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Oregon Bulletin

December 1, 2013

Oregon Health Authority, Division of Medical Assistance Programs, Chapter 410

Rule Caption: Amend rules governing payment for Medicaid EHR Incentive Program

Adm. Order No.: DMAP 56-2013

Filed with Sec. of State: 10-22-2013

Certified to be Effective: 10-22-13

Notice Publication Date: 9-1-2013

Rules Amended: 410-165-0000, 410-165-0020, 410-165-0060, 410-165-0080, 410-165-0100, 410-165-0120, 410-165-0140

Subject: The Division needs to amend these rules because new federal legislation from the Centers for Medicare and Medicaid Services (CMS) affects how providers are eligible for the Medicaid EHR Incentive Program. These amended rules incorporate these changes including how a key eligibility criterion, Medicaid patient volume (or for some providers, needy individual patient volume), is determined and calculated.

Rules Coordinator: Sandy Cafourek—(503) 945-6430

410-165-0000

Basis and Purpose

(1) These rules (OAR chapter 410 division 165) govern the Oregon Health Authority (Authority), Division of Medical Assistance Programs (Division), Medicaid Electronic Health Record (EHR) Incentive Program. The Medicaid EHR Incentive Program provides incentive payments, consistent with federal law concerning such payments, to eligible providers participating in the Medicaid program who adopt, implement or upgrade, or successfully demonstrate meaningful use of certified EHR technology and who are qualified by the program.

(2) The Medicaid EHR Incentive Program is implemented pursuant to:

(a) The American Reinvestment and Recovery Act of 2009, Pub. L. No. 111-5, section 4201;

(b) The Centers for Medicare and Medicaid Services (CMS) federal regulation 42 CFR Part 495 (2010 & 2012) pursuant to the Social Security Act sections 1903(a)(3)(F) and 1903(t);

(c) The Division’s General Rules Program, OAR chapter 410, division 120;

(d) The Authority’s Provider Rules, OAR chapter 943, division 120.

(3) The following retroactive effective dates apply to these rules:

(a) For eligible hospitals, the effective date is October 1, 2012, the start date for program year 2013;

(b) For eligible professionals, the effective date is January 1, 2013 the start date for program year 2013.

Stat. Auth.: ORS 413.042

Stats. Implemented: ORS 413.042 & 414.033

Hist.: DMAP 13-2011, f. 6-29-11, cert. ef. 7-1-11; DMAP 20-2013(Temp), f. & cert. ef. 4-26-13 thru 10-23-13; DMAP 56-2013, f. & cert. ef. 10-22-13

410-165-0020

Definitions

The following definitions apply to OAR 410-165-0010 through 410-165-0140:

(1) Acceptance documents — Written evidence supplied by a provider demonstrating that the provider met Medicaid EHR Incentive Program eligibility criteria or participation requirements according to standards specified by the Oregon Health Authority’s (Authority) Division of Medicaid Assistance Programs.

(2) Acute care hospital — A healthcare facility, including but not limited to a critical access hospital, with a Centers for Medicare and Medicaid Services’ (CMS) certification number (CCN) that ends in 0001-0879 or 1300-1399; and where the average length of patient stay is 25 days or fewer.

(3) Adopt, implement or upgrade:

(a) Acquire, purchase, or secure access to certified EHR technology capable of meeting meaningful use requirements;

(b) Install or commence utilization of certified EHR technology capable of meeting meaningful use requirements; or

(c) Expand the available functionality of certified EHR technology capable of meeting meaningful use requirements at the practice site, including staffing, maintenance, and training, or upgrade from existing EHR technology to certified EHR technology.

(4) Attestation — A statement that

(a) Is made by an eligible provider or preparer during the application process,

(b) Represents that the eligible provider met the thresholds and requirements of the Medicaid EHR Incentive Program and

(c) Is made under penalty of prosecution for falsification or concealment of a material fact.

(5) Certified EHR technology — As defined in 42 CFR 495.4 (2010 and 2012) and 45 CFR 170.102 (2010, 2011 and 2012) per the Office of the National Coordinator for Health Information Technology EHR certification criteria.

(6) Children’s hospital — A separately certified hospital, either freestanding or hospital-within hospital that predominantly treats individuals under 21 years of age and that either

(a) Has a CMS Certification Number (CCN) that ends in 3300–3399; or

(b) Does not have a CCN but has been provided an alternative number by CMS for purposes of enrollment in the Medicaid EHR Incentive Program as a children’s hospital.

(7) Dentist — As defined in OAR 410-120-0000; and as defined in 42 CFR 440.100.

(8) Eligible hospital — An acute care hospital with at least 10% Medicaid patient volume or a children’s hospital.

