Or. Admin. Code § 410-133-0040

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

Section 410-133-0040 - Definitions

In addition to the definitions in OAR 410-120-0000 and OAR 410-141-0001, the following definitions apply to these rules:

(1) "Adapted vehicle" means a specially adapted vehicle that has been physically adjusted or designed to meet the needs of the individual student under IDEA (e.g., special harnesses, wheelchair lifts, ramps, specialized environmental controls, etc.) to accommodate students with disabilities in the school-based setting. Special physical adaptations may also include air conditioning and specialized suspension systems. In all cases, the medical need for physical or environmental adaptations during transport from home to school and back home must be identified in the IEP/IFSP.

(2) "Agent" has the same meaning as defined in OAR 410-120-0000.

(3) "Assessment" means a process of obtaining information to determine if a child or young adult qualifies for or continues to qualify for SBHS, including but not limited to assessing the child or young adult's need for health services, which services are needed, whether provided services are leading to improved outcomes, or if services need to be adjusted.

(4) "Assistive technology service" means a service provided by a medically-qualified individual within the scope of practice under state law with training and expertise in the use of assistive technology.

(5) "Behavioral health supports" means a broad range of mental health wellness supports for students with social and/or relational health needs. Supports may include social skills training or groups, regular check-ins with school staff, development of behavior intervention plans, substance use prevention groups, supporting essential health and well-being needs (such as food insecurity or housing), referral to treatment, and/or coordination with community providers.

(6) "Behavioral health treatment" means intensive services for children or young adults with identified mental health or substance use needs. Treatment may include therapeutic interventions such as individual or family therapy sessions, intensive treatment groups related to specific mental health or substance use needs, or risk assessments and safety planning for students experiencing suicidal ideation or other acute behavioral health crises.

(7) "Care coordination" has the same meaning as defined in OAR 410-120-0000. For SBHS, care coordination is performed by or under the supervision of medically-qualified individuals and involves organizing care activities, sharing information, and consultation to ensure and deliver safe, medically-necessary, medically-appropriate, and effective care aligned with the child or young adult's needs. Care coordination includes but is not limited to training and supervision provided by medically-qualified individuals and communicating and sharing information per the Individual Plan of Care (IPOC) with the child or young adult's parent/guardian, physician, community practitioner(s), community organization(s), coordinated care organization (CCO), and staff.

(8) "Case Management Services" means services provided to ensure a child or young adult obtains health services necessary to maintain physical, mental, and emotional development and oral health. Case management services include a comprehensive, ongoing assessment of medical, mental health, substance use disorder, or dental needs plus the development and implementation of a plan to obtain or make referrals for needed medical, mental, chemical dependency, or dental services, referring members to community services and supports.

(9) "Centers for Medicare and Medicaid Services (CMS)" means the federal regulatory agency for Medical Assistance Programs, including Medicaid.

(10) "Child or young adult" means an individual from birth through the school year in which they turn 21.

(11) "Children's Health Insurance Program (CHIP)" means a federal and state funded portion of the Oregon Health Plan (OHP) established by Title XXI of the Social Security Act and administered by the Authority.

(12) "Delegated health care" means a specific nursing procedure delegated by a registered nurse (RN) per the Nurse Practice Act. Delegation process means the formal process used by a RN to authorize an unregulated assistive person (UAP) to perform a nursing procedure for a client, the outcome of which the RN retains accountability for.

(13) "Diagnosis code" means a code as identified in the International Classification of Diseases, 10th revision, Clinical Modification (ICD-10-CM).

(14) "Early and Periodic Screening, Diagnostic and Treatment (EPSDT)" means the program requiring specific coverage for children and young adults, as described in OAR Chapter 410, Division 151.

(15) "Early Intervention/Early Childhood Special Education" means a seamless system to support the developmental and educational needs of children ages birth to five (5) years of age and their families. Early Intervention/Early Childhood Special Education (EI/ECSE) programs ensure that children who qualify for special education receive a Free and Appropriate Public Education (FAPE), as required in the Individuals with Disabilities Act (IDEA).

(16) "Education agency" means, for the purposes of these rules, a public school district, EI/ECSE contractor or subcontractor, education service district, or a state institution providing educational services or transition services (defined in OAR Chapter 581, Division 15) to children and young adults, birth through age 21, that receives state or federal funds either directly or by contract or subcontract with the Oregon Department of Education (ODE), that is also considered a local unit of government pursuant to 42 CFR 433.51.

