos.­state.­or.­us/oard/view.­action?ruleNumber=410-120-1160.

410–120–0000
Acronyms and Definitions 410–120–0003
OHP Standard Benefit Package 410–120–0006
Medical Eligibility Standards 410–120–0011
Effect of COVID-19 Emergency Authorities on Administrative Rules 410–120–0025
Administration of Division of Medical Assistance Programs, Regulation and Rule Precedence 410–120–0030
Children’s Health Insurance Program 410–120–0035
Public Entity 410–120–0045
Applications for Medical Assistance at Provider locations 410–120–0250
Managed Care Entity 410–120–1140
Verification of Eligibility and Coverage 410–120–1160
Medical Assistance Benefits and Provider Rules 410–120–1180
Medical Assistance Benefits: Out-of-State Services 410–120–1190
Medically Needy Benefit Program 410–120–1195
SB 5548 Population 410–120–1200
Excluded Services and Limitations 410–120–1210
Medical Assistance Benefit Packages and Delivery System 410–120–1260
Provider Enrollment 410–120–1280
Billing 410–120–1285
Recoupment and Data Sharing with Third-Party Insurers 410–120–1295
Non-Participating Provider 410–120–1300
Timely Submission of Claims 410–120–1320
Authorization of Payment 410–120–1340
Payment 410–120–1350
Buying-Up 410–120–1360
Requirements for Financial, Clinical and Other Records 410–120–1380
Compliance with Federal and State Statutes 410–120–1385
Compliance with Public Meetings Law 410–120–1390
Premium Sponsorships 410–120–1395
Program Integrity 410–120–1396
Provider and Contractor Audits 410–120–1397
Recovery of Overpayments to Providers — Recoupments and Refunds 410–120–1400
Provider Sanctions 410–120–1460
Type and Conditions of Sanction 410–120–1510
Fraud and Abuse 410–120–1560
Provider Appeals 410–120–1570
Claim Re-Determinations 410–120–1580
Provider Appeals — Administrative Review 410–120–1600
Provider Appeals — Contested Case Hearings 410–120–1855
Client’s Rights and Responsibilities 410–120–1860
Contested Case Hearing Procedures 410–120–1865
Denial, Reduction, or Termination of Services 410–120–1870
Client Premium Payments 410–120–1875
Agency Hearing Representatives 410–120–1880
Contracted Services 410–120–1920
Institutional Reimbursement Changes 410–120–1940
Interest Payments on Overdue Claims 410–120–1960
Payment of Private Insurance Premiums 410–120–1980
Requests for Information and Public Records 410–120–1990
Telehealth
Last Updated

Jun. 8, 2021

Rule 410-120-1160’s source at or​.us