(9) Eligible professional — A professional who

(a) Is a physician; a dentist; a nurse practitioner, including a nurse-midwife nurse practitioner; or a physician assistant practicing in a Federally Qualified Health Center (FQHC) or a Rural Health Clinic (RHC), that is so led by a physician assistant,

(b) Meets patient volume requirements described in OAR 410-165-0060; and

(c) Is not a hospital-based professional.

(10) Eligible provider — Eligible hospital or eligible professional.

(11) Encounter:

(a) For an eligible hospital, either

(A) Services rendered to an individual per inpatient discharge; or

(B) Services rendered to an individual in an emergency department on any one day;

(b) For an eligible professional, services rendered to an individual on any one day.

(12) Enrolled provider — A hospital or health care practitioner who is actively registered with the Authority pursuant to OAR 943-120-0320.

(13) Entity promoting the adoption of certified EHR technology — An entity, designated by the Authority, that promotes the adoption of certified EHR technology by enabling: oversight of the business, operational and legal issues involved in the adoption and implementation of certified EHR technology; or the exchange and use of electronic clinical and administrative data between participating providers, in a secure manner, including but not limited to maintaining the physical and organizational relationship integral to the adoption of certified EHR technology by eligible providers.

(14) Federal fiscal year (FFY) — October 1 to September 30.

(15) Federally Qualified Health Center (FQHC) — As defined in OAR 410-120-0000.

(16) Grace period — A period of time following the end of a payment year when an eligible provider may submit an application to the Medicaid EHR Incentive Program for that payment year:

(a) For program years 2011 and 2012, the following applies:

(i) For a first year application, the grace period is 60 days;

(ii) For all subsequent years, the grace period is 90 days.

(b) For program year 2013 and later, the grace period is 90 days.

(17) Group — A clinic as defined in OAR 407-120-0100.

(18) Hospital-based professional — A professional who furnishes 90 percent or more of his or her Medicaid-covered services in a hospital emergency room (place of service code 23), or inpatient hospital (place of service code 21) in the calendar year (CY) preceding the payment year, except that hospital-based professional does not include a professional practicing predominantly at a Federally Qualified Health Center (FQHC) or a Rural Health Clinic (RHC).

(19) Individuals receiving Medicaid — Individuals served by an eligible provider where the services rendered would qualify under the Medicaid encounter definition.

(20) Meaningful EHR user — An eligible provider that, for an EHR reporting period for a payment year, demonstrates (in accordance with 42 CFR 495.5 and 42 CFR 495.8) meaningful use of certified EHR technology by meeting the applicable objectives and associated measures in 42 CFR 495.6 and as prescribed by 42 CFR Part 495.

(21) Medicaid encounter:

(a) For an eligible hospital applying for payment year 2011 or 2012, either:

(A) Services rendered to an individual per inpatient discharge where Medicaid (or a Medicaid demonstration project approved under the Social Security Act section 1115) paid for part or all of the service; or Medicaid (or a Medicaid demonstration project approved under the Social Security Act section 1115) paid all or part of the individual’s premiums, copayments, or cost-sharing; or

(B) Services rendered in an emergency department on any one day where Medicaid (or a Medicaid demonstration project approved under the Social Security Act section 1115) paid for part or all of the service; or Medicaid (or a Medicaid demonstration project approved under the Social Security Act section 1115) paid all or part of the individual’s premiums, copayments, and cost-sharing;

(b) For an eligible hospital applying for payment year 2013 or later, either

(A) Services rendered to an individual per inpatient discharge where the individual was enrolled in Medicaid (or a Medicaid demonstration project approved under the Social Security Act section 1115) or Children’s Health Insurance Program (CHIP) if part of a state’s Medicaid expansion (does not apply to Oregon’s as it is designated as a separate CHIP state), at the time the billable service was provided; or

(B) Services rendered in an emergency department on any one day where the individual was enrolled in Medicaid (or a Medicaid demonstration project approved under the Social Security Act section 1115) or Children’s Health Insurance Program (CHIP) if part of a state’s Medicaid expansion (does not apply to Oregon’s as it is designated as a separate CHIP state), at the time the billable service was provided;

(c) For an eligible professional applying for payment year 2011 or 2012, either

(A) Services rendered to an individual on any one day where Medicaid (or a Medicaid demonstration project approved under the Social Security Act section 1115) paid for part or all of the service; or

(B) Medicaid (or a Medicaid demonstration project approved under the Social Security Act section 1115) paid all or part of the individual’s premiums, copayments, and cost-sharing.

(d) For an eligible professional applying for payment year 2013 or later, services rendered to an individual on any one day where the individual was enrolled in a Medicaid program (or a Medicaid demonstration project approved under the Social Security Act section 1115) or Children’s Health Insurance Program (CHIP) if part of a state’s Medicaid expansion (does not apply to Oregon’s as it is designated as a separate CHIP state), at the time the billable service was provided.

(22) National Provider Identifier — As defined in 45 CFR Part 160 and OAR 410-120-0000.

