OAR 410-146-0085: Encounter and Recognized Practitioners

Encounter and Recognized Practitioners (1) The Division shall reimburse enrolled AI/AN providers as follows: (a) For services, items, and supplies that meet the criteria of a valid encounter in sections (5) through (7) of this rule; (b) Reimbursement is limited to the Division’s Medicaid-covered services according to a client’s OHP benefit package. These services may include any services included in the State Plan under Title XIX or Title XXI of the Social Security Act and provided pursuant to the determinations, conditions, and requirements of the Prioritized List of Health Services found in the Health Evidence Review Commission’s Prioritized List of Health Services (see OAR 410-141-0520). (2) IHCPs reimbursed according to a cost-based rate under the Prospective Payment System (PPS) shall use OAR 410-147-0120, Encounter and Recognized Practitioners, in the Division’s FQHC and RHC program. (3) IHCPs reimbursed according to the IHS rate are subject to the requirements of this rule. (4) Services provided to Citizenship Waived Medical (CWM) and Qualified Medicare Beneficiary (QMB) only clients are not billed according to encounter criteria and not reimbursed at the IHS encounter rate (refer to OAR 410-120-1210, Medical Assistance Benefit Packages and Delivery System). (5) For the provision of services defined in Titles XIX and XXI and provided through an IHS or Tribal 638 facility, an “encounter” is defined as a face-to-face, telephone contact, or a prescription fill as defined in OAR 410-146-0085(8) between a health care professional and an eligible OHP client within a 24-hour period ending at midnight, as documented in the client’s medical record. Section (7) of this rule outlines limitations for telephone contacts that qualify as encounters. For purposes of this rule, face-to-face “encounter” includes services provided via a synchronous two-way audiovisual link between a patient and a provider per 410-130-0610. (6) An encounter includes all services, items, and supplies provided to a client during the course of an office visit and “incident-to” services (except as excluded in section (17) of this rule). The following services are inclusive of the visit with the core provider meeting the criteria of a reimbursable valid encounter and are not reimbursed separately: (a) Drugs or medication treatments provided during the clinic visit, with the exception of contraception supplies and medications as costs for these items are excluded from the IHS encounter rate calculation (refer to OAR 410-146-0200, Pharmacy); (b) Medical supplies, equipment, or other disposable products (e.g. gauze, Band-Aids, wrist brace); and (c) Venipuncture for laboratory tests. (7) An IHS or Tribal 638 Pharmacy encounter is a separate encounter and not made in conjunction with a medical, behavioral health, substance use disorder, or dental visit or with any other non-pharmacy visit related to a covered benefit. (8) A single pharmacy encounter includes one prescription dispensed by one IHS or Tribal 638 Pharmacy to a Medicaid-eligible individual in a single 24-hour period ending at midnight. There is no limit on the number of encounters that may occur in the 24-hour period. The encounter rate is inclusive of dispensing services. (9) Telephone encounters qualify as a valid encounter for services provided in accordance with OAR 410-130-0595, Maternity Case Management; OAR 410-146-0200, Tribal Pharmacy; and OAR 410-130-0190, Tobacco Cessation (OAR 410-120-1200). Except as set forth below, Providers may not make telephone contacts at the exclusion of face-to-face visits. (a) Telephone encounters must include all the same components of the service as if provided face-to-face. (b) During a state of emergency of an epidemic outbreak of an infectious disease impacting the safety of public health, in accordance with the Health Evidence Review Commission’s Prioritized List, guideline notes, and OAR 410-130-0610 (for dates of service on or before December 31, 2020) and OAR 410-120-1990 (for dates of service on or after January 1, 2021), telephonic evaluation management services, assessment and management services, and psychotherapy are appropriate to ensure access to care while avoiding and preventing unnecessary potential infectious exposure, and may be made in place of a face-to-face visit. (10) The following services may be Medicaid-covered services according to an OHP client’s benefit package as a stand-alone service; however, when furnished as a stand-alone service, they are not reimbursable: (a) Case management services for coordinating care for a client; (b) Sign language and oral interpreter services; (c) Supportive rehabilitation services including, but not limited to, environmental intervention, supported employment, or skills training and activity therapy to promote community integration and job readiness. (11) IHCPs may provide certain services, items, and supplies that are prohibited from being billed under the health centers provider enrollment and that require separate enrollment (see OAR 410-146-0021, AI/AN Provider Enrollment). These services include: (a) Durable medical equipment, prosthetics, orthotics, or medical supplies (DMEPOS) (e.g., diabetic supplies) not generally provided during the course of a clinic visit (refer to OAR chapter 410, division 122, DMEPOS); (b) Prescription pharmaceuticals and biologicals not generally provided during the clinic visit that are dispensed by an IHS or Tribal 638 Pharmacy may be billed to and shall be reimbursed by the Division through the pharmacy program (refer to OAR chapter 410, division 121, Pharmaceutical Services) or