OAR 410-133-0040
Definitions

In addition to the definitions in OAR 410-120-0000 (Acronyms and Definitions), the following definitions apply to these rules:
(1) “Adapted vehicle” means a vehicle specifically designed or modified to transport passengers with disabilities.
(2) “Adequate recordkeeping” means in addition to General Rules OAR 410-120-0000 (Acronyms and Definitions), Definitions and 410-120-1360 (Requirements for Financial, Clinical and Other Records), Requirements for Financial, Clinical, and Other Records, documentation in the student’s educational record and on the Individualized Education Plan (IEP) or Individualized Family Service Plan (IFSP) showing the necessary and appropriate health services provided to the student detailed in the School-Based Health Services (SBHS) administrative rules (410-133-0000 (Purpose) and 410-133-0320 (Documentation and Record keeping Requirements)).
(3) “Agent” means a third party or organization that contracts with a provider, allied agency, or Prepaid Health Plan (PHP) to perform designated services in order to facilitate a transaction or conduct other business functions on its behalf. Agents include billing agents, claims clearinghouses, vendors, billing services, service bureaus, and accounts receivable management firms. Agents may also be clinics, group practices, and facilities that submit billings on behalf of providers but the payment is made to a provider, including the following: an employer of a provider, if a provider is required as a condition of employment to turn over his fees to the employer; the facility in which the service is provided, if a provider has a contract under which the facility submits the claim; or a foundation, plan, or similar organization operating an organized health care delivery system, if a provider has a contract under which the organization submits the claim. Agents may also include electronic data transmission submitters.
(4) “Assessment” means a process of obtaining information to determine if a student qualifies for or continues to qualify for the Division covered school-based health services.
(5) “Assistive technology service” means services provided by medically qualified staff within the scope of practice under state law with training and expertise in the use of assistive technology (see 410-133-0080 (Coverage) Coverage and 410-133-0200 (Not Covered Services) Not Covered Services in these rules).
(6) “Audiologist” means a licensed audiologist within the scope of practice as defined by state or federal law who meet the standards of licensing or certification for the health service provided as described in OAR 410-133-0120 (Medically Qualified Staff) Medically Qualified Staff.
(7) “Audiology” means assessment of children with hearing loss; determination of the range, nature, and degree of hearing loss, including the referral for medical or other professional attention for restoration or rehabilitation due to hearing disorders; provision of rehabilitative activities, such as language restoration or rehabilitation, auditory training, hearing evaluation and speech conversation, and determination of the child’s need for individual amplification; obtaining and interpreting information; and coordinating care and integrating services relative to the student receiving services.
(8) “Authority” means the Oregon Health Authority. (Please see General Rules 410-120-0000 (Acronyms and Definitions) Acronyms and Definitions.)
(9) “Billing agent or billing service” means a third party or organization that contracts with a provider to perform designated services in order to facilitate an Electronic Data Interchange (EDI) transaction on behalf of the provider. Also see definition for Electronic Data Interchange (EDI) Submitter.
(10) “Billing Provider (BP)” means a person, agent, business, corporation, clinic, group, institution, or other entity that submits claims to and receives payment from the Division on behalf of a performing provider and has been delegated the authority to obligate or act on behalf of the performing provider. (See the Department-wide Support Services (DWSS) administrative rules in, chapter 407, division 120 Provider Rules, and the Division’s General Rules OAR 410-120-1260 (Provider Enrollment) and SBHS OAR 410-133-0140 (School Medical Provider Enrollment Provisions).)
(11) “Billing time limit” means the period allowed to bill services to the Division, see General Rules OAR 410-120-1300 (Timely Submission of Claims), Timely Submission of Claims. In general, those rules require initial submission within 12 months of the date of service or 18 months for resubmission.
(12) “Centers for Medicare and Medicaid Services (CMS)” means the federal regulatory agency for Medicaid programs.
(13) “Certification.” See “licensure.”
(14) “Children’s Health Insurance Program (CHIP)” means a federal and state funded portion of the Oregon Health Plan (OHP) established by Title XXI of the Social Security Act and administered in Oregon by the Authority and the Division.
(15) “Clinical Social Work Associate (CSWA)” means a person working toward Licensed Clinical Social Worker (LCSW) licensure in compliance with Division 20, Procedure for Certification of Clinical Social Work Associates and Licensing of Licensed Clinical Social Workers, OAR Chapter 877 division 020.
