OAR 410-141-3825: Excluded Services and Limitations

(1) The following services are excluded from the Oregon Health Plan Benefit Package, except as otherwise provided in OAR 410-141-3820: (a) Any service identified for exclusion in OAR 410-120-1200 or 410-120-1210; (b) Any service identified in applicable provider guides as a non-covered service, unless the service is identified as specifically covered under the OHP administrative rules; (c) Any service that is not a funded service, even if it is provided for a condition that appears in the funded region of the list, or if the service in question is a funded service when provided for an unfunded diagnosis on the prioritized list; (d) Services that, when provided, are funded services on the Prioritized List of Health Services, but which are otherwise excluded from the OHP Benefit Package for the client in question; (e) Diagnostic services not reasonably necessary to establish a diagnosis or guide management or treatment decisions, regardless of whether the condition or treatment in question is a funded service; (f) Services requested by OHP clients in an emergency care setting that do not satisfy the coverage rules in OAR 410-141-3820; (g) Services provided to an OHP client outside the territorial limits of the United States, except in those instances in which the country operates a Medical Assistance (Title XIX) program; (h) Services other than inpatient care provided to an OHP client who is in the custody of a law enforcement agency or an inmate of a non-medical public institution, including juveniles in detention facilities, per OAR 410-141-3810; (i) Services received while the client is outside the MCE's service area, except for services that were: (A) Ordered or referred by the client’s primary care provider; or (B) Urgent or emergency services; or (C) Otherwise covered pursuant to rule or the MCE contract; (D) This exclusion does not apply if the client was outside the MCE's service area because of circumstances beyond the client’s control. Factors to be considered include but are not limited to death of a family member outside of the MCE’s service area. If the client successfully establishes this fact, including during the grievance and appeal process, then this exclusion does not apply. (2) The following services are limited or restricted: (a) Any service which exceeds those that are medically appropriate and necessary to provide reasonable diagnosis and treatment; enable the OHP client to attain or retain the capability for independence or self-care; or screen for preventable disease or disease exacerbation. This limitation includes services that, upon medical review, could not reasonably have been expected to provide more than minimal benefit in treatment or information to aid in a diagnosis; (b) Diagnostic services not reasonably required to diagnose a presenting problem, whether the resulting diagnosis and indicated treatment are on the currently funded lines under the OHP Prioritized List of Health Services; (c) Services that are limited under OAR 410-120-1200 and 410-120-1210.