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Medical-Surgical Services Program

Medical-Surgical Services Program

Oregon Administrative Rules and supplemental information administered by the Health Systems Division.

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
  
130-0220-05012016Permanent Rule Filing
410-130-0220
Incorporate Code Set and HERC Changes into List of Billing Codes Not Covered by OHP
 
5/1/2016
Nprm-130-0220-04212016Notice of Proposed Rulemaking
410-130-0220
Incorporate Code Set and HERC Changes into List of Billing Codes Not Covered by OHP
There is no hearing for this rulemaking. The changes were made by CMS and HERC.
The public comment period ends April 21, 2016, at 5 p.m.
Send comments to dmap.rules@state.or.us.
4/21/2016
130-0220-03042016Temporary Rule Filing
410-130-0220
Incorporate Code Set and HERC Changes into List of Billing Codes Not Covered by OHP
3/4/2016
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
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Administrative rulebooks

Each rulebook is an interactive PDF that contains all program rules effective on the "Effective Date" listed for the rulebook.
  
  
130rb050120165/1/2016
130rb030420163/4/2016
130rb0101161/1/2016
130rb12011512/1/2015
130rb11011511/1/2015
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Supplemental information and guidelines

To learn more about National Drug Code (NDC) reporting, visit OHP'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/Bundled/Not Valid Procedures (Procedure Group 1118):  Please see rule 410-130-0220​ for more information.

  
Undefined Diagnosis Codes (Group 6030), 4-1-2016
Undefined Diagnosis Codes (Diagnosis Code Group 6030), 1-1-2016
Informational Diagnosis Codes (Diagnosis Code Group 6033), 4-1-2016
Informational Diagnosis Codes (Diagnosis Code Group 6033), 1-1-2016
Diagnostic Workup File (Diagnosis Code Group 6032), 1-1-2016
Diagnostic Workup File (Code Group 6032), 4-1-2016
Diagnostic Procedure Codes (Procedure Code Group 1119), 4-1-2016
Diagnostic Procedure Codes (Procedure Code Group 1119), 1-1-2016
Conditions Not Covered (Diagnosis Code Group 6031), 4-1-2016
Conditions Not Covered (Diagnosis Code Group 6031), 1-1-2016

Oregon Medicaid PA Criteria

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

  
  
Oregon Medicaid PA Criteria, May 20165/1/2016
Oregon Medicaid PA Criteria, February 20162/12/2016
Oregon Medicaid PA Criteria, January 20161/1/2016
Oregon Medicaid PA Criteria, October 201510/9/2015
Oregon Medicaid PA Criteria, August 20158/25/2015
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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.

​​​
  
  
Oregon Medicaid Preferred Drug List - May 1, 20165/1/2016
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
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Forms

​​​​
  
Description
OHP 2472

Maternity Case Management - Home and Environmental Assessment​

OHP 2473

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

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

Hysterectomy Consent - Spanish​

OHP 742A

Consent to Sterilization - Spanish​ (ages 21 and up)

OHP 9033

Lead Risk Assessment Questionnaire​

MSC 3971
DHS/OHA Prior Authorization Request - instructions
OHP 1074

Prior Authorization for Out-of-State Services​

OHP 2410

Newborn Notification Form​

OHP 2470

Maternity Case Management - Initial Assessment​

OHP 2471

Maternity Case Management - Training and Education Tracking​

OHP 741

Hysterectomy Consent​

OHP 742A

Consent to Sterilization​ (ages 21 and up)

OHP 742B
Ages 15-20 Consent to Sterilization
OHP 742B
Ages 15-20 Consent to Sterilization - Spanish

Announcements

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Fee-for-service claims and Place of Service code 194/22/2016
Fee-for-service professional claim reprocessing scheduled for March 26, 20163/23/2016
Fee-for-service RVU-weight-based rates effective April 1 20163/22/2016
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Who to call for help

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