(16) “Coordinated care” means services directly related to covered school-based health services (SBHS) specified in the individualized education program (IEP) or individualized family service plan (IFSP), performed by medically qualified staff, and allowed under OAR 410-133-0080 (Coverage) Coverage to manage integration of those health services in an education setting. Coordinated care includes the following activities:
(a) Conference. The portion of a conference in a scheduled meeting between medically qualified staff and interested parties to develop, review, or revise components of school-based health services provided to a Medicaid-eligible student to establish, re-establish, or terminate a Medicaid covered health service on a Medicaid-eligible student’s Individualized Education Program (IEP) or Individualized Family Service Plan (IFSP); or to develop, review, or revise components of a health service currently provided to a Medicaid-eligible student to determine whether or not those covered health services continue to meet the student’s needs as specified on the student’s IEP or IFSP;
(b) Consultation. Performed by medically qualified staff within the scope of practice providing technical assistance to or conferring with special education providers, physicians, and families to assist them in providing a covered health service for Medicaid-eligible students related to a specific health service and health service goals and objectives in the individualized education program (IEP) or individualized family service plan (IFSP);
(c) Physician coordinated care. Meeting or communication with a physician in reference to oversight of care and treatment provided for a health service specified on a Medicaid-eligible student’s individualized education program (IEP) or individualized family service plan (IFSP).
(17) “Cost Determination” means the process of establishing an annual discipline fee (cost rate), based on the prior-year actual audited costs, used by an EA for the purpose of billing for covered school-based health services (see 410-133-0245 (Cost Determination and Payment) Cost Determination and Payment in these rules).
(18) “Covered entity” means a health plan, health care clearing house, health care provider, or allied agency that transmits any health information in electronic form in connection with a transaction, including direct data entry (DDE), and that must comply with the National Provider Identifier (NPI) requirements of 45 CFR 162.402 through 162.414. When a school provides covered SBHS services in the normal course of business and bills Medicaid for reimbursed covered transactions electronically in connection with that health care such as electronic claims, it is then a covered entity and must comply with the HIPAA Administrative Simplification Rules for Transactions and Code sets and Identifiers with respect to its transactions.
(19) Data transmission means the transfer or exchange of data between the Department and a web portal or electronic data interchange (EDI) submitter by means of an information system that is compatible for that purpose and includes without limitation web portal, EDI, electronic remittance advice (ERA), or electronic media claims (EMC) transmissions.
(20) “Delegated Health Care Aide” means a non-licensed person trained and supervised by a licensed registered nurse (RN) or nurse practitioner (NP) to perform selected tasks of nursing care specific to the Medicaid-eligible student identified in the nursing plan of care pursuant to the Individualized Education Program/Individualized Family Service Plan (IEP/IFSP).
(21) “Delegation of nursing task” means a selected nursing task that is performed by an unlicensed person, trained and monitored by a licensed RN. Delegation and supervision of selected nursing tasks must comply with Oregon Administrative Rules (OARs), Oregon State Board of Nursing, chapter 851, divisions 45 and 47. A school medical (SM) provider must maintain documentation of the actual delegation, training, supervision, and provision of the nursing service billed to Medicaid.
(22) “Department” means the Department of Human Services established in OAR chapter 407, including any divisions, programs, and offices as may be established therein.
(23) “Diagnosis code” means as identified in the International Classification of Diseases 10th Revision, Clinical Modification (ICD-10-CM), the primary Diagnosis Code is shown in all billing claims, unless specifically excluded in individual Division provider rules. Where they exist, diagnosis codes shall be shown to the degree of specificity outlined in OAR 410-120-1280 (Billing) Billing.
(24) “Direct services” means face-to-face delivery of health services by or under the direction of medically qualified staff who is the service provider to a Medicaid-eligible student.
(25) “Early Intervention/Early Childhood Special Education (EI/ECSE)”: EI is a program designed to address the unique needs of a child age 0-3 years, and ECSE is a program for preschool children with a disability ages 3-5 years or eligible for Kindergarten.
(26) “Educational Agency (EA)” means for purposes of these rules, any public school, school district, Education Service District (ESD), state institution, or youth care center providing educational services to students, birth to age 21 through grade 12, that receives federal or state funds either directly or by contract or subcontract with the Oregon Department of Education (ODE).
(27) “Education records” means those records, files, documents and other materials that contain information directly related to a student and maintained by an Education Agency (EA) or by a person acting for such EA as set forth in OAR 581-021-0220 (Definitions). (A school-based health services (SBHS) provider is required to keep and maintain supporting documentation for Medicaid reimbursed school-based health services for a period of seven years; this documentation is part of the student’s education record but may be filed and kept separately by school health professionals.) See 410-133-0320 (Documentation and Record keeping Requirements) Documentation and Recordkeeping Requirements in these rules.
(28) “Education Service District (ESD)” means an education agency established to offer a resource pool of cost-effective, education-related, physical or mental health-related, state-mandated services to multiple local school districts within a geographic area described in ORS 334.010 (Creation of education service districts).
