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Medical-Surgical Services Program

Medical-Surgical Services Program

Oregon Administrative Rules and supplemental information administered by the Division of Medical Assistance Programs.

Recent rule filings

You can sort or filter by document type or effective date. You can also view Medical-Surgical Services Program rules as filed with the Secretary of State (please note that rules filed by the first of the month will not be posted on the Secretary of State website until the middle of the filing month).

  
  
File Description
  
130-0200-01012016Permanent Rule Filing
410-130-0200
OHP FFS Program, Begin Requiring PA for Billing Out-of-Hospital Birth and Gender Dysphoria Surgery Services
1/1/2016
Nprm-130-0200-12152015Notice of Rulemaking Hearing
410-130-0200
Begin to Require Prior Authorization for Payment of Gender Dysphoria Surgeries, OHP-FFS Program
Rulemaking Hearing: December 15, 2015 at 10:30 a.m. in Room 137C
Last Opportuity for Public Comment: December 17, 2015 at 5 p.m.
Send Comments: dmap.rules@state.or.us
12/15/2015
Nprm-130-0200-OOH-12152015Notice of Rulemaking Hearing
410-130-0200
OHP FFS Program, Begin Requiring Prior Authorization for Billing Out-of-Hospital Birth Services
Rulemaking Hearing: December 15, 2015 at 10:30 a.m. in Room 137C
Last opportunity for public comments: December 17, 2015 at 5 p.m.
Send comments to dmap.rules@state.or.us.
12/15/2015
130-0200-12012015Temporary Rule Filing
410-130-0200
OHP FFS Program, Begin Requiring Prior Authorization for Billing Out-of-Hospital Birth Services
12/1/2015
130-0220-11012015Permanent Rule Filing
410-130-0220
Revision to List of Medical Billing Codes Excluded from Payment under OHP's FFS Program
11/1/2015
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Administrative rulebooks

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130rb0101161/1/2016
130rb12011512/1/2015
130rb11011511/1/2015
130rb10011510/1/2015
130rb0529155/29/2015
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Supplemental information and guidelines

To learn more about National Drug Code (NDC) reporting, visit DMAP's NDC reporting page. For vaccine codes covered under the Vaccines for Children (VFC) program, see State Supplied Vaccine Codes (use Modifier SL or 26 to receive $21.96 VFC administration fee).

Provider guides

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Professional Billing Instructions
Oregon Medicaid reimbursement for doula services
Billing for Child Abuse Assessments and Related Services
Prior Authorization Handbook
Medical-Surgical Services Provider Guide, 8-31-2015
OHP birth control methods and reimbursement
Claim Adjustment Handbook
Paving the Road to Good Health
EPSDT Coverage Guide

Out-of-hospital birth resources

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Out of Hospital Birth Reimbursement Guide
OAR 333-076-0650 Table 3 - Mother and infant postpartum risk factors that would require transfer to a higher level of care
OAR 333-076-0650 Table 2 - Intrapartum risk factors that would require transfer to a higher level of care
OAR 333-076-0650 Table 1 - Absolute risk factors that would prohibit admission to a birthing center for labor and delivery

National Drug Code reporting

  
Codes Requiring NDC Information (Procedure Group 6069)
National Drug Code reporting tips
National Drug Code reporting webinar
NCPDP Unit of Measure (UOM) List

Code groups for claim processing

Not Covered Procedures (Procedure Group 1118):  Please see rule 410-130-0220​ for more information.

  
Undefined Diagnosis Codes (Diagnosis Code Group 6030)
Informational Diagnosis Codes (Diagnosis Code Group 6033)
Diagnostic Workup File (Diagnosis Code Group 6032)
Diagnostic Procedure Codes (Procedure Code Group 1119)
Conditions Not Covered (Diagnosis Code Group 6031)

Oregon Medicaid PA Criteria

The Oregon Pharmacy Call Center uses these criteria when reviewing prior authorization requests for fee-for-service prescriptions.

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Oregon Medicaid PA Criteria, January 20161/1/2016
Oregon Medicaid PA Criteria, October 201510/9/2015
Oregon Medicaid PA Criteria, August 20158/25/2015
Oregon Medicaid PA Criteria, July 20157/1/2015
Oregon Medicaid PA Criteria, April 20154/18/2015
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Preferred Drug List

Physical health drugs on this list do not require PA. Access the list using Epocrates Rx ('Oregon Medicaid - open card"), and access formularies for other payers, including OHP health plans. Lists before 2012 are in the Pharmeceutical Services administrative rulebooks.

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Oregon Medicaid Preferred Drug List - January 1, 20161/1/2016
Oregon Medicaid Preferred Drug List - November 1, 201511/1/2015
Oregon Medicaid Preferred Drug List - October 1, 201510/1/2015
Oregon Medicaid Preferred Drug List - July 1, 20157/1/2015
Oregon Medicaid Preferred Drug List - April 18, 20154/18/2015
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Forms

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Description
DMAP 1074

Prior Authorization for Out-of-State Services​

DMAP 2410

Newborn Notification Form​

DMAP 2470

Maternity Case Management - Initial Assessment​

DMAP 2471

Maternity Case Management - Training and Education Tracking​

DMAP 2472

Maternity Case Management - Home and Environmental Assessment​

DMAP 2473

Maternity Case Management - Five A's Intervention Record (FAIR) for Smoking Cessation​

DMAP 3978
Prior Authorization Request for Pharmacy and Oral Nutritional Supplements
DMAP 741

Hysterectomy Consent​

DMAP 741

Hysterectomy Consent - Spanish​

DMAP 742A

Consent to Sterilization​

DMAP 742A

Consent to Sterilization - Spanish​

DMAP 742B
Ages 15-20 Consent to Sterilization
DMAP 742B
Ages 15-20 Consent to Sterilization - Spanish
DMAP 9033

Lead Risk Assessment Questionnaire​

MSC 3971
DHS/OHA Prior Authorization Request - instructions

Announcements

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Fee-for-service RVU-weight-based rates effective January 1, 20161/28/2016
Fee-for-service professional claim reprocessing scheduled for December 18, 201512/16/2015
Fee-for-service claim reprocessing planned for December 11, 201512/7/2015
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Who to call for help

Provider Services 800-336-6016 or email us
Address and telephone contacts​​​ ​​​​​​​​​​​​​​​​​​​​