Or. Admin. Code § 410-123-1060

Current through Register Vol. 63, No. 11, November 1, 2024

Section 410-123-1060 - Definition of Terms

(1) "Abuse" has the meaning as provided in OAR 410-120-0000.

(2) "Acute" has the meaning as provided in OAR 410-120-0000.

(3) "Ambulatory Surgical Center (ASC)" has the meaning as provided in OAR 410-120-0000.

(4) "Anesthesia" refers to the Oregon Board of Dentistry administrative rules (OAR chapter 818, division 026).

(5) "Anesthesia Services" has the same meaning as OAR 410-120-0000 and means administration of anesthetic agents to cause loss of sensation to the body or body part.

(6) "By Report (BR)" has the meaning as provided in OAR 410-120-0000.

(7) "Current Dental Terminology (CDT)" means a listing of descriptive terms identifying dental procedure and nomenclature used by the American Dental Association.

(8) "Citizenship Waived Medical" has the meaning as provided in OAR 410-120-0000. The acronym "CWM" has the same meaning.

(9) "CMS-416" means the annual EPSDT participation report required by Section 1902(a)(43)(D) of the Social Security Act, which assesses the Oregon Health Plan's effectiveness in providing screening and dental services for EPSDT eligible children according to the appropriate periodicity schedule. For the purpose of the measurement, "Dental" services refer to services provided by or under the supervision of a dentist. "Oral health" services refer to services provided by a licensed practitioner that is not a dentist. For example, a pediatrician that applies a fluoride varnish, or an independently practicing dental hygienist not under the supervision of a dentist.

(10) "Covered Services" has the meaning as provided in OAR 410-120-0000.

(11) "COVID-19 Emergency" means the period:

(a) Starting on the earliest of any COVID-19 public health emergency affecting the delivery of health care services and declared by the Secretary of HHS pursuant to 42 U.S.C. § 247d, by the Governor of Oregon, or by the Authority; and

(b) Ending on the latest of any COVID-19 public health emergency affecting the delivery of health care services and declared by the Secretary of HHS pursuant to 42 U.S.C. § 247d, by the Governor of Oregon, or by the Authority.

(12) "Dental" means conditions having to do with the teeth and supporting structures.

(13) "Dental Care Organization" (DCO).

(14) "Dental Care Organization" (DCO) as provided for in ORS 414.025(24) means a pre-paid managed care health services organization that provides, either by contract with a coordinated care organization or through other mechanisms;

(a) dental services to the coordinated care organization's members, on a pre-paid capitated basis; or

(b) administrative services on behalf of the coordinated care organization as they relate to the delivery of dental services, including, without limitation: provider credentialing, prior authorization or denial of services, or encounter claims processing; or

(c) or both of the foregoing.

(15) "Dental Emergency Services" has the meaning as provided in OAR 410-120-0000. For the purpose of Division rules, Dental Emergency Services is synonymous with emergency dental care and emergency oral health care.

(16) "Dental Hygienist" has the meaning as provided in OAR 410-120-0000.

(17) "Dental Hygienist with Expanded Practice Dental Hygiene Permit (EPDH)" has the meaning as provided in OAR 410-120-0000.

(18) "Dental Practitioner" means an individual licensed pursuant to state law to engage in the provision of dental services within the scope of the practitioner's license and certification.

(19) "Dental Services" has the meaning as provided in OAR 410-120-0000, and means services provided within the scope of practice as defined under state law by or under the supervision of a dentist or dental hygienist or denture services provided within the scope of practice as defined under state law by a denturist or Expanded Practice Permit (EPP).

(20) "Dental Services Documentation" means meeting the requirements of the Oregon Dental Practice Act statutes, administrative rules for member records and requirements of OAR 410-120 1360 Requirements for Financial, Clinical and Other Records, and any other Documentation requirements as outlined in OAR chapter 410 division 123 (Dental rules).

(21) "Dental Emergency Condition" means any incident involving the teeth and gums which would require immediate treatment to stop ongoing tissue bleeding, alleviate severe and sudden pain or infection, treat unusual swelling of the face or gums, or to preserve an avulsed tooth:

(a) Emergency conditions are based on the presenting symptoms (not the final diagnosis) as perceived by a prudent layperson (rather than a Health Care Professional) and includes cases in which the absence of immediate medical attention would not in fact have had the adverse results;

(b) The treatment of an emergency dental condition is limited only to Covered Services. The Division recognizes that some non-Covered Services may meet the criteria of treatment for the emergency condition; however, this rule does not extend to those non-Covered Service.