(29) “Electronic Data Interchange (EDI)” means the exchange of business documents from application to application in a federally mandated format or, if no federal standard has been promulgated, using bulk transmission processes and other formats as the Department designates for EDI transactions. For purposes of these rules (OAR 407-120-0100 (Definitions) through 407-120-0200 (Department System Administration)), EDI does not include electronic transmission by web portal.
(30) “EDI submitter” means an individual or an entity authorized to establish an electronic media connection with the Department to conduct an EDI transaction. An EDI submitter may be a trading partner or an agent of a trading partner. Also see definition for billing agent in these rules.
(31) “Electronic Verification System (EVS)” means eligibility information that have met the legal and technical specifications of the Division in order to offer eligibility information to enrolled providers.
(32) “Eligibility for special education services” means a determination by a designated education agency (EA) through a team that a child meets the eligibility criteria for early intervention (EI), early childhood special education (ECSE), or special education as defined in ORS 343 and OAR chapter 581, division 15.
(33) “Evaluation” —means procedures performed by medically qualified staff to determine whether a Medicaid-eligible student is disabled and the nature and extent of the health services the student needs under the Individuals with Disabilities Education Act (IDEA) and in accordance with Oregon Department of Education OAR chapter 581 division 15. The Authority can only reimburse evaluations that establish, re-establish, or terminate a school-based health services (SBHS) covered health service on a Medicaid-eligible student’s Individualized Education Program (IEP) or Individualized Family Service Plan (IFSP) under the Individuals with Disabilities Education Act (IDEA).
(34) “Federal Medical Assistance Percentage (FMAP)” means the percentage of federal matching dollars for qualified state medical assistance program expenditures.
(35) “Healthcare Common Procedure Coding System (HCPCS)” means a method for reporting health care professional services, procedures, and supplies. HCPCS consists of the Level I -American Medical Association’s Physician’s Current Procedural Terminology (CPT), Level II – National codes, and Level III – Local codes. The Division uses HCPCS codes. See General Rules (OAR 410-120-1280 (Billing) Billing).
(36) “Health assessment plan (nursing)” means a systematic collection of data for the purpose of assessing a Medicaid-eligible student’s health or illness status and actual or potential health care needs in the educational setting. It includes taking a nursing history and an appraisal of the student’s health status through interview information from the family and information from the student’s past health or medical record. A SBHS provider is required to keep and maintain the health assessment plan and supporting documentation for Medicaid reimbursed health services described in a Medicaid-eligible student’s individualized education program (IEP) or individualized family service plan (IFSP) for a period of seven years as part of the student’s education record, which may be filed and kept separately by school health professionals. (See 410-133-0320 (Documentation and Record keeping Requirements) Documentation and Recordkeeping Requirements.)
(37) “Health care practitioner” means a person licensed pursuant to state law to engage in the provision of health care services within the scope of the health care practitioner’s license and certification standards established by their health licensing agency. Medical provider and health care practitioner are interchangeable terms. See Definition for medical provider in these rules.
(38) “Health Evidence Review Commission (HERC)” means a 13-member commission that is charged with reporting to the Governor the ranking of health benefits from most to least important and representing the comparable benefits of each service to the entire population to be served.
(39) “Health services” means medical evaluation services provided by a physician for diagnostic and evaluation purposes for a Medicaid-eligible student that is found eligible under the Individuals with Disabilities Education Act (IDEA) and leads to an established Individualized Education Program (IEP) or Individualized Family service Plan (IFSP), physical or mental health evaluations, and assessment or treatment performed by medically qualified staff to achieve the goals set forth in a Medicaid-eligible student’s IEP or IFSP. A covered health service is one that is covered by the medical assistance program and is provided to enable the Medicaid-eligible student to benefit from a special education program (age 3-21) or to achieve developmental milestones in an early intervention program (age 0-3). “Health services” are synonymous with “medical services” in these rules. To determine whether a health service specified on an Individualized Education Program (IEP) or Individualized Family Service Plan (IFSP) is a covered School-Based Health Service (SBHS), see 410-133-0080 (Coverage) Coverage and 410-133-0200 (Not Covered Services) Not Covered Services.
(40) “Health Systems Division, Medical Assistance Programs (Division)” means a division within the Oregon Health Authority (Authority). The Division is responsible for coordinating the medical assistance programs within the State of Oregon including the Oregon Health Plan (OHP) Medicaid demonstration, the State Children’s Health Insurance Program (SCHIP- Title XXI), and several other programs.
(41) “ID number” means a number issued by the Authority used to identify Medicaid-eligible students. This number may also be referred to as recipient identification number, prime number, client medical ID Number, or medical assistance program ID number.
