OAR 410-133-0040: Definitions

In addition to the definitions in OAR 410-120-0000 and OAR 410-141-0001, the following definitions apply to these rules: (1) “Adapted vehicle” means a vehicle that has been physically adjusted or designed to meet the needs of the individual student under IDEA (e.g., special harnesses, wheelchair lifts, ramps, specialized environmental controls, etc.) to accommodate students with disabilities. Special physical adaptations may also include air conditioning and specialized suspension systems. (2) “Assessment” means an SBHS-recognized provider’s process of obtaining information regarding an individual’s health status. Assessment is process-oriented, focusing on measuring an individual's abilities and providing feedback for improvement. (3) “Assistive technology” means any item, piece of equipment, software program, or product that is used to increase, maintain, or improve functional capabilities to aid an individual with disabilities or functional limitations to perform tasks. (4) “Behavioral health” has the same meaning as defined in OAR 410-172-0600. (5) “Behavioral health supports” means a broad range of mental health wellness supports for students with social and/or relational health needs. Supports may include social skills training or groups, regular check-ins with school staff, development of behavior intervention plans, substance use prevention groups, supporting essential health and well-being needs (such as food insecurity or housing), referral to treatment, and/or coordination with community providers. (6) “Behavioral health treatment” means intensive services for children or young adults with identified mental health or substance use needs. Treatment may include therapeutic interventions such as individual or family therapy sessions, intensive treatment groups related to specific mental health or substance use needs, or risk assessments and safety planning for students experiencing suicidal ideation or other acute behavioral health crises. (7) “Care coordination” means the act and responsibility to deliberately organize culturally and linguistically appropriate services, care activities, and information sharing among all participants involved with a child or young adult’s care according to their physical, developmental, behavioral, dental and social needs. Care coordination involves organizing care activities, sharing information, and consultation to ensure and deliver safe and effective care aligned with the child or young adult’s needs. Care coordination includes but is not limited to training and supervision and communicating and sharing information with the child or young adult’s parent/guardian, physician, community practitioner(s), community organization(s), coordinated care organization (CCO), and staff. (8) “Case Management Services” means services provided to ensure a child or young adult obtains health services necessary to maintain physical, behavioral, and emotional development and oral health. Case management services include a comprehensive, ongoing assessment of medical, behavioral, or dental needs plus the development and implementation of a plan to obtain or make referrals for needed medical, behavioral, or dental services, referring members to community services and supports. (9) “Centers for Medicare and Medicaid Services (CMS)” means the federal regulatory agency for Medical Assistance Programs, including Medicaid. (10) “Child or young adult” means an individual from birth through the school year in which they turn 21. (11) “Delegation process” has the same meaning as defined in OAR 851-006-0011. The delegation process must be completed in compliance with OAR Chapter 851, Division 47 Standards for Registered Nurse Delegation Process. (12) “Diagnosis code” has the same meaning as defined in OAR 410-120-0000. (13) “Early and Periodic Screening, Diagnostic and Treatment (EPSDT)” has the same meaning as defined in OAR 410-120-0000. (14) “Early Intervention/Early Childhood Special Education (EI/ECSE)” has the same meaning as defined in OAR 581-015-2000. (15) “Education agency” means, for the purposes of these rules, a public school district, EI/ECSE contractor or subcontractor, education service district, or a state institution providing educational services or transition services (defined in OAR Chapter 581, Division 15) to children and young adults that receives state or federal funds either directly or by contract or subcontract with the Oregon Department of Education (ODE). The ODE is considered a local unit of government pursuant to 42CFR 433.51. (16) “Education service district (ESD)” means a district created under ORS 334.010 that provides regional educational services to component school districts. (17) “Evaluation” means an objective examination of an individual’s health status based upon well-defined criteria to inform health-related needs or diagnosis or for the purpose of planning treatment. See also re-evaluation services. (18) “Federal Medical Assistance Percentage (FMAP)” means the federal government’s share of expenditures for the Medicaid and Children’s Health Insurance Program (CHIP) programs. (19) “Health Evidence Review Commission (HERC)” has the same meaning as defined in OAR 410-120-0000. (20) “Health Insurance Portability and Accountability Act of 1996 (HIPAA)” means the federal law (Public Law 104-191, August 21, 1996) with the legislative objective to assure health insurance portability, reduce health care fraud and abuse, enforce standards for health information, and guarantee security and privacy of health information. (21) “Individual Plan of Care (IPOC)” means a prescriptive document for billing Medicaid for planned services provided to a child or young adult in education settings. To serve as the prescriptive document the plan must include the education agency’s name, the specific child or young adult’s first and last name, and each necessary and appropriate health service category including the nature, extent, or units of service and therapeutic value for each service. The IPOC may be an Individualized Education Program (IEP) or Individualized Family Service Plan (IFSP) or any other established and documented individualized health or behavioral health plan if such document contains the necessary, prescriptive elements required to serve as the prescriptive document for billing Medicaid. (22) “Individuals with Disabilities Education Act (IDEA) of 1975” means the federal law ensuring the rights of children with disabilities to a free and appropriate public education (FAPE). (23) “Individualized Education Program (IEP)” has the same meaning as defined in 34 CFR 300.320. (24) “Individualized Family Service Plan (IFSP)” has the same meaning as defined in 34 CFR 303.320. (25) “Medicaid” has the same meaning as defined in OAR 410-120-0000. (26) “Medicaid-enrolled” means an individual member or provider who is enrolled in Oregon’s Medicaid Program. (27) “Medicaid Management