OAR 410-146-0120: Maternity Case Management Services

(1) The Division shall reimburse IHCP for MCM services according to their encounter rate. (2) MCM service is optional coverage for Prepaid Health Plans (PHPs). Before providing MCM services to clients enrolled in a PHP, determine if the PHP covers MCM services: (a) If the PHP does not cover MCM services, the provider may bill the Division directly per the clinic’s encounter rate. Prior authorization is not required if the PHP does not provide coverage for MCM services; (b) If the PHP does cover MCM services, and services were furnished to a: (A) Non-AI/AN client, the provider needs to request the necessary authorizations from the PHP; (B) AI/AN client enrolled with a PHP with which the IHCP does not have an agreement, the IHCP may bill the Division directly. (3) Clients’ records must clearly document all MCM services provided including all mandatory topics. For specific requirements, refer to the Medical-Surgical Services program OAR 410-130-0595, Maternity Case Management. (4) The primary purpose of the MCM program is to optimize pregnancy outcomes including the reduction of low birth weight babies. MCM services are intended to target pregnant women early during the prenatal period and can only be initiated when the client is pregnant: (a) MCM services may not be initiated the day of delivery, during postpartum, or for newborn evaluation; (b) Clients are not eligible for MCM services if the provider has not completed the MCM initial evaluation prior to the day of delivery; (c) No other MCM service may be performed until an initial assessment has been completed. (5) Multiple MCM contacts in a single day do not qualify as multiple encounters. (6) A medical/prenatal visit encounter and an MCM encounter may qualify as two separate encounters when furnished on the same day only when the MCM service is: (a) The initial evaluation to receive MCM services; or (b) A nutritional counseling MCM service provided after the initial evaluation visit. (7) MCM Services limitations: (a) The Division shall reimburse the initial evaluation one time per pregnancy per provider; (b) The Division shall reimburse nutritional counseling one time per pregnancy if a client meets the criteria in OAR 410-130-0595(14); and (c) The Division shall reimburse a maximum of ten MCM services/visits in addition to subsections (a) and (b) above, providing visits/services are furnished in compliance with OAR 410-130-0595. (8) Case management services may not duplicate services for case management activities or direct services provided under the State Plan or OHP through fee for service, managed care, or other contractual arrangement that meet the same need for the same client at the same point in time. This includes the Division’s Maternity Case Management program (OAR chapter 410, division 130) and any Targeted Case Management (TCM) program outlined in OAR chapter 410, division 138. (9) Community health representatives may be eligible to provide specific MCM services, with the exclusion of the initial assessment (G9001), while working under the supervision of a licensed health care practitioner listed in OAR 410-130-0595(7)(a).