(42) “Individuals with Disabilities Education Act (IDEA)” means the federal law ensuring the rights of children with disabilities to a “free and appropriate education” (FAPE).
(43) “Individualized Education Plan (IEP)” means a written statement of an educational program for a child with a disability that is developed, reviewed, or revised in a meeting in accordance with Oregon Department of Education OAR chapter 581, division 15. When an IEP is used as a prescription for Medicaid reimbursement for covered School-Based Health Services (SBHS), it must include type of health service, amount, and duration and frequency for the service provided. In order to bill Medicaid for covered health services, they must be delivered by or under the supervision of medically qualified staff and must be recommended by a physician or appropriate health care practitioner acting within the scope of practice. See the definition of medically qualified staff in this rule.
(44) “Individualized Family Service Plan (IFSP)” means a written plan of early childhood special education (ECSE) services, early intervention (EI) services, and other services developed in accordance with criteria established by the Oregon Department of Education (ODE) for each child (ages birth to 5 years) eligible for IFSP services. The plan is developed to meet the needs of a child with disabilities in accordance with requirements and definitions in OAR chapter 581, division 15. When an IFSP is used as a prescription for Medicaid reimbursement for SBHS covered services, it must include type of health service, amount, and duration and frequency for the service provided. In order to bill Medicaid for covered health services, they must be delivered by or under the supervision of medically qualified staff and must be recommended by a physician or health care practitioner within their scope of practice. See the definition of medically qualified staff in this rule.
(45) “Individualized Education Plan/Individualized Family Service Plan (IEP/IFSP) Team” means a group of teachers, specialists, and parents responsible for determining eligibility, and developing, reviewing, and revising an IEP or IFSP in compliance with the Oregon Department of Education (ODE) OAR chapter 581, division 15.
(46) "Licensed Clinical Social Worker (LCSW)” means a person licensed to practice clinical social work pursuant to state law.
(47) “Licensed Physical Therapist Assistant (LPTA)” means a person licensed to assist in the administration of physical therapy, solely under the supervision and direction of a physical therapist.
(48) "Licensed Practical Nurse (LPN)” means a person licensed to practice under the direction of a licensed professional within the scope of practice as defined by state law.
(49) “Licensure” means documentation from state agencies demonstrating that licensed or certified individuals are qualified to perform specific duties and a scope of services within a legal standard recognized by the licensing agency. In the context of health services, licensure refers to the standards applicable to health service providers by health licensing authorities. For health services provided in the State of Oregon, licensure refers to the standards established by the appropriate State of Oregon licensing agency.
(50) “Medicaid-eligible student” means the child or student who has been determined to be eligible for Medicaid health services by the Authority. For purposes of this rule, Medicaid-eligible student is synonymous with “recipient” or “Oregon Health Plan (OHP) client”. For convenience, the term “student” used in these rules applies to both students covered by an Individualized Education Program (IEP) and children covered by an Individualized Family Service Plan (IFSP). Also, for purposes of this rule, students or children whose eligibility is based on the Children’s Health Insurance Program (CHIP) shall be referred to as Medicaid-eligible students.
(51) “Medical Assistance Program” means a program for payment of health services provided to eligible Oregonians. Oregon’s medical assistance program includes Medicaid services including the Oregon Health Plan (OHP) Medicaid Demonstration, and the Children’s Health Insurance Program (CHIP). The Medical Assistance Program is administered by the Health Systems Division, Medical Assistance Programs (Division) of the Oregon Health Authority.
(52) “Medical Management Information System (MMIS)” means a data collection system for processing an integrated group of procedures and computer processing operations (subsystems) developed at the general design level to meet principal objectives. For Title XIX purposes, “systems mechanization” and “mechanized claims processing and information retrieval systems” is identified in section 1903(a)(3) of the Act and defined in regulation at 42 CFR 433.111. The objectives of this system and its enhancements include the Title XIX program control and administrative costs; service to recipients, providers and inquiries; operations of claims control and computer capabilities; and management reporting for planning and control.
(53) “Medical provider” means an individual licensed by the state to provide health services within their governing body’s definitions and respective scope of practice. Medical provider and health care practitioner are interchangeable terms.
(54) “Medical services” means the care and treatment provided by a licensed health care practitioner to prevent, diagnose, treat, correct, or address a medical problem, whether physical, mental, or emotional. For the purposes of these rules, this term shall be synonymous with health services or health-related services listed on an Individualized Education Program (IEP) or Individualized Family Service Plan (IFSP), as defined in OAR chapter 581, division 15. Not all health-related services listed on an IEP or IFSP are covered as SBHS. See 410-133-0080 (Coverage) Coverage and 410-133-0200 (Not Covered Services) Not Covered Services.