(17) "Education service district (ESD)" means a district created under ORS 334.010 that provides regional educational services to component school districts.

(18) "Electronic Data Interchange (EDI)" means the exchange of business documents from application to application in a federally mandated format or, if no federal standard has been promulgated, using bulk transmission processes and other formats as the Authority designates for EDI transactions. For purposes of rules OAR 943-120-0100 through OAR 943-120-0200, EDI does not include electronic transmission via Medicaid Management Information System (MMIS) Provider Web Portal.

(19) "EDI submitter" means an individual or an entity authorized to establish an electronic media connection with the Authority to conduct an EDI transaction. An EDI submitter may be a trading partner or an agent of a trading partner.

(20) "Evaluation services" means procedures used to determine a health-related need, diagnosis, or eligibility for an IPOC. See also re-evaluation services.

(21) "Federal Medical Assistance Percentage (FMAP)" means the percentage of federal match funds for qualified state medical assistance program (Medicaid) expenditures.

(22) "Healthcare Common Procedural Coding System (HCPCS)" means a method for reporting health care professional services, procedures, and supplies. The HCPCS consists of the Level l - American Medical Association's Physician's Current Procedural Terminology (CPT), Level II - National codes, and Level III - Local codes. The Authority uses HCPCS codes; however, the Authority uses Current Dental Terminology (CDT) codes for the reporting of dental care services and procedures.

(23) "Health care practitioner" or "Practitioner of the healing arts" means a person licensed pursuant to state law to engage in the provision of health care services within the scope of their license and certification standards established by their health licensing agency.

(24) "Health Evidence Review Commission (HERC)" means the commission that develops and maintains a list of health services ranked by priority from the most to the least important representing the comparative benefits of each service to the population served.

(25) "Health Insurance Portability and Accountability Act (HIPAA)" means the federal law (Public Law 104-191, August 21, 1996) with the legislative objective to assure health insurance portability, reduce health care fraud and abuse, enforce standards for health information, and guarantee security and privacy of health information.

(26) "Individual Plan of Care (IPOC)" means a prescriptive document for billing Medicaid for each school-based health service provided to a child or young adult in the school setting. To serve as the prescriptive document the plan must include the education agency's name, the specific child or young adult's first and last name, and each necessary and appropriate health service category including the nature, extent, or units of service and therapeutic value for each service. The IPOC may be an Individualized Education Program (IEP) or Individualized Family Service Plan (IFSP) or Section 504 Accommodation Plan or any other established and documented individualized health or behavioral health plan if such document contains the necessary, prescriptive elements required to serve as the prescriptive document for billing Medicaid.

(27) "Individuals with Disabilities Education Act (IDEA)" means the federal law ensuring the rights of children with disabilities to a free and appropriate public education (FAPE).

(28) "Individualized Education Program (IEP)" means a written statement of an educational program for a child or young adult with a disability that is developed, reviewed, or revised in a meeting in accordance with OAR Chapter 581, Division 15.

(29) "Individualized Family Service Plan (IFSP)" means a written plan of early childhood special education (ECSE) services, early intervention (EI) services, and other services developed in accordance with criteria established by the Oregon Department of Education (ODE) for each child aged from birth through five (5) years of age that is eligible for Individuals with Disabilities Education Act (IDEA) services. The plan is developed to meet the needs of a child with disabilities in accordance with requirements and definitions in OAR Chapter 581, Division 15.

(30) "IEP/IFSP Team" means a group of teachers, specialists, and parents responsible for developing, reviewing, and revising an Individualized Education Program (IEP) or Individualized Family Service Plan (IFSP) in compliance with the OAR Chapter 581, Division 15.

(31) "Medicaid" means a federal program that is administered and partially funded by the state for medical assistance established by Title XIX of the Social Security Act as amended and administered by the Authority.

(32) "Medicaid-enrolled" means an individual is eligible and enrolled in Oregon's Medicaid Program.

(33) "Medicaid Management Information System (MMIS)" means a statewide system that houses Medicaid data necessary for the business operations of Medicaid administration including, but not limited to, eligible member information, enrolled provider information, procedure and diagnosis codes, prior authorizations, claims data, and reimbursement rules.

(34) "Medical Assistance Programs" means a program for payment of health services provided to eligible Oregonians, including Medicaid and CHIP services under the OHP Medicaid Demonstration Project and Medicaid and CHIP services under the State Plan, or Healthier Oregon, or Bridge Program, or any other programs that may be prescribed by the Authority from time to time, in accordance with ORS 414.025(17).

