Or. Admin. Code § 333-006-0190

Current through Register Vol. 63, No. 12, December 1, 2024

Section 333-006-0190 - Reimbursement Methodology

The health benefit plan reimbursement methodology for newborn nurse home visiting services is a claim invoicing process.

(1) If a health benefit plan requires credentialing as a prerequisite to claim submission, health benefit plans must credential Authority-certified newborn nurse home visiting providers. Newborn nurse home visiting providers must be credentialed as an organization. The organization also serves as the rendering provider.

(2) A bundled claim submitted for the newborn nurse home visiting services case rate must include, at a minimum, a comprehensive newborn nurse home visit, meeting the requirements of OAR 333-006-0120(5) and (6). The bundled claim may include one to two support visits that occur after the comprehensive visit and may include one support visit that occurs prior to a comprehensive visit.

(a) If a support visit is completed prior to a comprehensive newborn nurse home visit and the comprehensive newborn nurse home visit is subsequently not completed, the newborn nurse home visiting provider must submit a claim for the single support visit rate.

(b) Claims must follow the Authority's billing guidance for newborn nurse home visiting services and generally accepted medical services billing standards.

(3) All services provided as part of the Universally Offered Newborn Nurse Home Visiting Program shall be documented in the client's medical record by the home visitor who provides newborn nurse home visiting services on behalf of a certified newborn nurse home visiting services provider.

(4) Claims for newborn nurse home visiting services to health benefit plans with no contract in place with newborn nurse home visiting providers must be submitted as an out of network claim by the provider.

(5) Single case out of network claims must be reimbursed by health benefit plans in the amount of the case rate and per the billing procedures described in OAR 333-006-0180 through 333-006-0190.

(6) OAR 333-006-0180 through 333-006-0190 apply to health benefit plans not subject to ORS 433.301 who voluntarily provide reimbursement for newborn nurse home visiting services.

(7) Health benefit plans must reimburse at the case rate for newborn nurse home visiting services conducted via telemedicine pursuant to OAR 333-006-0120 and ORS 743A.058.

Or. Admin. Code § 333-006-0190

PH 201-2022, adopt filed 10/13/2022, effective 1/1/2023

Statutory/Other Authority: ORS 413.042, ORS 433.301, ORS 743A.078

Statutes/Other Implemented: ORS 433.301, ORS 743A.078