(22) "Dental Therapist" has the meaning provided in ORS 679.010.

(23) "Dentally Appropriate" has the meaning as provided in OAR 410-120-0000.

(24) "Dentist" has the meaning as provided in OAR 410-120-0000.

(25) "Denturist" has the meaning as provided in OAR 410-120-0000.

(26) "Distant Site" means the site where the dentist is being contacted for consultation by the originating site.

(27) "Documentation" means dental services documentation which meets the requirements of the Oregon Dental Practice Act statutes, administrative rules for member records and requirements of OAR 410-120 1360 Requirements for Financial, Clinical and Other Records, and any other documentation requirements as outlined in OAR chapter 410 division 123 (Dental rules).

(28) "Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) Services" means the federally mandated comprehensive and preventative child health program for individuals under the age of 21, under the Omnibus Budget Reconciliation Act of 1989 and Section 1905(r)(5) of the Social Security Act. Consistent with state and federal law and regulations, the OHP Dental Program ensures that all dentally necessary services and screenings are provided, either directly or through an Authority contracted MCE for EPSDT covered services.

(29) "Fee-for-Service Provider (FFS)" has the meaning as provided in OAR 410-120-0000.

(30) "Fraud" has the meaning as provided in OAR 410-120-0000.

(31) "Health Care Interpreter (HCI)" means an individual who has been approved and certified by the Authority under ORS 413.558 to accurately interpret oral statements and documents to a person with limited English proficiency or in sign language. Qualified Health Care Interpreter has the same meaning.

(32) "Health Systems Division" has the meaning as provided in OAR 410-120-0000, and is within the Authority. The Division is responsible for managing the Oregon Health Plan (OHP), which is Oregon's Medicaid program.

(33) "Hospital Dentistry" means dental services normally done in a dental office setting but due to specific member need (as detailed in OAR 410-123-1490) are provided in an ambulatory surgical center, inpatient or outpatient hospital setting under general anesthesia, or IV conscious sedation, if appropriate.

(34) "Interpreter Services" means services available to those with Limited English Proficiency (LEP) as described in Title VI of the Civil Rights Act of 1964; Section 1557 of the Affordable Care Act; and ORS 413.550 for Meaningful Language Access Interpreter services may also be accessed for deaf or hard of hearing members to ensure effective communication, as required by the Americans with Disabilities Act. The interpreter shall be a certified or qualified health care interpreter (HCI).

(35) "Managed Care Entity (MCE)" is a general term that means an entity that enters into one or more contracts with the Authority to provide services in a managed care delivery system, including but not limited to the following types of entities defined in and subject to 42 CFR Part 438 : managed care organizations (MCOs), primary care case managers (PCCMs), prepaid ambulatory health plans (PAHPs), and prepaid inpatient health plans (PIHPs). A CCO is an MCE for its managed care contract(s) with the Authority, without regard to whether the contract(s) involves federal funds or state funds or both.

(36) "Medical Practitioner" means an individual licensed pursuant to state law to engage in the provision of medical services within the scope of the practitioner's license and certification.

(37) "Medicament" means a substance or combination of substances intended to be pharmacologically active, specially prepared to be prescribed, dispensed, or administered to prevent or treat disease.

(38) "Oral Health" means conditions of the lips, tongue, inner cheeks, soft and hard palate.

(39) "Oral Health Care" means services including, but not limited to, diagnostic, preventive, therapeutic, urgent, or emergency services provided by dental practitioners, dental specialists, dental hygienists, dental therapists, and trained primary care providers. In the dental field, oral health care and dental health care are used synonymously.

(40) "Oral Health Services" means services provided by a non-dentist (such as primary care physicians and nurse practitioners) and not under a dentist's supervision.

(41) "Originating Site" means the site where the member is located, and dental care providers are working and performing services in conjunction with a dentist who is not at that site, all while using telehealth technology.

(42) "Overpayment" has the meaning as provided in OAR 410-120-0000.

(43) "Physician" has the meaning as provided in OAR 410-120-0000.

(44) "Prepaid Ambulatory Health Plans" has the meaning provided in 42 CFR § 438.2. The acronym "PAHP" has the same meaning.

(45) "Primary Care Dentist (PCD)" as stated in OAR 410-120-0000, means a dental practitioner responsible for supervising and coordinating initial and primary dental care within their scope of practice for their members.

