OAR 410-133-0080: Coverage

(1) Services provided or supervised by Medicaid-enrolled SBHS-recognized providers are covered when EPSDT medical necessity and appropriateness are supported by: (a) For planned services: (A) The child or young adult’s IPOC; and (B) The rendering provider’s service documentation. (b) For unplanned services, the rendering provider’s service documentation which must include: (A) Date of service; (B) Medicaid-enrolled child or young adult’s: (i) Full name; (ii) Medicaid ID; and (iii) Diagnosis code(s); (C) Name of the school medical provider; (D) Name of the rendering provider performing the service; (E) Name of the healthcare provider supervising the service (when applicable); (F) Medically necessary and appropriate need for the service; (G) Location and duration of the service; and (H) Nature, extent, or units of service. (2) Specialized transportation services are covered when: (a) The child or young adult requires specialized transportation to serve their individual health-related needs; (b) Specified as a related service in the child or young adult’s IEP or IFSP; (c) Documentation supports specialized transportation is medically necessary and appropriate; (d) A separate school-based health service, other than transportation, specified on the child or young adult’s IEP or IFSP is provided and reimbursed on the same day; and (e) Supported by a transportation vehicle trip log.