(23) Needy individual — Individuals served by an eligible professional where the services rendered qualify under the needy individual encounter definition.

(24) Needy individual encounter:

(a) For an eligible professional applying for program year 2011 or 2012, services rendered to an individual on any one day where:

(A) Medicaid or Children’s Health Insurance Program (CHIP) (or a Medicaid or CHIP demonstration project approved under the Social Security Act section 1115) paid for part or all of the service;

(B) Medicaid or CHIP (or a Medicaid or CHIP demonstration project approved under the Social Security Act section 1115) paid all or part of the individual’s premiums, copayments, or cost-sharing;

(C) The services were furnished at no cost, and calculated consistent with 42 CFR 495.310(h); or

(D) The services were paid for at a reduced cost based on a sliding scale determined by the individual’s ability to pay.

(b) For an eligible professional applying for program year 2013 or later, services rendered to an individual on any one day where:

(A) The services were rendered to an individual enrolled in a Medicaid program (or a Medicaid demonstration project approved under the Social Security Act section 1115) or Children’s Health Insurance Program (CHIP), at the time the billable service was provided;

(B) The services were furnished at no cost, and calculated consistently with 42 CFR 495.310(h); or

(C) The services were paid for at a reduced cost based on a sliding scale determined by the individual’s ability to pay.

(25) Nurse practitioner — As defined in OAR 410-120-0000; and as defined in 42 CFR 440.166.

(26) Panel — A managed care panel, medical or health home program panel, or similar provider structure with capitation or case assignment that assigns patients to providers.

(27) Patient volume:

(a) For eligible hospitals: The proportion of Medicaid encounters to total encounters expressed as a percentage;

(b) For eligible professionals who do not meet the definition of “practices predominantly”: The proportion of Medicaid encounters to total encounters expressed as a percentage;

(c) For eligible professionals who meet the definition of “practices predominantly”: The proportion of Needy Individual encounters to total encounters expressed as a percentage.

(28) Payment year:

(a) The calendar year (CY) for an eligible professional; or

(b) The federal fiscal year (FFY) for an eligible hospital.

(29) Pediatrician — A physician who predominantly treats individuals under 21.

(30) Physician — As defined in OAR 410-120-0000; and as defined in 42 CFR 440.50.

(31) Physician assistant — As defined in OAR 410-120-0000; and as defined in 42 CFR 440.60.

(32) Practices predominantly — An eligibility criterion to permit use of needy individual patient volume. An eligible professional “practices predominantly” if:

(a) For program year 2011 or 2012, more than 50 percent of an eligible professional’s total patient encounters over a period of six months in the calendar year preceding the payment year occur at an FQHC or RHC.

(b) For program year 2013 and later, more than 50 percent of an eligible professional’s total patient encounters occur at an FQHC or RHC:

(A) During a six month period in the calendar year preceding the payment year; or

(B) During a six month period in the most recent 12 months prior to attestation.

(33) Preparer — A person authorized by an eligible provider to act on behalf of the provider to complete an application for a Medicaid EHR incentive via an electronic media connection with the Authority.

(34) Provider Web Portal — The Department of Human Services’ web site that provides a secure gateway for eligible providers or preparers to apply for the Medicaid EHR Incentive Program.

(35) Qualify — Meet the eligibility criteria and participation requirements to receive a Medicaid EHR incentive payment for the payment year. The Medicaid EHR Incentive Program (Program) makes the determination whether an eligible provider qualifies.

(36) Rural Health Clinic (RHC) — A clinic located in a rural and medically underserved community, designated as an RHC by CMS. Payment by Medicare and Medicaid to an RHC is on a cost-related basis for outpatient physician and certain non-physician services.

(37) So led — When an FQHC or RHC has a physician assistant who is:

(a) The primary provider in the clinic;

(b) A clinical or medical director at the clinical site of practice; or

(c) An owner of the RHC.

Stat. Auth.: ORS 413.042

Stats. Implemented: ORS 413.042 & 414.033

Hist.: DMAP 13-2011, f. 6-29-11, cert. ef. 7-1-11; DMAP 20-2013(Temp), f. & cert. ef. 4-26-13 thru 10-23-13; DMAP 56-2013, f. & cert. ef. 10-22-13

410-165-0060

Eligibility

For the purposes of the Medicaid Electronic Health Record (EHR) Incentive Program Oregon Administrative Rules, chapter 410, division 165, there are three categories of eligibility criteria: criteria for an eligible professional, criteria for an eligible professional practicing predominately in a Federally Qualified Health Center (FQHC) or a Rural Health Clinic (RHC), and criteria for an eligible hospital.

