Or. Admin. R. 410-133-0080 – Coverage

(1) Services provided or supervised by Medicaid-enrolled SBHS-recognized providers are covered when EPSDT medical necessity and appropriateness are supported by:
1. (a) For planned services:
  1. (A) The child or young adult’s IPOC; and
  2. (B) The rendering provider’s service documentation.
2. (b) For unplanned services, the rendering provider’s service documentation which must include:
  1. (A) Date of service;
  2. (B) Medicaid-enrolled child or young adult’s:
    1. (i) Full name;
    2. (ii) Medicaid ID; and
    3. (iii) Diagnosis code(s);
  3. (C) Name of the school medical provider;
  4. (D) Name of the rendering provider performing the service;
  5. (E) Name of the healthcare provider supervising the service (when applicable);
  6. (F) Medically necessary and appropriate need for the service;
  7. (G) Location and duration of the service; and
  8. (H) Nature, extent, or units of service.
(2) Specialized transportation services are covered when:
1. (a) The child or young adult requires specialized transportation to serve their individual health-related needs;
2. (b) Specified as a related service in the child or young adult’s IEP or IFSP;
3. (c) Documentation supports specialized transportation is medically necessary and appropriate;
4. (d) A separate school-based health service, other than transportation, specified on the child or young adult’s IEP or IFSP is provided and reimbursed on the same day; and
5. (e) Supported by a transportation vehicle trip log.

Statutory/Other Authority

ORS 413.042

Statutes/Other Implemented

ORS 414.065

History

DMAP 65-2025, amend filed 08/29/2025, effective 08/29/2025
DMAP 121-2024, amend filed 09/06/2024, effective 09/06/2024
DMAP 56-2020, amend filed 10/02/2020, effective 10/05/2020
DMAP 19-2020, temporary amend filed 04/09/2020, effective 04/09/2020 through 10/05/2020
DMAP 33-2016, f. 6-29-16, cert. ef. 7-1-16
DMAP 15-2011, f. 6-29-11, cert. ef. 7-1-11
DMAP 19-2009, f. 6-12-09, cert. ef. 7-1-09
OMAP 53-2005, f. 9-30-05, cert. ef. 10-1-05
OMAP 24-2005(Temp), f. & cert. ef. 4-5-05 thru 10-1-05
OMAP 53-2003, f. 8-13-03 cert. ef. 9-1-03
OMAP 31-2003, f. & cert ef. 4-1-03
OMAP 31-1998, f. & cert. ef. 9-1-98
HR 21-1995, f. & cert. ef. 12-1-95
HR 39-1991, f. & cert. ef. 9-16-91