OAR 410-125-0045
Coverage and Limitations


In general, most medically appropriate services are covered. There are, however, some restrictions and limitations. Please refer to the Division of Medical Assistance Programs’ (Division) General Rules Program for information on general scope of coverage and limitations. Some of the limitations and restrictions that apply to hospital services are:

(1)

Prior authorization (PA): Some services require PA for the Oregon Health Plan (OHP) Plus Benefit Package check OAR 410-125-0080 (Inpatient Services).

(2)

Non-covered services:

(a)

Services that are not medically appropriate, unproven medical efficacy or services that are the responsibility of another Department of Human Services (Department) or Oregon Health Authority (Authority) Division are not covered by the Division of Medical Assistance Programs;

(b)

Service coverage is based on the Health Evidence Review Commission’s (HERC) Prioritized List of Services and the client’s benefit package;

(c)

See the General Rules Program (chapter 410, division 120) and other program divisions in chapter 410 for a list of not covered services. Further information on covered and non-covered services is found in the Revenue Code section in the Hospital Services Supplemental Information.

(3)

Limitations on hospital benefit days: Clients have no hospital benefit day limitations for treatment of covered services.

(4)

Dental services: Clients have dental/denturist services identified as covered on the HERC Prioritized List (OAR 410-141-520).

(5)

Services provided outside of the hospital’s licensed facilities; for example, in the client’s home or in a nursing home, are not covered by Division as hospital services. The only exceptions to this are Maternity Case Management services and specific nursing or physician services provided during a ground or air ambulance transport.

(6)

Dialysis services require a written physician prescription. The prescription must indicate the ICD-10 diagnosis code and must be retained by the provider of dialysis services for the period of time specified in the General Rules Program.

Source: Rule 410-125-0045 — Coverage and Limitations, https://secure.­sos.­state.­or.­us/oard/view.­action?ruleNumber=410-125-0045.

410‑125‑0000
Determining When the Patient Has Medical Assistance
410‑125‑0020
Retroactive Eligibility
410‑125‑0030
Hospital Hold
410‑125‑0040
Title XIX/Title XXI Clients
410‑125‑0041
Non-Title XIX/XXI Clients
410‑125‑0045
Coverage and Limitations
410‑125‑0050
Client Copayments
410‑125‑0080
Inpatient Services
410‑125‑0085
Outpatient Services
410‑125‑0086
Prior Authorization for FCHP/MHO Clients
410‑125‑0090
Inpatient Rate Calculations — Type A, Type B, and Critical Access Oregon Hospitals
410‑125‑0095
Hospitals Providing Specialized Inpatient Services
410‑125‑0101
Hospital-Based Nursing Facilities and Medicaid Swing Beds
410‑125‑0102
Medically Needy Clients
410‑125‑0103
Medicare Clients
410‑125‑0115
Non-Contiguous Area Out-of-State Hospitals — Effective for services rendered on or after October 1, 2003
410‑125‑0120
Transportation To and From Medical Services
410‑125‑0121
Contiguous Area Out-of-State Hospitals — Effective for services rendered on or after October 1, 2003
410‑125‑0124
Retroactive Authorization
410‑125‑0125
Free-Standing Inpatient Psychiatric Facilities
410‑125‑0140
Prior Authorization Does Not Guarantee Payment
410‑125‑0141
DRG Rate Methodology
410‑125‑0142
Graduate Medical Education Reimbursement for Public Teaching Hospitals
410‑125‑0146
Supplemental Reimbursement for Public Academic Teaching University Medical Practitioners
410‑125‑0150
Disproportionate Share
410‑125‑0155
Upper Limits on Payment of Hospital Claims
410‑125‑0162
Hospital Transformation Performance Program
410‑125‑0165
Transfers and Reimbursement
410‑125‑0170
Death Occurring on Day of Admission
410‑125‑0175
Hospitals Providing Specialized Outpatient Services
410‑125‑0180
Public Rates
410‑125‑0181
Non-Contiguous and Contiguous Area Out-of-State Hospitals — Outpatient Services
410‑125‑0190
Outpatient Rate Calculations — Type A, Type B, and Critical Access Oregon Hospitals
410‑125‑0195
Outpatient Services In-State DRG Hospitals
410‑125‑0200
Time Limitation for Submission of Claims
410‑125‑0201
Independent ESRD Facilities
410‑125‑0210
Third Party Resources and Reimbursement
410‑125‑0220
Services Billed on the Electronic 837I or on the Paper UB-04 and Other Claim Forms
410‑125‑0221
Payment in Full
410‑125‑0230
Qualified Directed Payments
410‑125‑0360
Definitions and Billing Requirements
410‑125‑0400
Discharge
410‑125‑0401
Definitions: Emergent, Urgent, and Elective Admissions
410‑125‑0410
Readmission
410‑125‑0450
Provider Preventable Conditions
410‑125‑0550
X-Ray or EKG Procedures Furnished in Emergency Room
410‑125‑0600
Non-Contiguous Out-of-State Hospital Services
410‑125‑0620
Special Reports and Exams and Medical Records
410‑125‑0640
Third Party Payers — Other Resources, Client Responsibility and Liability
410‑125‑0641
Medicare
410‑125‑0720
Adjustment Requests
410‑125‑1020
Filing of Cost Statement
410‑125‑1040
Accounting and Record Keeping
410‑125‑1060
Fiscal Audits
410‑125‑1070
Type A and Type B Hospitals
410‑125‑1080
Documentation
410‑125‑2000
Access to Records
410‑125‑2020
Post Payment Review
410‑125‑2030
Recovery of Payments
410‑125‑2040
Provider Appeals — Administrative Review
410‑125‑2060
Provider Appeals — Hearing Request
410‑125‑2080
Administrative Errors
Last Updated

Jun. 8, 2021

Rule 410-125-0045’s source at or​.us