1. (1) The National Drug Code (NDC) must be included on all claim formats for physician administered drug codes required by the Deficit Reduction Act of 2005.

2. (2) For discharges prior to January 1, 2012, In-State Diagnostic Related Grouper (DRG) hospital outpatient and emergency services are reimbursed under a cost-based methodology.

   1. (a) Interim reimbursement:

      1. (A) The interim reimbursement percentage is developed using the cost-to-charge ratio methodology, derived from the Medicare cost report, and applied to billed charges;
      2. (B) The interim payment is the estimated percentage needed to achieve 100 percent of hospital cost in aggregate; and
      3. (C) This interim percentage is applied to all outpatient charges except for clinical laboratory services. Interim reimbursement for clinical laboratory services is calculated according to rates published in the Agency fee schedule.

   2. (b) Settlement reimbursement:

      1. (A) For Medicaid and Children’s Health Insurance Program-eligible (Titles XIX and XXI of the Social Security Act) clients, an adjustment to 100 percent of outpatient costs is made during the cost settlement process;
      2. (B) For General Assistance (GA) clients, outpatient hospital services are reimbursed at 50 percent of billed charges or 59 percent of costs, whichever is less.

3. (3) Effective for discharges on or after January 1, 2012:

   1. (a) In-State DRG hospital outpatient and emergency services shall be reimbursed in accordance with Code of Federal Regulations 42 Part 419 Prospective Payment System for Hospital Outpatient Department Services, using the Ambulatory Payment Classification (APC) Group methodology, and
   2. (b) Payments shall be based on rates determined by State Actuarial Services to be equivalent to 100 percent of Medicare outpatient payments for each DRG hospital.

Statutory/Other Authority

ORS 413.042

Statutes/Other Implemented

ORS 414.065

History

DMAP 90-2025, amend filed 12/17/2025, effective 12/17/2025
DMAP 59-2025, temporary amend filed 07/30/2025, effective 08/01/2025 through 01/27/2026
DMAP 55-2025, amend filed 06/26/2025, effective 06/29/2025
DMAP 32-2012, f. 6-29-12, cert. ef. 7-1-12
DMAP 48-2011(Temp), f. 12-23-11, cert. ef. 1-1-12 thru 6-25-12
DMAP 31-2009, f. 9-22-09, cert. ef. 10-1-09
DMAP 10-2009(Temp), f. 4-29-09, cert. ef. 5-1-09 thru 10-28-09
DMAP 39-2008, f. 12-11-08, cert. ef. 1-1-09
OMAP 43-2006, f. 12-15-06, cert. ef. 1-1-07
OMAP 17-2006, f. 6-12-06, cert. ef. 7-1-06
OMAP 73-2005, f. 12-29-05, cert. ef. 1-1-06
OMAP 21-2005, f. 3-21-05, cert. ef. 4-1-05
OMAP 78-2004(Temp), f. & cert. ef. 10-1-04 thru 3-15-05
OMAP 90-2003, f. 12-30-03, cert. ef. 1-1-04
OMAP 37-2003, f. & cert. ef. 5-1-03
OMAP 16-2003(Temp), f. & cert. ef. 3-10-03 thru 8-1-03
OMAP 13-2003, f. 2-28-03, cert. ef. 3-1-03
OMAP 34-1999, f. & cert. ef. 10-1-99
HR 36-1993, f. & cert. ef. 12-1-93
HR 22-1993(Temp), f. & cert. ef. 9-1-93
HR 53-1991, f. & cert. ef. 11-18-91, Renumbered from 410-125-0780 & 410-125-0800
HR 32-1991(Temp), f. & cert. ef. 7-29-91
HR 28-1991(Temp), f. & cert. ef. 7-1-91
HR 15-1991(Temp), f. & cert. ef. 4-8-91
HR 2-1991, f. & cert. ef. 1-4-91
HR 31-1990(Temp), f. & cert. ef. 9-11-90
HR 21-1990, f. & cert. ef. 7-9-90, Renumbered from 461-015-0540 & 461-015-0550
HR 18-1990(Temp), f. 6-29-90, cert. ef 7-1-90
AFS 72-1989, f. & cert. ef. 12-1-89, Renumbered from 461-015-0124
AFS 49-1989(Temp), f. 8-24-89, cert. ef. 9-1-89
AFS 45-1989, f. & cert. ef. 8-21-89
AFS 37-1989(Temp), f. 6-30-89, cert. ef. 7-1-89
AFS 36-1989(Temp), f. & cert. ef. 6-30-89
AFS 15-1989(Temp), f. 3-31-89, cert. ef. 4-1-89
AFS 7-1989(Temp), f. 2-17-89, cert. ef. 3-1-89
AFS 63-1988, f. 10-3-88, cert. ef. 12-1-88
AFS 47-1988(Temp), f. 7-13-88, cert. ef. 7-1-88
AFS 26-1988, f. 3-31-88, cert. ef. 4-1-88
AFS 12-1988, f. 2-10-88, cert. ef. 6-1-88
AFS 62-1987(Temp), f. 12-30-87, cert. ef. 1-1-88
AFS 46-1987, f. & cert. ef. 10-1-87
AFS 33-1987(Temp), f. & cert. ef. 7-22-87
AFS 61-1986, f. 8-12-86, cert. ef. 9-1-86
AFS 46-1986(Temp), f. 6-25-86, cert. ef. 7-1-86
AFS 52-1985, f. 9-3-85, cert. ef. 10-1-85
AFS 6-1985, f. 1-28-85, cert. ef. 2-1-85
AFS 45-1984, f. & cert. ef. 10-1-84
AFS 1-1984, f. & cert. ef. 1-9-84
AFS 37-1983(Temp), f. & cert. ef. 7-15-83
Renumbered from 461-015-0120(5)
AFS 60-1982, f. & cert. ef. 7-1-82
AFS 18-1982(Temp), f. & cert. ef. 3-1-82
AFS 57-1980, f. 8-29-80, cert. ef. 9-1-80
AFS 14-1980, f. 3-27-80, cert. ef. 4-1-80