Professional Ambulatory Services
(1)Providers must use the following rules in conjunction with all individual program rules to determine service coverage and limitations for Oregon Health Plan (OHP) clients according to their benefit packages: Medical, EPSDT, Diagnostic, Dental, Vision, Physical Therapy, Occupational Therapy, Podiatry, Mental Health, Alcohol and Chemical Dependency, Maternity Case Management, Speech, Hearing, and Home Health services are governed by the Federally Qualified Health Center (FQHC) and Rural Health Clinic (RHC) rules (OAR 410 division 147), General Rules (410 division 120), OHP Administrative Rules (410-141-0480, 410-141-0500, and 410-141-0520), and the Health Services Commission’s (HSC) Prioritized List of Health Services (List), and the Oregon Health Authority (Authority) rules related to provider enrollment and claiming (943-120-0300 (Definitions) through 0380).
(2)Federally Qualified Health Centers (FQHCs) and Rural Health Clinics (RHCs) are eligible for reimbursement of covered professional services provided within the scope of the clinic and within the individual practitioner’s scope of license or certification. See also OAR 410-147-0120 (Division Encounter and Recognized Practitioners)(6). For the purposes of this rule, a clinic’s “scope” refers to authorization or certification to provide services if required:
(a)For FQHCs only, services must be provided in accordance with the FQHC’s scope as approved by the Health Resources and Services Administration (HRSA) Notice of Grant Award Authorization; and
(b)Both FQHCs and RHCs must provide services within the scope of the Addictions and Mental Health Division (AMH) certification for the facility, if required. See OAR 410-147-0320 (Federally Qualified Health Center Rural Health Clinics Enrollment)(3) and (5).
(3)The date of service determines the appropriate version of the FQHC and RHC rules, General Rules, and HSC Prioritized List to determine coverage.
Rule 410-147-0020 — Professional Ambulatory Services,