(1) To be eligible for a Medicaid EHR incentive payment for the payment year, a eligible professional, as listed in Table 165-0060-1, must meet the Medicaid EHR Incentive Program criteria each year:

(a) To be eligible for an incentive payment, an eligible professional must, at a minimum:

(A) Meet and follow the scope of practice regulations, as applicable for each professional as defined in 42 CFR Part 440;

(B) Meet the following certified EHR technology and meaningful use requirements for the corresponding payment year:

(i) First payment year: Adopt, implement, or upgrade certified EHR technology; and

(ii) Subsequent payment years: Demonstrate meaningful use as prescribed by 42 CFR 495.8 and meet the corresponding meaningful use criteria for the payment year as prescribed by 42 CFR 495.6; or

(ii) In all payment years, demonstrate meaningful use as prescribed by 42 CFR 495.8 and meet the corresponding meaningful use criteria for the payment year as prescribed by 42 CFR 495.6; or

(C) Either not be a hospital-based professional or for program year 2013 or later, meet the requirements that allow a reversal of a hospital based determination. To be considered non-hospital-based in future program years after an initial reversal determination, the professional must attest in each subsequent program year that the professional continues to meet the requirements. To meet the requirements, the professional must do all of the following:

(i) Fund the acquisition, implementation and maintenance of Certified EHR Technology, including supporting hardware and interfaces needed for meaningful use, without reimbursement from an eligible hospital, and use such Certified EHR Technology in the inpatient or emergency department of a hospital;

(ii) Provide documentation to the Program for review and approval for the program year and in accordance with the program application rules in OAR 410-165-0040;

(iii) Meet all applicable requirements to receive an incentive payment;

(d) If attesting to meaningful use, demonstrate using all encounters at all locations equipped with Certified EHR Technology, including those in the inpatient and emergency departments of the hospital; and

(D) Meet one of the following criteria:

(i) Have a minimum of 30 percent patient volume attributable to individuals receiving Medicaid; or

(ii) Be a pediatrician who has a minimum of 20 percent patient volume attributable to individuals receiving Medicaid;

(b) An eligible professional must calculate patient volume, as listed in Table 165-0060-2, by using the patient volume calculation method either of patient encounter or of patient panel. The patient panel volume calculation method may be used only when all of the following apply:

(A) The patient panel is appropriate as a patient volume calculation method for the eligible professional; and

(B) There is an auditable data source to support the patient panel data;

(c) An eligible professional must calculate patient volume, as listed in Table 165-0060-2, by using either the patient volume of the eligible professional or the patient volume of the group. The patient volume of the group may be used only when all of the following apply:

(A) The group’s patient volume is appropriate as a patient volume methodology calculation for the eligible professional;

(B) There is an auditable data source to support the group’s patient volume determination;

(C) All eligible professionals in the group must use the same patient volume calculation method for the payment year;

(D) The group uses the entire practice or clinic’s patient volume and does not limit patient volume in any way; and

(E) If an eligible professional works inside and outside of the group, then the patient volume calculation includes only those encounters associated with the group, and not the eligible professional’s outside encounters.

(d) An eligible professional’s patient volume must be calculated using one of the following methods:

(A) The patient encounter calculation method based on the patient volume of the eligible professional requires that:

(i) For program year 2011 or 2012, the eligible professional must divide the total Medicaid encounters by the total patient encounters that were rendered by the eligible professional in any representative, continuous 90-day period in the preceding calendar year; or

(ii) For program year 2013 and later, the eligible professional must divide the total Medicaid encounters by the total patient encounters that were rendered by the eligible professional in any representative, continuous 90-day period either in the preceding calendar year or in the twelve month timeframe preceding the date of attestation. The eligible professional may not use the same 90-day timeframe to calculate patient volume in different program years.

(B) The patient encounter calculation method based on the patient volume of the group requires that:

(i) For program year 2011 or 2012, the eligible professional must divide the group’s total Medicaid encounters by the group’s total patient encounters in any representative, continuous 90-day period in the preceding calendar year;

(ii) For program year 2013 and later, the eligible professional must divide the group’s total Medicaid encounters by the group’s total patient encounters in any representative, continuous 90-day period either in the preceding calendar year or in the twelve month timeframe preceding the date of attestation. The eligible professional may not use the same 90-day timeframe to calculate patient volume in different program years.

(C) The patient panel calculation method based on the patient volume of the eligible professional requires that:

(i) For program year 2011 or 2012 the eligible professional must:

(I) Add the total Medicaid patients assigned to the eligible professional’s panel in any representative 90-day period in the prior calendar year, provided at least one Medicaid encounter took place with the patient in the preceding calendar year, to the eligible professional’s unduplicated Medicaid encounters rendered in the same 90-day period; and

(II) Divide the result calculated above in (1)(d)(C)(i)(I) by the sum of the total patients assigned to the eligible professional’s panel in the same 90-day period, provided at least one encounter took place with the patient during the preceding calendar year, plus all of the unduplicated patient encounters in the same 90-day period;

(ii) For program year 2013 and later, the eligible professional must:

