Oregon Health Authority : School-Based Health Services Frequently Asked Questions : Oregon Health Plan : State of Oregon

OHA and ODE guidance materials are available on their respective websites: ODE's Medicaid in Education and OHA's Oregon Health Plan (OHP) School-Based Health Services. To schedule training with the OHA-ODE SBHS team, contact Jennifer Dundon at jennifer.dundon@ode.oregon.gov.

To assist with determining the costs and benefits, ODE and OHA have jointly developed tools to determine readiness and feasibility to include: School Medicaid Billing Startup Checklist, School Medicaid Readiness Assessment Tool, and School Medicaid Cost-Benefit Analysis Tool.

Written, oral, or recorded consent is required and must be obtained and documented for the child or young adult to receive services using a telemedicine or telehealth delivery method. See OAR 410-133-0070. Please also see respective licensing board rules and practitioner-specific guides on the provision of telehealth in schools.

Education agencies may contract with a billing vendor to submit claims on their behalf or submit claims via the no-cost Oregon Medicaid Management Information System (MMIS) Provider Web Portal.

Yes. A separate TPA is necessary for each of an education agency's Oregon Medicaid IDs. See EDI and TPA Resources for information on completing a TPA.

The education agency, as the billing provider for SBHS Medicaid, is liable for claims submitted in error and responsible for any associated fraud or financial reconciliation.

What is the billing pathway when the school district contracts with the Community Mental Health Program (CMHP) to provide school-based mental health services?

The school district responsible for FAPE has the right to bill OHP for the contracted SBHS Medicaid services. The contract between the school district and the CMHP must clearly define service provision and billing to avoid duplication.

Please see SBHS Billing Codes and Instructions for a list of allowable procedure codes, modifiers, provider types, and provider specialties related to SBHS Medicaid billing.

Yes, delegated nursing procedures may be billed under SBHS Medicaid. Please see the Personal Care Services Guide for more information and Medicaid requirements.

No. SBHS Medicaid services are separate from community health services and do not affect the maximum benefit allowed for a child or young adult in the community setting. OAR 410-141-3565 (8)(h) states SBHS Medicaid services are supplemental to other health plan covered therapy services and are not considered duplicative services.

Yes. Education agencies may clearly define service provision and Medicaid billing in contracts with other agencies to ensure no duplication.

Please see the Education Agency Eligibility Criteria for more information on charter school participation in School Based Health Services.

You can determine if a provider is already enrolled using the instructions in the SBHS Provider Enrollment Guide. You can also contact OHP Provider Enrollment.

Yes. This does not, however, make the individual financially liable for financial reconciliation or fraud. The education agency is liable.

The taxonomy code and provider type are the same. The specialty codes differ based upon the SBHS program area. See page 4 of the SBHS Provider Enrollment Guide.

First ensure the National Provider Identifier (NPI) is active. If the NPI is active and the K-12 IDEA Oregon Medicaid ID is inactive, complete the re-enrollment process to reactivate the Oregon Medicaid ID. Re-enrollment forms and instructions are available on the OHP Provider Enrollment website.

School-Based Health Services Frequently Asked Questions

Program Support and Guidance

Consent Requirements

Billing and Reimbursement

Covered Services

Provider Enrollment

School-Based Health Services Frequently Asked Questions

Program Support and Guidance

What supports are available to assist with understanding and implementing SBHS Medicaid billing programs?

What are the start-up costs and future benefits of program participation?

Consent Requirements

Is consent for telehealth required?

Billing and Reimbursement

How do education agencies submit claims?

Is a trading partner agreement (TPA) with the Medicaid billing vendor and OHA’s Electronic Data Interchange (EDI) required for each of an education agency’s Oregon Medicaid IDs?

Who is liable if a claim is submitted in error?

Covered Services

What procedure codes are allowed for billing SBHS Medicaid?

Can delegated nursing procedures performed by an unregulated assistive person (UAP), such as an instructional aide, be billed under SBHS Medicaid?

Is it duplicate billing if a student received speech therapy both in school and in the community from an outpatient clinic?

Provider Enrollment

If the SBHS-recognized providers are contracted, rather than employed at the education agency, can the education agency enroll and participate in the SBHS Medicaid program?

Are charter schools eligible to enroll and participate?

How do I find out if my EA is already enrolled as a school medical provider?

Is it necessary for an education agency to provide a social security number (SSN) and date of birth (DOB) on the provider disclosure statement form?

Would the taxonomy code, provider type, and specialty be the same for IDEA services and non-IDEA services?

If the education agency has an existing, inactive K-12 IDEA enrollment, what is the process to reactivate the Oregon Medicaid ID?