OAR 410-125-0155
Upper Limits on Payment of Hospital Claims

(1)

Supplemental payments:

(a)

Private Hospital Supplemental Payments:

(A)

From the private Upper Payment Limit (UPL) gap, payments shall be made to all private Diagnosis Related Groups (DRG) hospitals in the form of a per discharge payment applied to hospital specific Medicaid fee-for-service discharges from the quarter preceding the month of the payment;

(B)

This payment will be equal to one quarter of the gap amount divided by the total private DRG hospital Medicaid fee-for-service discharges from the quarter proceeding the month of payment;

(C)

The supplemental payments for Private Hospitals will not exceed the UPL for inpatient hospital services.

(b)

Non-State Government Owned Hospital Supplemental Payments:

(A)

From the non-state government owned hospital upper payment limit gap, payments shall be made to all non-state government owned DRG hospitals in the form of a per discharge payment applied to hospital specific Medicaid fee-for-service discharges from the quarter preceding the month of the payment;

(B)

This payment will be equal to one quarter of the gap amount divided by the total non-state government owned DRG hospital Medicaid fee-for-service discharges from the quarter proceeding the month of payment;

(C)

The supplemental payments for non-state government owned Hospitals will not exceed the UPL for inpatient hospital services.

(2)

For Type A, Type B and Critical Access Hospitals, reimbursement shall be limited to the lesser of allowable costs or billed charges. This limitation shame be applied separately to inpatient and outpatient services.

(3)

Payments will not exceed final approved plan:

(a)

Total reimbursements to a state-operated facility made during the Division of Medical Assistance Program (Division) fiscal year (July 1 through June 30) may not exceed any limit imposed under federal law in the final approved plan;

(b)

Total aggregate inpatient and outpatient reimbursements to all hospitals made during the Division’s fiscal year (July 1 through June 30) may not exceed any limit imposed under federal law in the final approved plan.

Source: Rule 410-125-0155 — Upper Limits on Payment of Hospital Claims, https://secure.­sos.­state.­or.­us/oard/view.­action?ruleNumber=410-125-0155.

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 410-125-0155’s source at or​.us