(I) Add the total Medicaid patients assigned to the eligible professional’s panel in any representative 90-day period in either the preceding calendar year or during the 12 month timeframe preceding the attestation date, provided at least one Medicaid encounter took place with the individual during the 24 months before the beginning of the 90-day period, to the eligible professional’s unduplicated Medicaid encounters rendered same 90-day period; and

(II) Divide the result calculated above in (1)(d)(C)(ii)(I) by the sum of the total patients assigned to the eligible professional’s panel in the same 90-day period, provided at least one encounter took place with the patient during the 24 months before the beginning of the 90-day period, plus all of the unduplicated patient encounters in the same 90-day period; and

(III) Not use the same 90-day timeframe to calculate patient volume in different program years;

(D) The patient panel calculation method based on the patient volume of the group requires that:

(i) For program year 2011 or 2012 the eligible professional must:

(I) Add the total Medicaid patients assigned to the group’s panel in any representative 90-day period in the prior calendar year, provided at least one Medicaid encounter took place with the patient in the preceding calendar year, to the group’s unduplicated Medicaid encounters in the same 90-day period; and

(II) Divide the result calculated above in (1)(d)(D)(i)(I) by the sum of the total patients assigned to the group’s panel in the same 90-day period, provided at least one encounter took place with the patient during the preceding calendar year, plus all of the unduplicated patient encounters in the same 90-day period;

(ii) For program year 2013 and later, the eligible professional must:

(I) Add the total Medicaid patients assigned to the group’s panel in any representative 90-day period in either the preceding calendar year or during the 12 month timeframe preceding the attestation date, provided at least one Medicaid encounter took place with the individual during the 24 months before the beginning of the 90-day period, to the group’s unduplicated Medicaid encounters that same 90-day period; and

(II) Divide the result calculated above in (1)(d)(D)(ii)(I) by the sum of the total patients assigned to the group’s panel in the same 90-day period, provided at least one encounter took place with the patient during the 24 months before the beginning of the 90-day period, plus all of the unduplicated patient encounters in the same 90-day period; and

(III) Not use the same 90-day timeframe to calculate patient volume in different program years;

(2) To be eligible for a Medicaid EHR incentive payment for the payment year, an eligible professional practicing predominantly in an FQHC or an RHC, as listed in Table 165-0060-1, must meet the Medicaid EHR Incentive Program professional eligibility criteria each year, by meeting either the above section (1) of this rule or by meeting the following FQHC- and RHC-specific criteria:

(a) To be eligible for an incentive payment, an eligible professional must, at a minimum:

(A) Meet and follow the scope of practice regulations, as applicable for each professional as prescribed by 42 CFR Part 440;

(B) Meet the following certified EHR technology and meaningful use requirements for the corresponding payment year:

(i) First payment year:

(I) Adopt, implement, or upgrade certified EHR technology; or

(II) Demonstrate meaningful use as prescribed by 42 CFR 495.8 and meet the corresponding meaningful use requirements for the payment year as prescribed by 42 CFR 495.6;

(ii) Subsequent payment years: Demonstrate meaningful use as prescribed by 42 CFR 495.8 and meet the corresponding meaningful use requirements for the payment year as prescribed by 42 CFR 495.6; and

(C) Have a minimum of 30 percent patient volume attributable to needy individuals;

(b) An eligible professional must calculate patient volume, as listed in Table 165-0060-3, by using the patient volume calculation method either of patient encounter or of patient panel. The patient panel volume calculation method may be used only when all of the following apply:

(A) The patient panel is appropriate as a patient volume calculation method for the eligible professional; and

(B) There is an auditable data source to support the patient panel data;

(c) An eligible professional must calculate patient volume, as listed in Table 165-0060-3, by using either the patient volume of the(eligible professional or the patient volume of the group. The group’s patient volume may be used only when all of the following apply:

(A) The group’s patient volume is appropriate as a patient volume methodology calculation for the eligible professional;

(B) There is an auditable data source to support the group’s patient volume determination;

(C) All eligible professionals in the group must use the same patient volume calculation method for the payment year;

(D) The group uses the entire practice or clinic’s patient volume and does not limit patient volume in any way; and

(E) If an eligible professional works inside and outside of the group, then the patient volume calculation includes only those encounters associated with the group, and not the eligible professional’s outside encounters;

(d) An eligible professional’s needy individual patient volume must be calculated using one of the following methods:

(A) The patient encounter calculation method based on the patient volume of the eligible professional:

(i) For program year 2011 or 2012, the eligible professional must divide the total needy individual encounters by the total patient encounters that were rendered by the eligible professional in any representative, continuous 90 day period in the preceding calendar year;

(ii) For program year 2013 and later, the eligible professional must divide the total needy individual encounters by the total patient encounters that were rendered by the eligible professional in any representative, continuous 90-day period either in the preceding calendar year or in the twelve month timeframe preceding the date of attestation. The eligible professional may not use the same 90-day timeframe to calculate patient volume in different program years;

(B) The patient encounter calculation method based on the patient volume of the group requires that:

(i) For program year 2011 or 2012, the eligible professional must divide the group’s total needy individual encounters by the group’s total patient encounters in any representative, continuous 90-day period in the preceding calendar year;

(ii) For program year 2013 and later, the eligible professional must divide the group’s total needy individual encounters by the group’s total patient encounters in any representative, continuous 90-day period either in the preceding calendar year or in the twelve month timeframe preceding the date of attestation. The eligible professional may not use the same 90-day timeframe to calculate patient volume in different program years.