(55) “Medical transportation” means specialized transportation in a vehicle adapted to meet the needs of passengers with disabilities transported to and from a SBHS covered service.
(56) “Medically qualified staff” means:
(a) Staff employed by or through contract with an EA; and
(b) Licensed by the state to provide health services in compliance with state law defining and governing the scope of practice, described further in OAR 410-133-0120 (Medically Qualified Staff).
(57) “Medication management” means a task performed only by medically qualified staff within the scope of practice, pursuant to a student’s Individualized Education Program/Individualized Family Service Plan (IEP/IFSP), which involves administering medications, observing for side effects, and monitoring signs and symptoms for medication administration.
(58) “National Provider Identifier (NPI)” means a federally directed provider number mandated for use on Health Insurance Portability Accountability Act (HIPAA) covered transactions. Individuals, provider organizations, and subparts of provider organizations that meet the definition of health care provider (45 CFR 160.103) and who conduct HIPAA covered transactions electronically are eligible to apply for an NPI. Medicare covered entities are required to apply for an NPI.
(59) “Necessary and appropriate” health services mean those health services described in a Medicaid-eligible student’s IEP or IFSP that are:
(a) Consistent with the symptoms of a health condition or treatment of a health condition;
(b) Appropriate regarding standards of good health practice and generally recognized by the relevant scientific community and professional standards of care as effective;
(c) Not solely for the convenience of the Medicaid-eligible student or provider of the service; and
(d) The most cost-effective of the alternative levels of health services that can safely be provided to a Medicaid-eligible student.
(60) “Nursing Diagnosis and Management Plan” means a written plan that describes a Medicaid-eligible student’s actual and anticipated health conditions that are amenable to resolution by nursing intervention.
(61) “Nursing Plan of Care” means written guidelines that are made a part of and attached to the Individualized Education Program (IEP) or individualized Family Service Plan (IFSP) that identify specific health conditions of the Medicaid-eligible student and the nursing regimen that is “necessary and appropriate” for the student. Development and maintenance of this plan includes establishing student and nursing goals and identifying nursing interventions (including location, frequency, duration, and delegation of care) to meet the medical care objective identified in their IEP or IFSP. See Oregon State Board of Nursing Practice Act, Division 47. The SBHS provider is responsible for developing the nursing plan of care and is required to keep and maintain a copy of the nursing plan of care as supporting documentation for Medicaid reimbursed health services. (See definition “Education records.”)
(62) “Nurse practitioner” means a person licensed as a registered nurse and certified by the Board of Nursing to practice as a nurse practitioner pursuant to state law.
(63) “Nursing services” means services provided by a nurse practitioner (NP), registered professional nurse (RN), a licensed practical nurse (LPN), or delegated health care aide within the scope of practice as defined by state law. Nursing services include preparation and maintenance of the health assessment plan; nursing diagnosis and management plan; nursing plan of care, consultation, and coordination; and integration of health service activities, as well as direct patient care and supervision.
(64) “Observation” means surveillance or visual monitoring performed by medically-qualified staff as part of an evaluation, assessment, direct service, or care coordination for a necessary and appropriate Medicaid-covered health service specified on a Medicaid-eligible student’s Individualized Education Program (IEP) or Individualized Family Service Plan (IFSP) to better understand the child’s medical needs and progress in their natural environment. An observation by itself is not billable.
(65) “Occupational therapist (OT)” means a person licensed by the state’s Occupational Therapy Licensing Board.
(66) “Occupational Therapist Assistant” means a person who is licensed as an occupational therapy assistant assisting in the practice of occupational therapy under the supervision of a licensed occupational therapist.
(67) “Occupational therapy” means assessing, improving, developing, or restoring functions impaired or lost through illness, injury, or deprivation to improve the ability to perform tasks for independent functioning when functions are lost or impaired, preventing through early intervention initial or further impairment or loss of function. It also means obtaining and interpreting information, coordinating care, and integrating necessary and appropriate occupational therapy services relative to the Medicaid-eligible student.
(68) “Oregon Department of Education (ODE)” means the state agency that provides oversight to public educational agencies for ensuring compliance with federal and state laws relating to the provision of services required by the individuals with disabilities education act (IDEA).
(69) “Orientation and mobility training” mean services provided to blind or visually impaired students by qualified personnel to enable those students to attain systematic orientation to and safe movement within their environment in school, home, and community. These services are not covered under School-Based Health Services (SBHS). (See OAR 410-133-0200 (Not Covered Services) Not Covered Services.)
