OAR 410-148-0100
Reimbursement
(1)
Drug ingredients (medications) shall be reimbursed as defined in the Division of Medical Assistance Programs (Division) Pharmaceutical Services administrative rules (chapter 410, division 121).(2)
The following service/goods will be reimbursed on a fee-for-service basis according to the Division EPIV Fee Schedule found in the Home Enteral/Parenteral Nutrition and IV Services on the Division website:(a)
Enteral formula;(b)
Oral nutritional supplements which are medically appropriate and meet the criteria specified in 410-148-0260 (Home Enteral Nutrition);(c)
Parenteral nutrition solutions;(3)
Reimbursement for services will be based on the lesser of the amount billed, or the Division maximum allowable rate. When the service is covered by Medicare, reimbursement will be based on the lesser of the amount billed, Medicare’s allowed amount, or the Division maximum allowable rate.(4)
Reimbursement for supplies that require authorization or services/supplies that are listed as Not Otherwise Classified (NOC) or By Report (BR) must be billed to the Division at the providers’ acquisition cost, and will be reimbursed at such rate.(a)
For purposes of this rule, Acquisition Cost is defined as the actual dollar amount paid by the provider to purchase the item directly from the manufacturer (or supplier) plus any shipping and/or postage for the item. Submit documentation identifying acquisition cost with your authorization request;(b)
Per diem, as it relates to reimbursement, represents each day that a given patient is provided access to a prescribed therapy. This definition is valid for per diem therapies of up to and including every 72 hours.(c)
Per diem reimbursement includes, but is not limited to:(A)
Professional pharmacy services:(i)
Initial and ongoing assessment/clinical monitoring;(ii)
Coordination with medical professionals, family and other caregivers;(iii)
Sterile procedures, including IV admixtures, clean room upkeep and all biomedical procedures necessary for a safe environment;(iv)
Compounding of medication/medication set-up.(B)
Infusion therapy related supplies:(i)
Durable, reusable or elastomeric disposable infusion pumps;(ii)
All infusion or other administration devices;(iii)
Short peripheral vascular access devices;(iv)
Needles, gauze, sterile tubing, catheters, dressing kits, and other supplies necessary for the safe and effective administration of infusion therapy.(C)
Comprehensive, 24-hour per day, seven days per week delivery and pickup services (includes mileage).(5)
Reimbursement will not be made for the following:(a)
Central catheter insertion or transfusion of blood/blood products in the client’s home;(b)
Central catheter insertion in the nursing facility;(c)
Intradialytic parenteral nutrition in the client’s home or Nursing Facility;(d)
Oral infant formula that is available through the Women’s, Infant and Children (WIC) program;(e)
Oral nutritional supplements that are in addition to consumption of food items or meals.(f)
Tocolytic pumps for pre-term labor management;(g)
Home enteral/parenteral nutrition or IV services outside of the client’s place of residence (i.e. home, nursing facility or AIS).
Source:
Rule 410-148-0100 — Reimbursement, https://secure.sos.state.or.us/oard/view.action?ruleNumber=410-148-0100.