(C) The patient panel calculation method based on the patient volume of the eligible professional requires that:

(i) For program year 2011 or 2012, the eligible professional must:

(I) Add the total needy individual patients assigned to the eligible professional’s panel in any representative 90-day period in the prior calendar year, provided at least one Medicaid encounter took place with the patient in the preceding calendar year, to the eligible professional’s unduplicated needy individual encounters rendered in the same 90-day period; and

(II) Divide the result calculated above in (1)(d)(C)(i)(I) by the sum of the total patients assigned to the eligible professional’s panel in the same 90-day period, provided at least one encounter took place with the patient during the preceding calendar year, plus all of the unduplicated patient encounters in the same 90-day period;

(ii) For program year 2013 and later, the eligible professional must:

(I) Add the total needy individual patients assigned to the eligible professional’s panel in any representative 90-day period either in the preceding calendar year or during the twelve month timeframe preceding the attestation date, provided at least one Medicaid encounter took place with the individual during the 24 months before the beginning of the 90-day period, to the eligible professional’s unduplicated needy individual encounters rendered same 90-day period; and

(II) Divide the result calculated above in (1)(d)(C)(ii)(I) by the sum of the total patients assigned to the eligible professional’s panel in the same 90-day period, provided at least one encounter took place with the patient during the 24 months before the beginning of the 90-day period, plus all of the unduplicated patient encounters in the same 90-day period; and

(III) Not use the same 90-day timeframe to calculate patient volume in different program years;

(D) The patient panel calculation method based on the patient volume of the group requires that:

(i) For program year 2011 or 2012 the eligible professional must:

(I) Add the total needy individual patients assigned to the group’s panel in any representative 90-day period in the prior calendar year, provided at least one needy individual encounter took place with the patient in the preceding calendar year, to the group’s unduplicated Medicaid encounters in the same 90-day period; and

(II) Divide the result calculated above in (1)(d)(D)(i)(I) by the sum of the total patients assigned to the group’s panel in the same 90-day period, provided at least one encounter took place with the patient during the preceding calendar year, plus all of the unduplicated patient encounters in the same 90-day period;

(ii) For program year 2013 and later, the eligible professional must:

(I) Add the total needy individual patients assigned to the group’s panel in any representative 90-day period either in the preceding calendar year or during the twelve month timeframe preceding the attestation date, provided at least one needy individual encounter took place with the individual during the 24 months before the beginning of the 90-day period, to the group’s unduplicated Medicaid encounters that same 90-day period; and

(II) Divide the result calculated above in (1)(d)(D)(ii)(I) by the sum of the total patients assigned to the group’s panel in the same 90-day period, provided at least one encounter took place with the patient during the 24 months before the beginning of the 90-day period, plus all of the unduplicated patient encounters in the same 90-day period; and

(III) Not use the same 90-day timeframe to calculate patient volume in different program years.

(3) To be eligible for a Medicaid EHR incentive payment for the payment year, an eligible hospital must meet the Medicaid EHR Incentive Program criteria each year:

(a) To be eligible for an incentive payment, an eligible hospital must, at a minimum, meet the certified EHR technology and meaningful use requirements for the corresponding payment year:

(A) First payment year:

(i) Adopt, implement, or upgrade certified EHR technology; or

(ii) Demonstrate meaningful use under the Medicare EHR Incentive Program to Centers for Medicare and Medicaid Services (CMS) and be deemed a meaningful EHR user for the payment year, as prescribed by 42 CFR 495.8 and 42 CFR 495.6;

(B) Subsequent payment years:

(i) For eligible hospitals that participate in both the Medicare and Medicaid EHR Incentive Programs, demonstrate meaningful use under the Medicare EHR Incentive Program to Centers for Medicare and Medicaid Services (CMS) and be deemed a meaningful EHR user for the payment year, as prescribed by 42 CFR 495.8 and 42 CFR 495.6;

(ii) For eligible hospitals that participate in the Medicaid EHR Incentive Program only, demonstrate meaningful use as prescribed by 42 CFR 495.8 and meet the corresponding meaningful use criteria for the payment year as prescribed by 42 CFR 495.6;

(b) If an eligible hospital is an acute care hospital, it must calculate patient volume by dividing the total eligible hospital Medicaid encounters by the total encounters in any representative, continuous 90-day period:

(A) For program year 2011 and 2012, in the preceding federal fiscal year;

(B) For program year 2013 and later, either in the preceding federal fiscal year or in the twelve month timeframe preceding the attestation date. The eligible hospital may not use the same 90-day timeframe to calculate patient volume in different program years;

(4) Table 165-0060-1.

