1. (1) As defined by the Division of Medical Assistance Programs (Division), a valid Federally Qualified Health Center (FQHC) or Rural Health Clinic (RHC) encounter excludes pharmaceutical or biologicals not generally provided during a clinic visit. Refer to OAR 41-147-0120 Division Encounter and Recognized Practitioners.

   1. (a) Because Division includes the costs of drugs or medication treatments administered by a clinic to treat a client during an office visit in the PPS all-inclusive encounter rate for the office visit, providers cannot bill separately for the costs of the drugs or treatments;
   2. (b) Prescriptions are not included in the Prospective Payment System (PPS) encounter rate. To bill for filled prescriptions, the FQHC or RHC’s qualified enrolled pharmacy must bill Division using its pharmacy provider number.

2. (2) Clinics may directly bill Division using their clinic provider number for contraceptive supplies and contraceptive medications only for:

   1. (a) Clients enrolled in a prepaid health plan (PHP): Clinics must bill the PHP first. If the PHP will not reimburse for the contraceptive supply or contraceptive medication, then the clinic can bill Division fee-for-service at the clinic’s acquisition cost. See also OAR 410-130-0585, Family Planning Services;
   2. (b) Fee-for-service clients: Clinics can directly bill Division fee-for-service at the clinic’s acquisition cost for contraceptive supplies and contraceptive medications. See also OAR 410-130-0585, Family Planning Services.
3. (3) Refer to OAR 410 division 121, Pharmaceutical Services Program Rulebook for specific information.

Statutory/Other Authority

ORS 413.042 & 414.065

Statutes/Other Implemented

ORS 414.065

History

DMAP 25-2008, f. 6-13-08, cert. ef. 7-1-08
OMAP 27-2006, f. 6-14-06, cert. ef. 7-1-06
OMAP 71-2003, f. 9-15-03, cert. ef. 10-1-03
OMAP 63-2002, f. & cert. ef. 10-1-02, Renumbered from 410-135-0240
OMAP 62-2002, f. & cert. ef. 10-1-02, Renumbered from 410-128-0600
OMAP 39-2002, f. 9-13-02, cert. ef. 9-15-02
OMAP 42-2001, f. 9-24-01, cert. ef. 10-1-01
OMAP 37-2001, f. 9-24-01, cert. ef. 10-1-01
OMAP 19-2001, f. 3-30-01, cert. ef. 4-1-01
OMAP 8-2001, f. 3-30-01, cert. ef. 4-1-01
OMAP 21-2000, f. 9-28-00, cert. ef 10-1-00
OMAP 20-2000, f. 9-28-00, cert. ef. 10-1-00
OMAP 35-1999, f. & cert. ef. 10-1-99
OMAP 19-1999, f. & cert. ef. 4-1-99