Or. Admin. Code § 410-148-0100

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

Section 410-148-0100 - Reimbursement

(1) Drug ingredients (medications) shall be reimbursed as defined in the Division of Pharmaceutical Services administrative rules (chapter 410, division 121).

(2) The following service/goods shall 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 which is medically appropriate and meets the criteria specified in Chapter 410, Division 148 administrative rules;

(b) Oral nutritional supplements which are medically appropriate and meet the criteria specified in Chapter 410, Division 148 administrative rules;

(c) Parenteral nutrition solutions which are medically appropriate and meet the criteria specified in Chapter 410, Division 148 administrative rules;

(3) Reimbursement for services shall be based on the lesser of the amount billed, or the Division maximum allowable rate. When the service is covered by Medicare, reimbursement shall 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 shall 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 (7) days per week delivery and pickup services (includes mileage).

(5) Reimbursement shall 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 nutritional supplements when the client is able to meet recommended caloric/protein and micronutrient intake through the consumption of food items or meals;

(e) Tocolytic pumps for pre-term labor management;

(f) Home enteral/parenteral nutrition or IV services outside of the client's place of residence. A client's place of residence can be an assisted living facility, 24-hour residential care facility, adult foster home, child foster home, or a private home.

(6) The Oregon Health Plan (OHP) shall be primary payer, before the Women's, Infant and Children (WIC) program, for all formula covered by OHP to treat those infants and children who are enrolled in both OHP and participating in the WIC program.

Or. Admin. Code § 410-148-0100

HR 26-1990, f. 8-31-90, cert. ef. 9-1-90; OMAP 46-2001, f. 9-24-01, cert. ef. 10-1-01, Renumbered from 410-121-0720; OMAP 3-2003, f. 1-31-03, cert. ef. 2-1-03; OMAP 22-2003, f. 3-26-03, cert. ef. 4-1-03; OMAP 64-2004, f. 9-10-04, cert. ef. 10-1-04; DMAP 11-2007, f. 6-14-07, cert. ef. 7-1-07; DMAP 23-2009, f. 6-12-09, cert. ef. 7-1-09; DMAP 33-2024, temporary amend filed 01/12/2024, effective 1/12/2024 through 7/9/2024; DMAP 95-2024, amend filed 05/30/2024, effective 7/1/2024; DMAP 116-2024, amend filed 08/09/2024, effective 8/9/2024

Statutory/Other Authority: ORS 413.042

Statutes/Other Implemented: ORS 414.065