Or. Admin. Code § 410-123-1220
Current through Register Vol. 63, No. 12, December 1, 2024
Section 410-123-1220 - Coverage According to the Prioritized List of Health Services(1) This rule effective on the date stated in OAR 410-141-3830 incorporates by reference the Oregon Health Evidence Review Commission (HERC) Prioritized List of Health Services (The List), funded through line 469 and including all line items, diagnostic and treatment codes, guideline notes, statements of intent, coding specifications and annotations. All material included therein are incorporated in and made part of this rule by this reference, including interim modifications reported as required under ORS 414.690(7) and (8).(a) The Prioritized List of Health Services includes line items consisting of diagnosis and treatment codes that pair together with specific conditions on the same line. Each line has a description of both a condition(s) and treatment for the condition(s). Services on lines 1-469 are covered for OHP Members, with some dental services subject to exclusion for adults age 21 and over. Coverage of these services is included in the benefit package when providers follow The List's code pairing, Guideline Notes, annotations and statements of intent. The Benefit Package also covers additional services described in this rule;(b) Diagnostic and Preventive Service codes. Approved CDT codes for preventive dental services are included on the funded portion of The Prioritized List of Health Services, and limitations specified in related Guideline Notes. Dental and Oral Health Providers are subject to utilizing The List for procedure and diagnosis code pairing and funding of preventive and diagnostic services. Preventive services include prophylaxis, sealants, fluoride varnish application, caries arresting medicaments, and vaccinations. Diagnostic services include examinations, imaging, oral evaluations, and testing. All diagnosis and preventive service codes are subject to The List Guidelines Notes and limitations found in this rule;(c) Ancillary service codes. Covered ancillary codes are subject to applicable Ancillary Guidelines on The List. Approved ancillary codes are listed in this rule at OAR 410-123-1620;(d) The List shall be used in conjunction with applicable OHP provisions found in federal and state laws, the State Plan and Oregon's 1115(a) Waiver for coverage of services such as, but not limited to:(A) Services on unfunded lines for children ages from birth through 1;(B) Services provided for a condition appearing in the funded region of The List in conjunction with federal requirements for Early and Periodic Screening, Diagnosis and Treatment (EPSDT) and Oregon's 1115(a) Waiver.(2) Regardless of The List placement, dental and oral health services shall be dentally necessary and clinically appropriate for each individual member served.(3) Changes to services funded on The List are effective on the date of The List change: (a) The Division administrative rules (chapter 410, division 123) do not reflect the most current Prioritized List of Health Services changes until the rules are amended through the Division rule filing process;(c) In the event of an alleged variation between a Division-listed code and a national code, the Division shall apply the national code in effect on the date of request or date of service.(4) Refer to The List of Services and OAR 410-123-1260 for information about limitations on procedures funded according to The List. Examples of limitations include frequency and member's age.(5) The List does not include or fund the following general categories of dental services, and the Division does not cover them for any member. Several of these services are considered elective or "cosmetic" in nature (i.e., done for the sake of appearance): (b) Implant and implant services (See Prioritized List Guideline Notes 123 and 169);(c) Mastique or veneer procedure;(d) Orthodontia (except for cleft palate, cleft lip, or cleft palate with cleft lip treatments, or to correct cranial facial abnormalities);(f) Procedures, appliances, or restorations solely for aesthetic or cosmetic purposes;(g) Temporomandibular joint dysfunction treatment; andOr. Admin. Code § 410-123-1220
HR 3-1994, f. & cert. ef. 2-1-94; HR 21-1994(Temp), f. 4-29-94, cert. ef. 5-1-94; HR 32-1994, f. & cert. ef. 11-1-94; HR 20-1995, f. 9-29-95, cert. ef. 10-1-95; HR 9-1996, f. 5-31-96, cert. ef. 6-1-96; OMAP 13-1998(Temp), f. & cert. ef. 5-1-98 thru 9-1-98; OMAP 28-1998, f. & cert. ef. 9-1-98; OMAP 23-1999, f. & cert. ef. 4-30-99; OMAP 8-2000, f. 3-31-00, cert. ef. 4-1-00; OMAP 17-2000, f. 9-28-00, cert. ef. 10-1-00; OMAP 48-2002, f. & cert. ef. 10-1-02; OMAP 3-2003, f. 1-31-03, cert. ef. 2-1-03; OMAP 65-2003, f. 9-10-03 cert. ef. 10-1-03; DMAP 25-2007, f. 12-11-07, cert, ef. 1-1-08; DMAP 38-2008, f. 12-11-08, cert. ef. 1-1-09; DMAP 16-2009 f. 6-12-09, cert. ef. 7-1-09; DMAP 41-2009, f. 12-15-09, cert. ef. 1-1-10; DMAP 14-2010, f. 6-10-10, cert. ef. 7-1-10; DMAP 31-2010, f. 12-15-10, cert. ef. 1-1-11; DMAP 17-2011, f. & cert. ef. 7-12-11; DMAP 41-2011, f. 12-21-11, cert. ef. 1-1-12; DMAP 46-2011, f. 12-23-11, cert. ef. 1-1-12; DMAP 13-2013, f. 3-27-13, cert. ef. 4-1-13; DMAP 7-2015(Temp), f. & cert. ef. 2-17-15 thru 8-15-15; DMAP 28-2015, f. & cert. ef. 5/1/2015; DMAP 46-2015(Temp), f. 8-26-15, cert. ef. 10-1-15 thru 3-28-16; DMAP 65-2015, f. 11-3-15, cert. ef. 12/1/2015; DMAP 20-2016(Temp), f. 5-6-16, cert. ef. 5-10-16 thru 11-5-16; DMAP 48-2016(Temp), f. & cert. ef. 7-22-16 thru 11-5-16; DMAP 61-2016, f. & cert. ef. 10/13/2016; DMAP 71-2016(Temp), f. 12-28-16, cert. ef. 1-1-17 thru 6-29-17; DMAP 25-2017, f. & cert. ef. 6/29/2017; DMAP 41-2018, minor correction filed 05/25/2018, effective 5/25/2018; DMAP 69-2018, temporary amend filed 05/30/2018, effective 06/01/2018 through 11/27/2018; DMAP 83-2018, amend filed 07/31/2018, effective 8/1/2018; DMAP 97-2018, temporary amend filed 10/26/2018, effective 11/1/2018 through 04/29/2019; DMAP 105-2018, temporary amend filed 12/13/2018, effective 01/01/2019 through 04/29/2019; DMAP 5-2019, amend filed 03/08/2019, effective 3/8/2019; DMAP 64-2019, temporary amend filed 12/18/2019, effective 01/01/2020 through 06/14/2020; DMAP 21-2020, amend filed 04/29/2020, effective 5/1/2020; DMAP 61-2020, amend filed 12/11/2020, effective 1/1/2021; DMAP 50-2021, amend filed 12/24/2021, effective 1/1/2022; DMAP 9-2022, minor correction filed 02/04/2022, effective 2/4/2022; DMAP 79-2023, amend filed 09/26/2023, effective 10/1/2023; DMAP 61-2024, minor correction filed 02/21/2024, effective 2/21/2024; DMAP 92-2024, minor correction filed 05/23/2024, effective 5/23/2024Statutory/Other Authority: ORS 413.042 & ORS 414.065
Statutes/Other Implemented: ORS 414.065