Or. Admin. Code § 410-129-0070

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

Section 410-129-0070 - Limitations

(1) Speech Language Pathology (SLP) services:

(a) Shall be provided by a practitioner as described in OAR 410-129-0065;

(b) Requirements for rehabilitative and habilitative therapy treatment:

(A) Require Prior Authorization (PA) when it exceeds one hour per day each for a group or individual;

(B) Shall be either group or individual and may not be combined in the authorization period; and

(C) Require PA after thirty (30) habilitative and thirty (30) rehabilitative visits per calendar year.

(c) The following SLP services are not subject to prepayment review (PPR) and do not require PA but are limited to:

(A) Two SLP evaluations in a 12-month period;

(B) Two evaluations for dysphagia in a 12-month period;

(C) Up to four re-evaluations in a 12-month period;

(D) One evaluation for speech-generating/augmentative communication system or device (SGD) shall be reimbursed per recipient in a 12-month period;

(E) One evaluation for voice prosthesis or artificial larynx shall be reimbursed in a 12-month period;

(F) Purchase, repair, or modification of electrolarynx;

(G) Supplies for speech therapy shall be reimbursed up to two times in a 12-month period, not to exceed five dollars each.

(d) The purchase, rental, repair, or modification of a SGD requires PA. Rental of a SGD is limited to one month. All rental fees shall be applied to the purchase price.

(2) Audiology and hearing aid services:

(a) All hearing services shall be performed by a licensed physician, audiologist, or hearing aid specialist;

(b) Binaural hearing aids shall be reimbursed no more frequently than every five (5) years for individuals age 21 and older who meet the following criteria and medical necessity: Loss of 35 decibel (dB) hearing level or greater in two or more of the following frequencies: 1000, 2000, 3000, and 4000 Hertz (Hz);

(c) Binaural hearing aids shall be reimbursed no more frequently than every three (3) years for children, birth through age 20, who meet the following criteria:

(A) Pure tone average of 25dB for the frequencies of 500Hz, 1000Hz, and 2000Hz; or

(B) High frequency average of 35dB for the frequencies of 3000Hz, 4000Hz, and 6000Hz.

(d) An assistive listening device may be authorized for individuals aged 21 or over who are unable to wear or who cannot benefit from a hearing aid. An assistive listening device is defined as a simple amplification device designed to help the individual hear in a listening situation. It is restricted to a hand-held amplifier and headphones;

(e) The following services do not require PA:

(A) One basic audiologic assessment in a 12-month period;

(B) One basic comprehensive audiometry (audiologic evaluation) in a 12-month period;

(C) One hearing aid examination and selection in a 12-month period;

(D) One pure tone audiometry (threshold) test; air and bone in a 12-month period;

(E) One electroacoustic evaluation for hearing aid; monaural in a 12-month period;

(F) One electroacoustic evaluation for hearing aid; binaural in a 12-month period;

(G) Hearing aid batteries - maximum of 60 individual batteries in a 12-month period. Clients shall meet the criteria for a hearing aid.

(f) The following services require PA:

(A) Hearing aids;

(B) Repair of hearing aids, including ear mold replacement;

(C) Hearing aid dispensing and fitting fees;

(D) Assistive listening devices;

(E) Cochlear implant batteries:

(F) Bone anchored hearing aid (BAHA) replacement components.

(g) The following services require PA and must meet medical necessity and medical appropriateness under Early and Periodic Screening, Diagnostic and Treatment (EPSDT):

(A) FM systems;

(B) Vibro-tactile aids;

(C) Earplugs;

(h) Services not covered:

(A) Adjustment of hearing aids are included in the fitting and dispensing fee and is not reimbursable separately;

(B) Aural rehabilitation therapy is included in the fitting and dispensing fee and is not reimbursable separately;

(C) Tinnitus masker.

Or. Admin. Code § 410-129-0070

HR 27-1993, f. & cert. ef. 10-1-93; HR 36-1994, f. 12-30-94, cert. ef. 1-1-95; OMAP 36-1999, f. & cert. ef. 10-1-99; OMAP 38-2000, f. 9-29-00, cert. ef. 10-1-00; OMAP 39-2001, f. 9-24-01, cert.e f. 10-1-01; OMAP 14-2005, f. 3-11-05, cert. ef. 4-1-05; DMAP 17-2007, f. 12-5-07, cert. ef. 1-1-08; DMAP 22-2014, f. & cert. ef. 4-2-14; DMAP 49-2016, f. 7-26-16, cert. ef. 8/1/2016; DMAP 70-2016(Temp), f. 12-5-16, cert. ef. 1-1-17 thru 6-29-17; DMAP 19-2017, f. & cert. ef. 6/9/2017; DMAP 56-2017, amend filed 12/26/2017, effective 1/1/2018; DMAP 100-2018, amend filed 11/06/2018, effective 11/06/2018; DMAP 102-2018, amend filed 12/13/2018, effective 12/13/2018; DMAP 18-2019, temporary amend filed 06/18/2019, effective 7/1/2019 through 12/27/2019; DMAP 44-2019, amend filed 11/06/2019, effective 11/14/2019; DMAP 46-2021, amend filed 10/22/2021, effective 10/22/2021; DMAP 93-2023, amend filed 12/21/2023, effective 1/1/2024

Statutory/Other Authority: ORS 413.042 & ORS 414.065

Statutes/Other Implemented: ORS 414.065 & ORS 414.025