(46) "Primary Care Provider (PCP)" as stated in OAR 410-120-0000, means any enrolled medical assistance provider who has responsibility for supervising, coordinating, and providing initial and primary care within their scope of practice for identified members. PCPs initiate referrals for care outside their scope of practice, consultations, and specialist care and assure the continuity of medically appropriate member care. A Federally qualified PCP means a physician with a specialty or subspecialty in family medicine, general internal medicine, or pediatric medicine as defined in OAR 410-130-0005.

(47) "Prior Authorization" has the meaning as provided in OAR 410-120-0000. The acronym "PA" has the same meaning.

(48) "Prioritized List of Health Services" (The List) means the comprehensive list of health services, ranked by priority, from the most important to the least important. The Oregon Health Plan benefits are made from The List and determined by the Oregon Legislature.

(49) "Procedure Codes" means the procedure codes set forth in OAR chapter 410, division 123 that refer to Current Dental Terminology (CDT), unless otherwise noted. Codes listed in this rule and other documents incorporated in rule by reference are subject to change by the American Dental Association (ADA) without notification.

(50) "Provider" has the meaning as provided in OAR 410-120-0000.

(51) "Referral" as stated in OAR 410-120-0000, means the transfer of total or specified care of a member from one provider to another. As used by the Authority, the term referral also includes a request for a consultation or evaluation or a request or approval of specific services.

(52) "Standard of Care" means what reasonable and prudent practitioners would do in the same or similar circumstances.

(53) "Teledentistry" means the modes specified in OAR 410-123-1265, using electronic and telecommunications technologies, for the distance delivery of dental care services and clinical information designed to improve a member's health status and to enhance delivery of the health care services and clinical information.

(54) "Telehealth" means for the purposes of OAR 410-123-1265, OAR 410-120-1990 and as specified in ORS 679.543, methods using electronic and telecommunications technologies for the distance delivery of health care services, including dental care services and clinical information designed to improve a member's health status and to enhance delivery of the health care services and clinical information.

(55) "Urgent Dental Care" means the management of conditions that require prompt attention to relieve pain and/or risk of infection and to alleviate the burden on hospital emergency departments. These shall be treated as minimally invasively as possible. Urgent dental care is distinguished from emergency dental care in that, urgent dental care requires prompt but not immediate treatment. Examples include dull toothache, mildly swollen gums, or small chips or cracks in teeth. Pregnant members shall be seen or treated for Urgent Dental care within one week and non-pregnant members within two weeks. Urgent care treatment is limited to covered services.

Or. Admin. Code § 410-123-1060

HR 3-1994, f. & cert. ef. 2-1-94; OMAP 13-1998(Temp), f. & cert. ef. 5-1-98 thru 9-1-98; OMAP 28-1998, f. & cert. ef. 9-1-98; OMAP 23-1999, f. & cert. ef. 4-30-99; OMAP 17-2000, f. 9-28-00, cert. ef. 10-1-00; OMAP 48-2002, f. & cert. ef. 10-1-02; OMAP 49-2004, f. 7-28-04 cert. ef. 8-1-04; DMAP 25-2007, f. 12-11-07, cert, ef. 1-1-08; DMAP 16-2009 f. 6-12-09, cert. ef. 7-1-09; DMAP 41-2011, f. 12-21-11, cert. ef. 1-1-12; DMAP 46-2011, f. 12-23-11, cert. ef. 1-1-12; DMAP 13-2013, f. 3-27-13, cert. ef. 4-1-13; DMAP 75-2013(Temp), f. 12-31-13, cert. ef. 1-1-14 thru 6-30-14; DMAP 36-2014, f. & cert. ef. 6-27-14; DMAP 34-2016, f. 6-30-16, cert. ef. 7/1/2016; DMAP 61-2020, amend filed 12/11/2020, effective 1/1/2021; DMAP 50-2021, amend filed 12/24/2021, effective 1/1/2022; DMAP 24-2022, minor correction filed 02/16/2022, effective 2/16/2022; DMAP 89-2022, amend filed 12/16/2022, effective 1/1/2023; DMAP 79-2023, amend filed 09/26/2023, effective 10/1/2023; DMAP 59-2024, minor correction filed 02/21/2024, effective 2/21/2024

Statutory/Other Authority: ORS 413.042 & ORS 414.065

Statutes/Other Implemented: ORS 414.065