OAR 410-125-0195
Outpatient Services In-State DRG Hospitals


(1)

The National Drug Code (NDC) must be included on all claim formats for physician administered drug codes required by the Deficit Reduction Act of 2005.

(2)

For discharges prior to January 1, 2012, In-State Diagnostic Related Grouper (DRG) hospital outpatient and emergency services are reimbursed under a cost-based methodology.

(a)

Interim reimbursement:

(A)

The interim reimbursement percentage is developed using the cost-to-charge ratio methodology, derived from the Medicare cost report, and applied to billed charges;

(B)

The interim payment is the estimated percentage needed to achieve 100 percent of hospital cost in aggregate; and

(C)

This interim percentage is applied to all outpatient charges except for clinical laboratory services. Interim reimbursement for clinical laboratory services is calculated according to rates published in the Division of Medical Assistance Programs’ (Division) fee schedule.

(b)

Settlement reimbursement:

(A)

For Medicaid and Children’s Health Insurance Program-eligible (Titles XIX and XXI of the Social Security Act) clients, an adjustment to 100 percent of outpatient costs is made during the cost settlement process;

(B)

For General Assistance (GA) clients, outpatient hospital services are reimbursed at 50 percent of billed charges or 59 percent of costs, whichever is less.

(3)

Effective for discharges on or after January 1, 2012:

(a)

In-State DRG hospital outpatient and emergency services will be reimbursed in accordance with Code of Federal Regulations 42 Part 419 Prospective Payment System for Hospital Outpatient Department Services, using the Ambulatory Payment Classification (APC) Group methodology, and

(b)

Payments will be based on rates determined by State Actuarial Services to be equivalent to 100 percent of Medicare outpatient payments for each DRG hospital.

Source: Rule 410-125-0195 — Outpatient Services In-State DRG Hospitals, https://secure.­sos.­state.­or.­us/oard/view.­action?ruleNumber=410-125-0195.

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 410-125-0195’s source at or​.us