OAR 410-172-0860
Billing for Dual Eligible Individuals

(1)

As described in OAR 410-120-1280 (Billing) (8), when an individual has both Medicare and coverage through Medicaid, providers shall make reasonable efforts to obtain payment from other resources including Medicare or other Third Party Liability (TPL).

(2)

In accordance with OAR 410-120-1280 (Billing) (f), OAR 410-141-0420, and OAR 410-141-3420, behavioral health providers may bill the Division directly and may not be required to bill Medicare under the following circumstances:

(a)

For behavioral health services that are never covered by Medicare or another insurer;

(b)

For behavioral health services that are not covered when rendered by the following provider types:

(A)

Qualified Mental Health Professional (non-licensed) as defined in OAR 309-019-0105 (Definitions);

(B)

Qualified Mental Health Associate as defined in OAR 309-019-0105 (Definitions);

(C)

Professional Counselor or Marriage and Family Therapist licensed by the Oregon Board of Licensed Professional Counselors and Therapists;

(D)

Certified Peer Support Specialist as defined in OAR 410-180-0305 (Definitions);

(E)

Recovery Assistant;

(F)

Certified Alcohol and Drug Counselor.

Source: Rule 410-172-0860 — Billing for Dual Eligible Individuals, https://secure.­sos.­state.­or.­us/oard/view.­action?ruleNumber=410-172-0860 (accessed May 26, 2025).

410–172–0600
Acronyms and Definitions 410–172–0610
Provider Enrollment 410–172–0620
Documentation Standards 410–172–0630
Medically Appropriate 410–172–0640
Behavioral Health Services Fee Schedule 410–172–0650
Prior Authorization 410–172–0660
Rehabilitative Behavioral Health Services 410–172–0670
Substance Use Disorder Treatment Services 410–172–0680
Residential Treatment Services for Children 410–172–0690
Admission Procedure for Residential Treatment Services for Children 410–172–0695
Intensive In-Home Behavioral Health Treatment Services for Youth (IIHBT) 410–172–0705
Residential Rate Standardization 410–172–0710
Residential Personal Care 410–172–0720
Prior Authorization and Re-Authorization for Residential Treatment 410–172–0730
Payment Limitations for Behavioral Health Services 410–172–0745
Exception Criteria for Facial Gender Confirmation Surgery (FGCS) 410–172–0760
Applied Behavior Analysis 410–172–0770
Individual Eligibility for Applied Behavioral Analysis Treatment 410–172–0780
Behavioral Health Personal Care Attendant Program 410–172–0790
Eligibility for Behavioral Health Personal Care Attendant Services 410–172–0800
Personal Care Attendant Employer-Employee Relationship 410–172–0810
Personal Care Attendant Qualifications 410–172–0820
Provider Termination 410–172–0830
Personal Care Attendant Service Assessment, Authorization, and Monitoring 410–172–0840
Personal Care Attendant Payment Limitations 410–172–0850
Telemedicine for Behavioral Health 410–172–0860
Billing for Dual Eligible Individuals

May 26, 2025

Rule 410-172-0860's source at or​.us