at the All-Inclusive Rate (AIR) as established annually by the Indian Health Service (IHS); and (c) Targeted case management (TCM) services. For specific information, refer to OAR chapter 410, division 138, TCM. (12) Client contact with more than one health professional for the same diagnosis or multiple encounters with the same health professional that take place on the same day and at a single location constitute a single visit. For exceptions to this rule, see OAR 410-146-0086 for reporting multiple encounters. (13) For claims that require a procedure and diagnosis code, the provider must bill as instructed in the appropriate Division program rules and must use the appropriate HIPAA procedure Code Set established according to 45 CFR 162.1000 to 162.1011, which best describes the specific service or item provided (refer to OARs 410-120-1280, Billing and OAR 410-146-0040, ICD-10-CM Diagnosis Codes and CPT/HCPCs Procedure Codes). (14) Services furnished by AI/AN enrolled providers that may meet the criteria of a valid encounter (refer to individual program administrative rules for service limitations): (a) Medical (OAR chapter 410, division 130); (b) The Division covers reasonable services for diagnosing conditions, including the initial diagnosis of a condition that is below the funding line on the HERC’s Prioritized List of Health Services. Once a diagnosis is established for a service, treatment, or item that falls below the funding line, the Division may l not cover any other services related to the diagnosis; (c) Tobacco Cessation (OAR 410-130-0190); (d) Dental (OAR 410-146-0380 and OAR chapter 410, division 123); (e) Vision (OAR chapter 410, division 140); (f) Physical Therapy (OAR chapter 410, division 131); (g) Occupational Therapy (OAR chapter 410, division 131); (h) Podiatry (OAR chapter 410, division 130); (i) Behavioral health OAR chapter 309; (j) Substance Use Disorder services (OAR 410-146-0021) require a letter or licensure of approval by the Division; (k) Maternity Case Management (OAR 410-146-0120); (L) Speech (OAR 410 Division 129); (m) Hearing (OAR 410 Division 129); (n) The Division considers a home visit for assessment, diagnosis, treatment, or maternity case management (MCM) as an encounter. The Division does not consider home visits for MCM as home health services; (o) Professional services provided in a hospital setting; (p) Prescriptions dispensed by an IHS or Tribal 638 Pharmacy constitute a separate encounter reimbursed at the annually published IHS All-Inclusive-Rate; (q) Other Title XIX or XXI services as allowed under Oregon's Medicaid and CHIP State Plan Amendments, Oregon’s approved 1115 Medicaid Demonstration, and the Division’s administrative rules. (15) The following practitioners are recognized by the Division: (a) Doctors of medicine, osteopathy, and naturopathy; (b) Licensed physician associates; (c) Nurse practitioners; (d) Registered nurses may accept and implement orders within the scope of their license for client care and treatment under the supervision of a licensed health care professional recognized by the Division in this section and who is authorized to independently diagnose and treat according to appropriate State of Oregon’s Board of Nursing OARs; (e) Nurse midwives; (f) Dentists; (g) Dental hygienists who hold a Limited Access Permit (LAP) may provide dental hygiene services without the supervision of a dentist in certain settings. For more information, refer to the section on Limited Access Permits in ORS 680.200 and the appropriate Oregon Board of Dentistry OARs; (h) Pharmacists; (i) Psychiatrists; (j) Licensed Clinical Social Workers; (k) Clinical psychologists; (L) Acupuncturists, refer to OAR chapter 410, division 130 for service coverage and limitations; (m) Licensed professional counselor; (n) Licensed marriage and family therapist; and (o) Other health care professionals providing services within their scope of practice and working under the supervision requirements of: (A) Their individual provider certification or license; or (B) A clinic’s behavioral health certification or SUD program approval or licensure by the Division. (16) Encounters with a registered professional nurse or a licensed practical nurse and related medical supplies, including drugs and biologicals, furnished on a part-time or intermittent basis to home-bound AI/AN clients residing on tribal land and any other ambulatory services covered by the Division are also reimbursable as permitted within the clinic's scope of services. (17) The Division shall reimburse the following services fee-for-service outside of the IHS all-inclusive encounter rate and according to the physician fee schedule: (a) Laboratory and radiology services; (b) Contraception supplies and medications; (c) Administrative medical examinations and report services (refer to OAR chapter 410, division 150); (d) Death with Dignity services (refer to OAR 410-130-0670); and (e) Comprehensive environmental lead investigation (refer to OAR 410-130-0245, Early and Periodic Screening, Diagnostic and Treatment program). (18) Federal law requires that state Medicaid agencies take all reasonable measures to ensure that in most instances the Division will be the payer of last resort. Providers must make reasonable efforts to obtain payment first from other resources before billing the Division (refer to OAR 410-120-1140, Verification of Eligibility). (19) When a provider receives a payment from any source prior to the submission of a claim to the Division, the amount of the payment must be shown as a credit on the claim in the appropriate field (refer to OARs 410-120-1280, Billing and 410-120-1340, Payment).