Current through Register Vol. 63, No. 9, September 1, 2024
(1) This rule
effective on the date stated in OAR
410-141-3830 incorporates by
reference the Oregon Health Evidence Review Commission (HERC) Prioritized List
of Health Services (The List), funded through line 469 and including all line
items, diagnostic and treatment codes, guideline notes, statements of intent,
coding specifications and annotations. All material included therein are
incorporated in and made part of this rule by this reference, including interim
modifications reported as required under ORS
414.690(7) and
(8).
(a) The
Prioritized List of Health Services includes line items consisting of diagnosis
and treatment codes that pair together with specific conditions on the same
line. Each line has a description of both a condition(s) and treatment for the
condition(s). Services on lines 1-469 are covered for OHP Members, with some
dental services subject to exclusion for adults age 21 and over. Coverage of
these services is included in the benefit package when providers follow The
List's code pairing, Guideline Notes, annotations and statements of intent. The
Benefit Package also covers additional services described in this
rule;
(b) Diagnostic and Preventive
Service codes. Approved CDT codes for preventive dental services are included
on the funded portion of The Prioritized List of Health Services, and
limitations specified in related Guideline Notes. Dental and Oral Health
Providers are subject to utilizing The List for procedure and diagnosis code
pairing and funding of preventive and diagnostic services. Preventive services
include prophylaxis, sealants, fluoride varnish application, caries arresting
medicaments, and vaccinations. Diagnostic services include examinations,
imaging, oral evaluations, and testing. All diagnosis and preventive service
codes are subject to The List Guidelines Notes and limitations found in this
rule;
(c) Ancillary service codes.
Covered ancillary codes are subject to applicable Ancillary Guidelines on The
List. Approved ancillary codes are listed in this rule at OAR
410-123-1620;
(d) The List shall be used in conjunction
with applicable OHP provisions found in federal and state laws, the State Plan
and Oregon's 1115(a) Waiver for coverage of services such as, but not limited
to:
(A) Services on unfunded lines for
children ages from birth through 1;
(B) Services provided for a condition
appearing in the funded region of The List in conjunction with federal
requirements for Early and Periodic Screening, Diagnosis and Treatment (EPSDT)
and Oregon's 1115(a) Waiver.
(2) Regardless of The List placement, dental
and oral health services shall be dentally necessary and clinically appropriate
for each individual member served.
(3) Changes to services funded on The List
are effective on the date of The List change:
(a) The Division administrative rules
(chapter 410, division 123) do not reflect the most current Prioritized List of
Health Services changes until the rules are amended through the Division rule
filing process;
(b) For the most
current Prioritized List of Health Services, refer to the HERC website at
https://www.oregon.gov/oha/HPA/DSI-HERC/Pages/Prioritized-List.aspx;
(c) In the event of an alleged variation
between a Division-listed code and a national code, the Division shall apply
the national code in effect on the date of request or date of
service.
(4) Refer to
The List of Services and OAR
410-123-1260 for information
about limitations on procedures funded according to The List. Examples of
limitations include frequency and member's age.
(5) The List does not include or fund the
following general categories of dental services, and the Division does not
cover them for any member. Several of these services are considered elective or
"cosmetic" in nature (i.e., done for the sake of appearance):
(a) Desensitization;
(b) Implant and implant services (See
Prioritized List Guideline Notes 123 and 169);
(c) Mastique or veneer procedure;
(d) Orthodontia (except for cleft palate,
cleft lip, or cleft palate with cleft lip treatments, or to correct cranial
facial abnormalities);
(e) Overhang
removal;
(f) Procedures,
appliances, or restorations solely for aesthetic or cosmetic
purposes;
(g) Temporomandibular
joint dysfunction treatment; and
(h) Tooth bleaching.
Statutory/Other Authority: ORS
413.042 & ORS
414.065
Statutes/Other Implemented: ORS
414.065