(5) Table 165-0060-2.

(6) Table 165-0060-3.

[ED. NOTE: Tables referenced are available from the agency.]

Stat. Auth.: ORS 413.042

Stats. Implemented: ORS 413.042 & 414.033

Hist.: DMAP 20-2011, f. 7-21-11, cert. ef. 7-22-11; DMAP 20-2013(Temp), f. & cert. ef. 4-26-13 thru 10-23-13; DMAP 56-2013, f. & cert. ef. 10-22-13

410-165-0080

Meaningful Use

(1) An eligible provider must demonstrate being a meaningful Electronic Health Record (EHR) user as prescribed by 42 CFR 495.4 (2010 and 2012), 42 CFR 495.6 (2012), and 42 CFR 495.8 (2010 and 2012).

(2) An eligible provider must satisfy meaningful use objectives and measures as prescribed by 42 CFR 495.6. In Stage 1, the state of Oregon requires an eligible provider to satisfy the objective “Capability to submit electronic data to immunization registries or immunization information systems and actual submission in accordance with applicable law and practice”.

(a) If Centers for Medicare and Medicaid Services (CMS) deem an eligible hospital to be a meaningful EHR user for the Medicare EHR Incentive Program for a payment year, then the eligible hospital is automatically deemed to be a meaningful EHR user for the Medicaid EHR Incentive Program for the same payment year;

(b) An eligible hospital deemed to be a meaningful EHR user by Medicare for a payment year does not have to also meet Oregon’s Stage 1 requirement to satisfy the objective “Capability to submit electronic data to immunization registries or immunization information systems and actual submission in accordance with applicable law and practice” for the Medicaid EHR incentive payment for the same payment year.

Stat. Auth.: ORS 413.042

Stats. Implemented: ORS 413.042 & 414.033

Hist.: DMAP 13-2011, f. 6-29-11, cert. ef. 7-1-11; DMAP 20-2013(Temp), f. & cert. ef. 4-26-13 thru 10-23-13; DMAP 56-2013, f. & cert. ef. 10-22-13

410-165-0100

Participation and Incentive Payments

(1) To qualify for an incentive payment, an eligible provider applying for a Medicaid Electronic Health Record (EHR) incentive payment must meet the Medicaid EHR Incentive Program eligibility criteria and participation requirements for each year that the eligible provider applies. a) An eligible provider must meet the eligibility criteria for each payment year of:

(A) Type of eligible provider;

(B) Patient volume minimum; and

(C) Certified EHR technology adoption, implementation, or upgrade requirements for the first payment year and meaningful use requirements for the subsequent payment years;

(b) An eligible provider must meet the participation requirements for each payment year including:

(A) Be an enrolled Medicaid provider with the Oregon Health Authority’s (Authority) Division of Medical Assistance Programs (Division);

(B) Maintain current provider information with the Division;

(C) Possess an active professional license and comply with all licensing statutes and regulations within the state where the eligible provider practices;

(D) Have an active Provider Web Portal account;

(E) Ensure the designated payee is able to receive electronic funds transfer from the Authority; and

(F) Comply with all applicable Oregon Administrative Rules (OAR), including chapter , chapter 410, division 120, and chapter 943, division 120;

(c) An eligible professional may reassign the entire amount of the incentive payment to:

(A) The eligible professional’s employer with which the eligible professional has a contractual arrangement allowing the employer to bill and receive payments for the eligible professional’s covered professional services;

(B) An entity with which the eligible professional has a contractual arrangement allowing the entity to bill and receive payments for the eligible professional’s covered professional services; or

(C) An entity promoting the adoption of certified EHR technology.

(2) An eligible professional must follow the Medicaid EHR Incentive Program participation conditions including requirements that an eligible professional must:

(a) Receive an incentive payment from only one state for a payment year;

(b) Only receive an incentive payment from either Medicare or Medicaid for a payment year, but not both;

(c) Not receive more than the maximum incentive amount of $63,750 over a six-year period; or the maximum incentive of $42,500 over a six-year period if the eligible professional qualifies as a pediatrician who meets the 20 percent patient volume minimum and less than the 30 percent patient volume;

(d) Participate in the Medicaid EHR Incentive Program:

(A) Starting as early as calendar year (CY) 2011, but no later than CY 2016;

(B) Ending no later than CY 2021;

(C) For a maximum of six years; and

(D) On a consecutive or non-consecutive annual basis;

(e) Be allowed to switch between the Medicare and Medicaid EHR Incentive Program only one time after receiving at least one incentive payment, and only for a payment year before 2015.