(70) “Performing provider” means a person, agent, business, corporation, clinic, group, institution, or other entity that is the provider of a service or item with the authority to delegate fiduciary responsibilities to a billing provider, also termed billing agent, to obligate or act on the behalf of the performing provider regarding claim submissions, receivables, and payments relative to the Medical Assistance Program. For the purposes of these SBHS rules, the school medical (SM) provider is the performing provider.
(71) “Physical Therapist” means a person licensed by the relevant state licensing authority to practice physical therapy. (See OAR chapter 848, division10 Licensed Physical Therapists and Licensed Physical Therapist Assistants; chapter 848 division 40 Minimum Standards for Physical Therapy Practice and Records.)
(72) “Physical Therapy” means assessing, preventing, or alleviating movement dysfunction and related functional problems, obtaining and interpreting information, and coordinating care and integrating necessary and appropriate physical therapy services relative to the student receiving treatments.
(73) “Prime Number” See definition of ID Number.
(74) “Prioritized List of Health Services” means the Oregon Health Evidence Review Commission’s (HERC) prioritized list of health services with “expanded definitions’ of ancillary services and preventative services and the HERC practice guidelines, as presented to the Oregon Legislative Assembly for the purpose of administering the Oregon Health Plan (OHP).
(75) “Procedure code.” See definition of HCPC healthcare common procedure code.
(76) “Provider” means an individual, facility, institution, corporate entity, or other organization that supplies health care services or items, also termed a performing provider, or bills, obligates, and receives reimbursement on behalf of a performing provider of services, also termed a billing provider (BP). The term “Provider” refers to both performing providers and billing providers unless otherwise specified. Payment can only be made to Division-enrolled providers who have by signature on the provider enrollment forms and attachments agreed to provide services and to bill in accordance with General Rules OAR 410-120-1260 (Provider Enrollment) and the SBHS OAR 410-133-0140 (School Medical Provider Enrollment Provisions). If a provider submits claims electronically, the provider must become a trading partner with the Authority and comply with the requirements of the Electronic Data Interchange (EDI) rules pursuant to OAR Chapter 407 division 120.
(77) “Provider enrollment agreement” means an agreement between the provider and the Authority that sets forth the conditions for being enrolled as a provider with the Authority and to receive a provider number in order to submit claims for reimbursement for covered SBHS provided to Medicaid-eligible students. Payment can only be made to Division-enrolled providers who have by signature on the provider enrollment forms and program applicable attachments agreed to provide services and to bill in accordance with Provider Rules chapter 407, division 120 and the Division’s General Rules chapter 410, division 120, and these SBHS rules. Also see definitions for Trading Partner and Trading Partner Agreement in these rules.
(78) “Psychiatrist” means a person licensed to practice medicine and surgery in the State of Oregon and possesses a valid license from the Oregon Medical Board.
(79) “Psychologist” means a person with a doctoral degree in psychology and licensed by the State Board of Psychologist Examiners. See 858-010-0010 (Education Requirements — Psychologist).
(80) “Psychologist Associate” means a person who does not possess a doctoral degree that is licensed by the Board of Psychologists Examiners to perform certain functions within the practice of psychology under the supervision of a psychologist. See 858-010-0037 (Supervised Work Experience — Psychologist Associate) through 858-010-0038 (Continued Supervision — Licensed Psychologist Associate). An exception would be psychologist associate with the authority to function without immediate supervision. See OAR 858-010-0039 (Application for Independent Status — Psychologist Associate).
(81) “Record keeping requirements” means An SBHS SM provider is required to keep and maintain the supporting documentation in compliance with the respective medical provider’s scope of practice and governing licensure or certification board requirements for Medicaid reimbursed health services described in a Medicaid-eligible student’s Individualized Education Program (IEP) or Individualized Family Service Plan (IFSP) for a period of seven years as part of the student’s education record, which may be filed and kept separately by school health professionals. (See OAR 410-133-0320 (Documentation and Record keeping Requirements).)
(82) “Re-evaluation” means procedures used to measure a Medicaid-eligible student’s health status compared to an initial or previous evaluation are focused on evaluation of progress toward current goals, modifying goals or treatment, or making a professional judgment to determine whether or not the student will continue to receive continued care for a covered service pursuant to an IEP or IFSP under the Individuals with Disabilities Education Act (IDEA). Continuous assessment of the student’s progress as a component of ongoing therapy services is not billable as a re-evaluation.
(83) “Regional program” means regional program services provided on a multi-county basis under contract from the Oregon Department of Education (ODE) to eligible children (birth to 21) visually impaired, hearing impaired, deaf-blind, autistic, and severely orthopedically impaired. A regional program may be reimbursed for covered health services it provides to Medicaid-eligible students through the school medical (SM) provider (e.g., public school district or ESD) that administers the program.