(35) "Medically Appropriate" has the same meaning as "EPSDT Medically Appropriate" in OAR 410-151-0001.

(36) "Medically Necessary" has the same meaning as "EPSDT Medically Necessary" in OAR 410-151-0001.

(37) "Medically-qualified Individual" means an individual possessing a qualification identified in OAR 410-133-0120 who provides Medicaid-covered health services in an education setting.

(38) "MMIS Provider Web Portal" means an electronic portal that allows Oregon Medicaid enrolled providers to log in and access relevant information to provide and be reimbursed for services provided to Oregon Medicaid members. Oregon Medicaid enrolled providers can use the portal to verify member eligibility and managed care assignment, access and query Oregon's HERC Prioritized List of Health Services, submit and adjust claims for services provided, download claim remittance advices, and more. Non-enrolled individuals cannot log in to the portal, but they can apply through the portal to enroll as an Oregon Medicaid provider.

(39) "National Provider Identifier (NPI)" means a federally administered provider number mandated for use on HIPAA-covered transactions. Individuals, provider organizations, and subparts of provider organizations that meet the definition of health care provider under 45 CFR 160.103 and who conduct HIPAA-covered transactions electronically are eligible to apply for a NPI. Medicare and Medicaid covered entities are required to apply for an NPI.

(40) "Non-Billing Provider" also referred to as non-payable, means a provider who is issued a provider number for purposes of rendering, ordering, referring, prescribing, data collection, encounters, or non-claims-use of the Provider Web Portal (e.g., eligibility verification).

(41) "Oregon Department of Education (ODE)" means the state agency that provides oversight to public educational agencies for ensuring compliance with federal and state laws relating to education.

(42) "Oregon Health Authority (the Authority)" means the agency established in ORS Chapter 413 that administers the funds for Titles XIX and XXI of the Social Security Act. It is the single state agency for the administration of the medical assistance program under ORS Chapter 414.

(43) "Oregon Health Plan (OHP)" means the Medicaid and CHIP as administered in Oregon by the Authority and under Oregon's Medicaid State Plan.

(44) "Prioritized List of Health Services" means the listing of conditions and treatment pairs developed by the HERC for the purpose of administering the OHP.

(45) "Procedure code" means a code or codes used in the Healthcare Common Procedural Coding System (HCPCS).

(46) "Re-evaluation services" means procedures used to measure a child or young adult's health status compared to an initial or previous evaluation that are focused on evaluation of progress toward current goals, modifying goals or treatment, or making a professional judgment to determine whether or not the child or young adult shall continue to receive one or more school-based health service(s) pursuant to the child or young adult's IPOC. Continuous monitoring of the child or young adult's progress as a component of ongoing therapy services is not billable as a re-evaluation.

(47) "Referral" means the transfer of total or specified care of a client from one provider to another. As used by the Authority, the term referral also includes a request for a consultation or evaluation or a request or approval of specific services.

(48) "School medical provider" means an enrolled provider type that is established by the Authority to designate the provider eligible to receive Medicaid reimbursement for Medicaid-covered SBHS. Authority-enrolled education agencies, as defined in this rule, are school medical providers.

(49) "Section 504 of The Rehabilitation Act of 1973" means a federal civil rights law, guided by the Americans with Disabilities Act (ADA), that protects qualified individuals from discrimination based on their disability. Under Section 504, free and appropriate public education (FAPE) means providing regular or special education and related aids and services designed to meet individual needs of children and young adults.

(50) "Section 504 Accommodation Plan" means a formal plan that provides children and young adults with disabilities specific supports and accommodations needed to access the general education setting.

(51) "Special education services" means specially designed instruction to meet the unique needs of a child or young adult with a disability including regular classroom instruction, instruction in physical education, home instruction, and instruction in hospitals, institutions, special schools, and other settings.

(52) "Specialized transportation" means transportation to a medically necessary service (as outlined in the IEP/IFSP of a Medicaid-enrolled child) provided in a specially adapted vehicle that has been physically adjusted or designed to meet the needs of the individual student under IDEA (e.g., special harnesses, wheelchair lifts, ramps, specialized environmental controls, etc.) to accommodate students with disabilities in the school-based setting. Special physical adaptations may also include air conditioning and specialized suspension systems. In all cases, the medical need for physical or environmental adaptations during transport from home to school and back home must be identified in the IEP/IFSP.