Information System (MMIS)” means a statewide system that houses Medicaid data necessary for the business operations of Medicaid administration including, but not limited to, eligible member information, enrolled provider information, procedure and diagnosis codes, and claims data. (28) “Medically Appropriate” has the same meaning as “EPSDT Medically Appropriate” in OAR 410-151-0001. (29) “Medically Necessary” has the same meaning as “EPSDT Medically Necessary” in OAR 410-151-0001. (30) “MMIS Provider Web Portal” means an electronic portal that allows Oregon Medicaid enrolled providers to log in and access relevant information to provide and be reimbursed for services provided to Oregon’s Medicaid-enrolled members. Medicaid-enrolled providers can use the portal to verify member eligibility and managed care assignment, access and query Oregon’s HERC Prioritized List of Health Services, submit and adjust claims for services provided, download claim remittance advices, and more. Non-enrolled providers can apply through the portal to enroll as an Oregon Medicaid provider. (31) “National Provider Identifier (NPI)” has the same meaning as defined in OAR 410-120-0000. (32) “Non-Billing Provider” has the same meaning as defined in OAR 410-120-0000. (33) “Oregon Department of Education (ODE)” means the state agency that provides oversight to public education agencies for ensuring compliance with federal and state laws relating to education. (34) “Oregon Health Authority (Authority)” has the same meaning as defined in OAR 410-120-0000. (35) “Oregon Health Plan (OHP)” has the same meaning as defined in OAR 410-120-0000. (36) “Personal care services” means the provision of, assistance with, or cueing for functional activities, physical or behavioral, that a child or young adult requires for their continued well-being. Personal care services include, but are not limited to, ambulation, mobility, transfers, and positioning, basic personal hygiene, continence/incontinence care, nutrition and feeding, medication management (including administration), redirection and intervention for behavior, and trained, assigned, or delegated services, including delegated nursing procedures. Personal care services are planned services included in an IPOC and deemed medically necessary and appropriate by a supervisory-level, SBHS-recognized provider within their scope of practice. (37) “Planned services” means school-based health services that are provided pursuant to an IPOC. See also unplanned services. (38) “Practitioner” means an individual licensed under state law to engage in the provision of health care services within the scope of the practitioner’s license or certification, including a ‘health care practitioner’ a ‘licensed health care practitioner’ or a ‘practitioner of the healing arts.’ (39) “Prioritized List of Health Services” has the same meaning as defined in OAR 410-120-0000. (40) “Procedure code” means a code or codes used in the Healthcare Common Procedural Coding System (HCPCS) or Current Dental Terminology (CDT). (41) “Re-evaluation” means an objective examination completed after an initial evaluation that focuses on the overall effectiveness of the current treatment, including progress toward current goals, modifying goals or treatment, or making a professional judgment to determine whether or not the child or young adult shall continue to receive one or more health-related services. Continuous monitoring of the child or young adult’s progress as a component of ongoing therapy services is not billable as a re-evaluation. (42) "Referral" means the direction of an individual, based on the individual’s clinical needs and personal choice, to a facility or practitioner for a diagnostic test or health care treatment or service. (43) “SBHS Documentation” means the combination of required information to bill direct services under the SBHS program including, but not limited to, service documentation and the Individual Plan of Care (IPOC), when applicable. (44) “School medical provider” means an enrolled provider type that is established by the Authority to designate the provider eligible to receive Medicaid reimbursement for Medicaid-covered school-based health services. Authority-enrolled education agencies, as defined in this rule, are school medical providers. (45) “Section 504 of The Rehabilitation Act of 1973” means a federal civil rights law, guided by the Americans with Disabilities Act (ADA), that protects qualified individuals from discrimination based on their disability. (46) “Section 504 Accommodation Plan” means a formal plan that provides children and young adults with disabilities specific supports and accommodations needed to access the general education setting. (47) “Specialized transportation” means transportation to a medically necessary service (as outlined in the IEP/IFSP of a Medicaid-enrolled child) provided in a specially adapted vehicle. In all cases, the medical need for physical or environmental adaptations during transport from home to school and back home must be identified in the IEP/IFSP. (48) “Supervisory-level" means the SBHS-recognized provider is licensed or certified to practice independently and may supervise or train other SBHS-recognized providers. (49) “Teacher Standards and Practices Commission (TSPC)” means the commission that governs licensing of teachers, personnel, service specialists, and administrators as set forth in OAR Chapter 584. (50) “Transportation vehicle trip log” means a record or log kept specifically for tracking each transportation trip to or from a Medicaid-covered health service a Medicaid-eligible child or young adult receives. (51) “Treatment Plan” means a licensed healthcare practitioner’s written plan of health services, including treatment with proposed location, frequency, and duration of treatment. A treatment plan must be written by a licensed healthcare practitioner within the scope of the practitioner's license or certification and in compliance with the practitioner’s respective Oregon board. Treatment plans may include but are not limited to behavioral health service plans (see OAR 309-019-0140), a registered nurse’s plan of care (see Oregon’s Nurse Practice Act, OARs Chapter 851), occupational therapy service plans (See OARs Chapter 339, Division 10), and physical therapy plans of care (see OARs Chapter 848, Division 40). (52) “Unit” means a service measurement for billing and reimbursement efficiency. (53) “Unplanned services” means the services and interventions that are urgent or immediate in nature and typically provided outside of services specified on an IPOC. Unplanned services may or may not lead to establishing an IPOC. See also planned services. (54) “Unregulated Assistive Person (UAP)” has the same meaning as defined in OAR 851-006-0011. (55) “Visit” means a service measurement of time for billing and reimbursement efficiency. For billing purposes, a visit is always presented as one (1) visit.