OAR 410-140-0020
Service Delivery

(1)

The Division enrolls the following as providers of vision services:

(a)

An individual licensed by the relevant state licensing authority to practice optometry; and

(b)

A licensed ophthalmologist; and

(c)

An optician as defined in ORS 683.510 (Definitions for ORS 683.520 to 683.530)-683.530 (Discrimination against opticians prohibited);

(2)

Division clients are enrolled for covered health services to be delivered through one of the following means:

(a)

Prepaid Health Plan (PHP) or Coordinated Care Organization (CCO):

(A)

Payment for all vision services provided to PHP and CCO members by ophthalmologists, optometrists, and opticians is a matter between the provider and the PHP or CCO;

(B)

Providers shall comply with PHP and CCO policies, including PA requirements, for reimbursement. Providers shall inform PHPs and CCOs of the last date of service when inquiring on service limitations. Failure to follow PHP and CCO rules may result in the denial of payment; and

(C)

If the provider has been denied payment for failure to follow the rules established by the PHP or CCO, neither the Division, the PHP or CCO, nor the PHP or CCO member are responsible for payment; and

(D)

If the PHP or CCO uses the Division’s visual materials contractor or another visual materials contractor for visual materials and supplies, all issues shall be resolved between the PHP or CCO and the contractor;

(b)

Fee-for-service (FFS):

(A)

FFS clients are not enrolled in a PHP or CCO and may receive vision services from any Division-enrolled provider that accepts FFS clients subject to limitations and restrictions in the visual services program rules; and

(B)

All claims shall be billed directly to the Division.

(3)

The provider shall verify whether a PHP, CCO, or the Division is responsible for reimbursement.

(4)

If a client receives services under section (2)(b) of this rule:

(a)

The Division may require a PA for certain covered services or items before the service may be provided and before payment is made; and

(b)

Providers needing materials and supplies shall order those directly from SWEEP Optical, except when the OHP client has primary Medicare coverage.

(5)

Most OHP clients must pay a co-payment for some services. (See OAR 410-120-1230, Client Co-payment, and Table 120-1230-1 outlining details including client and service exemptions).

Source: Rule 410-140-0020 — Service Delivery, https://secure.­sos.­state.­or.­us/oard/view.­action?ruleNumber=410-140-0020.

Last Updated

Jun. 8, 2021

Rule 410-140-0020’s source at or​.us