OAR 410-120-1180
Medical Assistance Benefits: Out-of-State Services


(1) A provider located in a state other than Oregon whose services are rendered in that state shall be licensed and otherwise certified by the proper agencies in the state of residence as qualified to render the services. Certain cities within 75 miles of the Oregon border may be closer for Oregon residents than major cities in Oregon, and therefore, these areas are considered contiguous areas, and providers are treated as providing in-state services.
(2) Out-of-state providers must enroll with the Authority as described in OARs 943-120-0320 (Provider Enrollment) and 410-120-1260 (Provider Enrollment), Provider Enrollment. Out-of-state providers must provide services and bill in compliance with these rules and the OARs for the appropriate type of services provided.
(3) Payment rates for out-of-state providers are established in the individual provider rules through contracts or service agreements and in accordance with OAR chapter 943, division 120 and OAR 410-120-1340 (Payment), Payment.
(4) For enrolled non-contiguous, out-of-state providers, the Division reimburses for covered services under any of the following conditions:
(a) For clients enrolled in an MCE:
(A) The service is authorized by an MCE, and payment to the out-of-state provider is the responsibility of the MCE;
(B) If a client has coverage through an MCE, the request for non-emergency services must be referred to the MCE. Payment for these services is the responsibility of the MCE;
(C) The service or item is not available in the State of Oregon or provision of the service or item by an out-of-state provider is cost effective, as determined by the MCE.
(b) For clients not enrolled in an MCE:
(A) The service to a Division client is emergent as defined in 410-120-0000 (Acronyms and Definitions);
(B) A delay in the provision of services until the client is able to return to Oregon could reasonably be expected to result in prolonged impairment, or in increased risk that treatment will become more complex or hazardous, or in substantially increased risk of the development of chronic illness;
(C) The Division authorized payment for the service in advance of the provision of services or is otherwise authorized in accordance with payment authorization requirements in the individual provider rules or in the General Rules;
(D) The service is being billed for Qualified Medicare Beneficiary (QMB) deductible or co-insurance coverage;
(E) The client is traveling and unable to use an in-state pharmacy;
(F) The pharmacy is out-of-state and mail order; the primary insurance TPL policy requires the use of the pharmacy;
(G) The pharmacy is out-of-state and mail order and provides one or more pharmaceutical products that are only available through a limited distribution network.
(5) The Authority may give prior authorization (PA) for non-emergency out-of-state services provided by a non-contiguous enrolled provider under the following conditions:
(a) The service is billed for Qualified Medicare Beneficiary (QMB) deductible or co-insurance coverage; or
(b) The Division covers the service or item under the specific client’s benefit package; and
(c) The service or item is not available in the State of Oregon, or provision of the service or item by an out-of-state provider is cost effective, as determined by the Division; and
(d) The service or item is deemed medically appropriate and is recommended by a referring Oregon physician.
(6) Laboratory analysis of specimens sent to out-of-state independent or hospital-based laboratories is a covered service and does not require PA. The laboratory must meet the same certification requirements as Oregon laboratories and must bill in accordance with Division rules.
(7) The Division makes no reimbursement for services provided to a client outside the territorial limits of the United States. For purposes of this provision, the United States includes the District of Columbia, Puerto Rico, the Virgin Islands, Guam, the Northern Mariana Islands, and American Samoa.
(8) The Division shall reimburse within limits described in these General Rules and in individual provider rules all services provided by enrolled providers to children:
(a) Who the Division has placed in foster care;
(b) Who the Department has placed in a subsidized adoption outside the State of Oregon; or
(c) Who are in the custody of the Department and traveling with the consent of the Department.
(9) The Division does not require authorization of non-emergency services for the children covered by section (8) except as specified in the individual provider rules.
(10) Payment rates for out-of-state providers are established in the individual provider rules through contracts or service agreements and in accordance with OAR 943-120-0350 (Payments and Overpayments) and 410-120-1340 (Payment), Payment.

Source: Rule 410-120-1180 — Medical Assistance Benefits: Out-of-State Services, https://secure.­sos.­state.­or.­us/oard/view.­action?ruleNumber=410-120-1180.

410‑120‑0000
Acronyms and Definitions
410‑120‑0003
OHP Standard Benefit Package
410‑120‑0006
Medical Eligibility Standards
410‑120‑0011
Effect of COVID-19 Emergency Authorities on Administrative Rules
410‑120‑0025
Administration of Division of Medical Assistance Programs, Regulation and Rule Precedence
410‑120‑0030
Children’s Health Insurance Program
410‑120‑0035
Public Entity
410‑120‑0045
Applications for Medical Assistance at Provider locations
410‑120‑0250
Managed Care Entity
410‑120‑1140
Verification of Eligibility and Coverage
410‑120‑1160
Medical Assistance Benefits and Provider Rules
410‑120‑1180
Medical Assistance Benefits: Out-of-State Services
410‑120‑1190
Medically Needy Benefit Program
410‑120‑1195
SB 5548 Population
410‑120‑1200
Excluded Services and Limitations
410‑120‑1210
Medical Assistance Benefit Packages and Delivery System
410‑120‑1260
Provider Enrollment
410‑120‑1280
Billing
410‑120‑1285
Recoupment and Data Sharing with Third-Party Insurers
410‑120‑1295
Non-Participating Provider
410‑120‑1300
Timely Submission of Claims
410‑120‑1320
Authorization of Payment
410‑120‑1340
Payment
410‑120‑1350
Buying-Up
410‑120‑1360
Requirements for Financial, Clinical and Other Records
410‑120‑1380
Compliance with Federal and State Statutes
410‑120‑1385
Compliance with Public Meetings Law
410‑120‑1390
Premium Sponsorships
410‑120‑1395
Program Integrity
410‑120‑1396
Provider and Contractor Audits
410‑120‑1397
Recovery of Overpayments to Providers — Recoupments and Refunds
410‑120‑1400
Provider Sanctions
410‑120‑1460
Type and Conditions of Sanction
410‑120‑1510
Fraud and Abuse
410‑120‑1560
Provider Appeals
410‑120‑1570
Claim Re-Determinations
410‑120‑1580
Provider Appeals — Administrative Review
410‑120‑1600
Provider Appeals — Contested Case Hearings
410‑120‑1855
Client’s Rights and Responsibilities
410‑120‑1860
Contested Case Hearing Procedures
410‑120‑1865
Denial, Reduction, or Termination of Services
410‑120‑1870
Client Premium Payments
410‑120‑1875
Agency Hearing Representatives
410‑120‑1880
Contracted Services
410‑120‑1920
Institutional Reimbursement Changes
410‑120‑1940
Interest Payments on Overdue Claims
410‑120‑1960
Payment of Private Insurance Premiums
410‑120‑1980
Requests for Information and Public Records
410‑120‑1990
Telehealth
Last Updated

Jun. 8, 2021

Rule 410-120-1180’s source at or​.us