(84) “Registered Nurse (RN)” means a person licensed and certified by the Oregon Board of Nursing to practice as a registered nurse pursuant to state law.
(85) “Rehabilitative services” means for purposes of the School-Based Health Services (SBHS) program any health service that is covered by the Medical Assistance Program and that is a medical, psychological, or remedial health service recommended by a physician or other licensed health care practitioner within the scope of practice under state law and provided to a Medicaid-eligible student pursuant to an Individualized Education Program/Individualized Family Service Plan (IEP/IFSP) under the Individuals with Disabilities Education Act (IDEA) that help the Medicaid eligible student keep, learn, or improve skills and functioning, including reduction, correction, stabilization, or functioning improvement of physical or mental disability of a Medicaid-eligible student. (See 410-133-0060 (Health Services).)
(86) “Related services” means for purposes of this rule related services as listed on an Individualized Education Program (IEP) or Individualized Family Service Plan (IFSP) and may include: transportation and such developmental, corrective, and other supportive services (e.g., speech language, audiology services, psychological services, physical therapy, occupational therapy, social work services in schools, and nursing services) as are required to assist a child or student with a disability to benefit from special education, and includes early identification and assessment of disabling conditions in children.
(87) “School-Based Health Services (SBHS)” means special education, related services, or early intervention services addressing health-related needs that help the Medicaid eligible student keep, learn, or improve skills and functioning and any services authorized under Oregon’s approved Medicaid state plans that are also considered special education, related services, or early intervention that adversely affects the child/student’s educational performance. SBHS services reimbursed by Medicaid are recommended by a physician or other licensed health care practitioner within the scope of practice under state law and provided to a Medicaid-eligible student pursuant to an Individualized Education Program/Individualized Family Service Plan (IEP/IFSP) under the Individuals with Disabilities Education Act (IDEA) meeting the requirements of these rules and applicable federal and state laws and rules.
(88) “School medical (SM) provider” means an enrolled provider type established by the Division to designate the provider of school-based health services eligible to receive reimbursement from the Division. See the Authority’s general rules chapter 943 division 120, the Division’s General Rules OAR 410-120-1260 (Provider Enrollment), and School-Based Health Services Program OAR 410-133-0140 (School Medical Provider Enrollment Provisions) (School Medical (SM) Provider Enrollment Provisions).
(89) “Screening” means a limited examination to determine a Medicaid-eligible student’s need for a diagnostic medical evaluation.
(90) “Special Education Services” means specially designed instruction to meet the unique needs of a child with a disability, including regular classroom instruction, instruction in physical education, home instruction, and instruction in hospitals, institutions, special schools, and other settings.
(91) “Speech-Language Pathology Assistant (SLPA)” means a person who is licensed by the Oregon State Board of Examiners for Speech-Language Pathology and Audiology and provides speech-language pathology services under the direction and supervision of a speech-language pathologist licensed under ORS 681.250 (Requirement for license in speech-language pathology or audiology).
(92) “Speech-Language Pathologist” means a licensed speech pathologist within the scope of practice as defined by state or federal law licensed by the Oregon Board of Examiners for Speech-Language Pathology and Audiology or holds a license issued by the Teacher Standards and Practice Commission (TSPC) prior to July 1, 2016, exemption in ORS 681.230 (Exemptions from licensure requirement)(4) pursuant to SB287, and holds a Certificate of Clinical Competency (CCC) from the American Speech and Hearing Association (ASHA) or has completed the equivalent educational requirements and work experience necessary for the certificate or has completed the academic program and is acquiring supervised work experience to qualify for the certificate. (See Medically Qualified Staff 410-133-0120 (Medically Qualified Staff).)
(93) “Speech-language pathology services” means assessment of children with speech-language disorders, feeding/swallowing disorders, diagnosis, and appraisal of specific speech-language disorders and referral for medical and other professional attention necessary for the habilitation or rehabilitation of speech-language disorders, feeding/swallowing disorders and the provision of speech-language services for the prevention and treatment of communicative and feeding/swallowing disorders. It includes obtaining and interpreting information, coordinating care, and integrating necessary and appropriate speech-language pathology services relative to the student receiving services.
(94) “State Education Agency (SEA).” See “Oregon Department of Education (ODE).”
(95)” State-operated school” means the Oregon School for the Deaf. See “Educational Agency.”
(96) “Student health/medical/nursing records” means education records that document for purposes of the Health Systems Division, Medical Assistance Program the Medicaid-eligible student’s diagnosis or the results of tests, screens, or treatments, treatment plan, the Individualized Education Program (IEP) or Individualized Family Service Plan (IFSP), and the record of treatments or health services provided to the child or student in compliance with the respective licensed practitioner’s scope of practice and licensure or certification.
