OAR 410-147-0200: Maternity Case Management Services

(1) The Division of Medical Assistance Programs (Division) will reimburse federally qualified health centers (FQHCs) and rural health clinics (RHCs) for maternity case management (MCM) services. (2) MCM service is optional coverage for Prepaid Health Plans (PHPs). Before providing MCM services to a client enrolled in a PHP, determine if the PHP covers MCM services: (a) If the PHP does not cover MCM services, the provider can bill the Division directly per the clinic’s Prospective Payment System (PPS) 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, the provider needs to request the necessary authorizations from the PHP. (3) Clients’ records must clearly document all MCM services provided including all mandatory topics. Refer to OAR 410-130-0595, Maternity Case Management for specific requirements. (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 cannot 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 the day before delivery; (c) No other MCM service can 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 can qualify as two separate encounters when furnished on the same day only when the MCM service is: (a) The initial evaluation to receive MCM service; or (b) A nutritional counseling MCM service provided after the initial evaluation visit. See Section (7) of this rule for limitations. (7) MCM services limitations: (a) The Division reimburses the initial evaluation one time per pregnancy per provider; (b) The Division reimburses nutritional counseling one time per pregnancy if a client meets the criteria in OAR 410-130-0595(14); and (c) The Division will reimburse a maximum of ten MCM services/visits in addition to (a) and (b) above, providing visits/services are furnished in compliance with OAR 410-130-0595. (8) Case management services must not duplicate services for case management activities or direct services provided under the State Plan or the Oregon Health Plan (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 Maternity Case Management, and any Targeted Case Management (TCM) Programs outlined in OAR chapter 410, division 138.