OAR 410-130-0220: Not Covered/Bundled Services/Not Valid

(1) Under the Division’s Fee-for-Service Medical-Surgical program, no payment shall be made for (a) and (b) of this section except in accordance with applicable exceptions as defined in administrative rule: (a) For the purposes of this rule, the billing codes that are not covered shall be: (A) Services below the funding line or otherwise specified as not covered on the Health Evidence Review Commission (HERC) Prioritized List of Health Services as referenced in OAR 410-141-3830; (B) Services specified in OAR 410-120-1200; (C) For Ambulatory Surgical Centers, services listed on Medicare’s ASC Covered Surgical Procedures file addendum EE, Surgical Procedures to Be Excluded from Payment in ASCs as referenced in OAR 410-120-1340. (b) For the purposes of this rule, the billing codes that are not eligible for separate reimbursement shall be: (A) Services listed in Medicare’s Physician Fee Schedule RVU file as referenced in OAR 410-120-1340 that have a code status of B (Bundled Code) or P (Bundled/Excluded Codes). Services billed with billing codes 98960-98962 are excepted from this subsection and may be reimbursed separately; (B) For Ambulatory Surgical Centers, services listed on Medicare’s ASC Covered Surgical Procedures file as referenced in OAR 410-120-1340 that have payment indicator N1 (Packaged service) or L1 (Packaged item/service); (C) Certain services listed in the Medicare’s Physician Fee Schedule RVU file that have a code status of I (Not valid for Medicare purposes) as referenced in OAR 410-120-1340. Services with this status code are eligible for separate reimbursement only when listed on the Authority’s published fee schedule; (D) Services listed in the Medicare’s Physician Fee Schedule RVU file that have a code status of M (Measurement codes) or Q (Therapy functional information code) as referenced in OAR 410-120-1340. (2) In the event that a covered Fee-for-Service Medical-Surgical program service does not have a payment methodology specified in OAR 410-120-1340 or in other program specific rules, the division may set a reasonable rate for the service’s billing codes or designate that the service’s billing codes do not pay separately. No reimbursement shall be made for services designated to not pay separately. (3) Nothing in this rule is intended to prevent payment for services by CCOs or in programs other than the Division’s Fee-for-Service Medical-Surgical program. See applicable rules for CCO payment and other programs.