OAR 410-120-1180
Medical Assistance Benefits: Out-of-State Services

(1) A provider located in a state other than Oregon whose services are rendered in that state shall be licensed and otherwise certified by the proper agencies in the state of residence as qualified to render the services. Certain cities within 75 miles of the Oregon border may be closer for Oregon residents than major cities in Oregon, and therefore, these areas are considered contiguous areas, and providers are treated as providing in-state services.
(2) Out-of-state providers must enroll with the Authority as described in OARs 943-120-0320 (Provider Enrollment) and 410-120-1260 (Provider Enrollment), Provider Enrollment. Out-of-state providers must provide services and bill in compliance with these rules and the OARs for the appropriate type of services provided.
(3) Payment rates for out-of-state providers are established in the individual provider rules through contracts or service agreements and in accordance with OAR chapter 943, division 120 and OAR 410-120-1340 (Payment), Payment.
(4) For enrolled non-contiguous, out-of-state providers, the Division reimburses for covered services under any of the following conditions:
(a) For clients enrolled in an MCE:
(A) The service is authorized by an MCE, and payment to the out-of-state provider is the responsibility of the MCE;
(B) If a client has coverage through an MCE, the request for non-emergency services must be referred to the MCE. Payment for these services is the responsibility of the MCE;
(C) The service or item is not available in the State of Oregon or provision of the service or item by an out-of-state provider is cost effective, as determined by the MCE.
(b) For clients not enrolled in an MCE:
(A) The service to a Division client is emergent as defined in 410-120-0000 (Acronyms and Definitions);
(B) A delay in the provision of services until the client is able to return to Oregon could reasonably be expected to result in prolonged impairment, or in increased risk that treatment will become more complex or hazardous, or in substantially increased risk of the development of chronic illness;
(C) The Division authorized payment for the service in advance of the provision of services or is otherwise authorized in accordance with payment authorization requirements in the individual provider rules or in the General Rules;
(D) The service is being billed for Qualified Medicare Beneficiary (QMB) deductible or co-insurance coverage;
(E) The client is traveling and unable to use an in-state pharmacy;
(F) The pharmacy is out-of-state and mail order; the primary insurance TPL policy requires the use of the pharmacy;
(G) The pharmacy is out-of-state and mail order and provides one or more pharmaceutical products that are only available through a limited distribution network.
(5) The Authority may give prior authorization (PA) for non-emergency out-of-state services provided by a non-contiguous enrolled provider under the following conditions:
(a) The service is billed for Qualified Medicare Beneficiary (QMB) deductible or co-insurance coverage; or
(b) The Division covers the service or item under the specific client’s benefit package; and
(c) The service or item is not available in the State of Oregon, or provision of the service or item by an out-of-state provider is cost effective, as determined by the Division; and
(d) The service or item is deemed medically appropriate and is recommended by a referring Oregon physician.
(6) Laboratory analysis of specimens sent to out-of-state independent or hospital-based laboratories is a covered service and does not require PA. The laboratory must meet the same certification requirements as Oregon laboratories and must bill in accordance with Division rules.
(7) The Division makes no reimbursement for services provided to a client outside the territorial limits of the United States. For purposes of this provision, the United States includes the District of Columbia, Puerto Rico, the Virgin Islands, Guam, the Northern Mariana Islands, and American Samoa.
(8) The Division shall reimburse within limits described in these General Rules and in individual provider rules all services provided by enrolled providers to children:
(a) Who the Division has placed in foster care;
(b) Who the Department has placed in a subsidized adoption outside the State of Oregon; or
(c) Who are in the custody of the Department and traveling with the consent of the Department.
(9) The Division does not require authorization of non-emergency services for the children covered by section (8) except as specified in the individual provider rules.
(10) Payment rates for out-of-state providers are established in the individual provider rules through contracts or service agreements and in accordance with OAR 943-120-0350 (Payments and Overpayments) and 410-120-1340 (Payment), Payment.

Source: Rule 410-120-1180 — Medical Assistance Benefits: Out-of-State Services, https://secure.­sos.­state.­or.­us/oard/view.­action?ruleNumber=410-120-1180.

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 410-120-1180’s source at or​.us