(97) “Teacher Standards and Practices Commission (TSPC)” means the commission that governs licensing of teachers, personnel, service specialists, and administrators as set forth in OAR chapter 584. For schools or school providers to participate in the Medicaid program and receive Medicaid reimbursement, they must meet the Medicaid provider qualifications. It is not sufficient for a state to use Department of Education provider qualifications for reimbursement of Medicaid-covered health services provided in an education setting.
(98) Telehealth for School Based Health Services (SBHS) is a real time interactive and synchronous audio/video technology from site to site regarding a Medicaid-eligible child’s health-related service. Telehealth is the equivalent to face-to-face therapy/treatment between a licensed practitioner/clinician or under the supervision of a practitioner/clinician within the scope of practice.
(a) Telehealth may occur between an alternate site such as the child/student’s home, childcare facility, or other public education programs and settings, and the distant site setting of the practitioner/clinician.
(b) Telehealth can be interactive audio/telephonic services provided to a child/student in a geographical area where synchronous audio and video is not available or consent for audio/video is refused for services provided to a child/student.
(c) Telehealth may include coordinated care defined in Definitions 410-133-0040 (Definitions)(16).
(99) “Testing Technician” means a person/technician adequately trained to administer and score specific tests as delegated under the direction and supervision of a licensee and maintains standards for the testing environment and testing administration as set forth in the American Psychological Association Standards for Educational and Psychological Tests (1999) and Ethical Principles for Psychologists (2002). See ORS 675.010 (Definitions for ORS 675.010 to 675.150)(4) and 858-010-0002 (Guidelines for Supervising Technicians).
(100) “Trading partner” means a provider, prepaid health plan (PHP), clinic, or allied agency that has entered into a trading partner agreement with the Department in order to satisfy all or part of its obligations under a contract by means of electronic data interchange (EDI), electronic remittance advice (ERA), electronic media claims (EMC), or any other mutually agreed means of electronic exchange or transfer of data. EDI transactions must comply with the requirements of the EDI rules OAR 407-120-0100 (Definitions) through 407-120-0200 (Department System Administration). For the purposes of these rules EDI does not include electronic transmission by web portal.
(101) “Trading partner agreement (TPA)” means a specific request by a provider, PHP, clinic, or allied agency to conduct EDI transactions that governs the terms and conditions for EDI transactions in the performance of obligations under a contract. A provider, PHP, clinic, or allied agency that has executed a TPA will be referred to as a trading partner in relation to those functions.
(102) “Transportation Aide” means an individual trained for health and safety issues to accompany a Medicaid-eligible student transported to and from a covered Health Service as specified in the Individualized Education Program/individualized Family Service Plan (IEP/IFSP). The School Medical (SM) Provider must maintain documentation of the training, supervision, and provision of the services billed to Medicaid. For the purposes of these rules, individual transportation aides are included in the cost calculation for transportation costs and will not be billed separately. This computation will not include delegated health care aides for whom costs are direct costs.
(103) “Transportation as a related service” means specialized transportation adapted to serve the needs of a Medicaid-eligible student to and from a covered health service that is necessary and appropriate and described in the Individualized Education Program/individualized Family Service Plan (IEP/IFSP) as outlined in OAR 410-133-0080 (Coverage) (Coverage).
(104) “Transportation vehicle trip log” means a record or log kept specifically for tracking each transportation trip a Medicaid-eligible student receives transportation to or from a covered health service. (See SBHS OAR 410-133-0245 (Cost Determination and Payment), Cost Determination and Payment.)
(105) “Treatment Plan” means a written plan of care services, including treatment with proposed location, frequency and duration of treatment as required by the health care practitioner’s health licensing agency.
(106) “Unit” means a service measurement of time for billing and reimbursement efficiency. One unit equals 15 minutes unless otherwise stated.
(107) “Visit” means a service measurement of time for billing and reimbursement efficiency. One visit equals the school provider’s hourly cost rate for category of service provided (i.e., occupational therapy, physical therapy, speech therapy, etc.) specified in an IEP or IFSP, divided by 60 to yield a cost per minute, and multiplied by amount of service time provided in minutes. For billing purposes, a visit is always presented as one visit.
(108) “Web Portal submitter” means an individual or entity authorized to establish an electronic media connection with the Health Systems Division, Medical Assistance Programs to conduct a direct data entry transaction. A web portal submitter may be a provider or a provider’s agent.

Source: Rule 410-133-0040 — Definitions, https://secure.­sos.­state.­or.­us/oard/view.­action?ruleNumber=410-133-0040.

Last Updated

Jun. 8, 2021

Rule 410-133-0040’s source at or​.us