(53) "Synchronous" means an interaction between a provider and a client or member that occurs at the same time using an interactive technology. This may include audio only, video only, or audio with video and may include remote monitoring.

(54) "Supervisory-level" means the medically-qualified individual is licensed or certified to practice independently and may supervise other medically-qualified individuals providing services within their scope of practice and in compliance with their respective board rules.

(55) "Teacher Standards and Practices Commission (TSPC)" means the commission that governs licensing of teachers, personnel, service specialists, and administrators as set forth in OAR Chapter 584.

(56) "Telecommunication technologies" means the use of devices and services for telemedicine or telehealth delivered services. These technologies include, but are not limited to, videoconferencing, store-and-forward imaging, streaming media including services with information transmitted using landlines, and wireless communications, including the Internet and telephone networks.

(57) "Telehealth" means the use of electronic information and telecommunications technologies, including telemedicine, to support remote clinical healthcare, client or member and professional health-related education, public health, and health administration.

(58) "Telemedicine" means the mode of delivering remote clinical health services using information and telecommunication technologies to provide consultation and education or to facilitate diagnosis, treatment, care management or self-management of a client or member's healthcare.

(59) "Transportation vehicle trip log" means a record or log kept specifically for tracking each transportation trip to or from a covered health service a Medicaid-eligible child or young adult receives.

(60) "Treatment Plan" means a practitioner's written plan of health services, including treatment with proposed location, frequency, and duration of treatment. A treatment plan must be written by a practitioner within the scope of the practitioner's license or certification and in compliance with the practitioner's respective Oregon board. Treatment plans may include but are not limited to behavioral health service plans (see OAR 309-019-0140), nurse treatment plans of care (see Oregon's Nurse Practice Act, OARs Chapter 851), occupational therapy service plans (See OARs Chapter 339, Division 10), and physical therapy plans of care (see OARs Chapter 848, Division 40).

(61) "Unit" means a service measurement of time for billing and reimbursement efficiency. One unit equals 15 minutes unless otherwise stated.

(62) "Unregulated Assistive Person (UAP)" means an unlicensed, unregulated individual who performs a nursing procedure for a patient when the specific procedure has been delegated and authorized by a licensed registered nurse (RN) or nurse practitioner (NP) acting within the scope of their license. The delegating nurse retains accountability for the nursing procedure.

(63) "Visit" means a service measurement of time for billing and reimbursement efficiency. For billing purposes, a visit is always presented as one (1) visit.

(64) "Written recommendation" means a physician or a licensed health care practitioner has documented a specific service or treatment, within their scope of practice, that is medically necessary and appropriate for the individual child or young adult. The written recommendation must be written by a practitioner other than the performing provider, except when the performing provider may self-refer within their scope of practice. The written recommendation must be current, within twelve (12) months of the date of service, to allow for Medicaid reimbursement.

Or. Admin. Code § 410-133-0040

HR 39-1991, f. & cert. ef. 9-16-91; HR 29-1993, f. & cert. ef. 10-1-93; HR 21-1995, f. & cert. ef. 12-1-95;OMAP 31-1998, f. & cert. ef. 9-1-98; OMAP 38-1999, f. & cert. ef. 10-1-99; OMAP 15-2000, f. 9-28-00, cert. ef 10-1-00; OMAP 31-2003, f. & cert. ef. 4-1-03; OMAP 53-2003, f. 8-13-03 cert. ef. 9-1-03; OMAP 24-2005(Temp), f. & cert. ef. 4-5-05 thru 10-1-05; OMAP 53-2005, f. 9-30-05, cert. ef. 10-1-05; DMAP 43-2008, f. 12-17-08, cert. ef. 12-28-08; DMAP 19-2009, f. 6-12-09, cert. ef. 7-1-09; DMAP 15-2011, f. 6-29-11, cert. ef. 7-1-11; DMAP 51-2015, f. 9-22-15, cert. ef. 10/1/2015; DMAP 33-2016, f. 6-29-16, cert. ef. 7/1/2016; DMAP 19-2020, temporary amend filed 04/09/2020, effective 04/09/2020 through 10/05/2020; DMAP 56-2020, amend filed 10/02/2020, effective 10/5/2020; DMAP 121-2024, amend filed 09/06/2024, effective 9/6/2024

Statutory/Other Authority: ORS 413.042

Statutes/Other Implemented: 414.065