(3) Payments are disbursed to an eligible professional following verification of eligibility for the payment year:

(a) An eligible professional is paid an incentive amount for the corresponding payment year for each year of qualified participation in the Medicaid EHR Incentive Program;

(b) The payment structure is as follows for:

(A) An eligible professional qualifying with 30 percent minimum patient volume:

(i) The first payment year incentive amount is $21,250; and

(ii) The second, third, fourth, fifth, or sixth payment year incentive amount is $8,500; or

(B) An eligible pediatrician qualifying with 20 percent, but less than 30 percent minimum patient volume:

(i) The first payment year incentive amount is $14,167; and

(ii) The second, third, fourth, fifth, or sixth payment year incentive amount is $5,667.

(4) An eligible hospital must follow the Medicaid EHR Incentive Program participation conditions including requirements that the eligible hospital:

(a) Receives a Medicaid EHR incentive payment from only one state for a payment year;

(b) May participate in both the Medicare and Medicaid EHR Incentive Programs only if the eligible hospital meets all eligibility criteria for the payment year for both programs;

(c) Participates in the Medicaid EHR Incentive Program:

(A) Starting as early as federal fiscal year (FFY) 2011 but no later than FFY 2016;

(B) Ending no later than FFY 2021;

(C) For a maximum of three years;

(D) On a consecutive or non-consecutive annual basis for federal fiscal years prior to FFY 2016; and

(E) On a consecutive annual basis for federal fiscal years starting in FFY 2016;

(d) A multi-site hospital with one Centers for Medicare and Medicaid Services’ Certification Number (CCN) is considered one hospital for purposes of calculating payment.

(5) Payments are disbursed to an eligible hospital following verification of eligibility for the payment year. An eligible hospital is paid the aggregate incentive amount over three years of qualified participation in the Medicaid EHR Incentive Program:

(a) The payment structure as listed in Table 165-0100-1 is as follows:

(A) The first payment year incentive amount is equal to 50% of the aggregate EHR amount;

(B) The second payment year incentive amount is equal to 40% of the aggregate EHR amount; and

(C) The third payment year incentive amount is equal to 10% of the aggregate EHR amount;

(b) The aggregate EHR amount is calculated as the product of the “overall EHR amount” times the “Medicaid Share” as listed in Table 165-00100-2. The aggregate EHR amount is calculated once, for the first year participation, and then paid over three years according to the payment schedule:

(A) The overall EHR amount for an eligible hospital is based upon a theoretical four years of payment the hospital would receive, and is the sum of the following calculation performed for each of such four years. For each year, the overall EHR amount is the product of the initial amount, the Medicare share and the transition factor:

(i) The initial amount as listed in Table 165-0100-3 is equal to the sum of the base amount, which is set at $2,000,000 for each of the theoretical four years, plus the discharge-related amount, that is calculated for each of the theoretical four years:

(I) For initial amounts calculated in program years 2011 or 2012, the discharge-related amount is $200 per discharge for the 1,150th through the 23,000th discharge, based upon the total discharges for the eligible hospital (regardless of source of payment) from the hospital fiscal year that ends during the federal fiscal year (FFY) prior to the FFY year that serves as the first payment year. No discharge-related amount is added for discharges prior to the 1,150th or any discharges after the 23,000th;

(II) For initial amounts calculated in program year 2013 or later, the discharge-related amount is $200 per discharge for the 1,150th through the 23,000th discharge, based upon the total discharges for the eligible hospital (regardless of source of payment) from the hospital fiscal year that ends before the FFY that serves as the first payment year. No discharge-related amount is added for discharges prior to the 1,150th or any discharges after the 23,000th;

(III) For purposes of calculating the discharge-related amount for the last three of the theoretical four years of payment, discharges are assumed to increase each year by the hospital’s average annual rate of growth; negative rates of growth must also be applied. Average annual rate of growth is calculated as the average of the annual rate of growth in total discharges for the most recent three years for which data are available per year.

(ii) The Medicare share that equals 1;

(iii) The transition factor, that equals:

(I) 1 for the first of the theoretical four years;

(II) 0.75 for the second of the theoretical four years;

(III) 0.5 for the third of the theoretical four years; and

(IV) 0.25 for the fourth of the theoretical four years;

(B) The Medicaid share for an eligible hospital is equal to a fraction:

(i) The numerator for the FFY and with respect to the eligible hospital is the sum of:

(I) The estimated number of inpatient-bed-days that are attributable to Medicaid individuals; and

(II) The estimated number of inpatient-bed-days that are attributable to individuals who are enrolled in a managed or coordinated care organization, a pre-paid inpatient health plan, or a pre-paid ambulatory health plan administered under 42 CFR Part 438;

(ii) The denominator is the product of:

(I) The estimated total number of inpatient-bed-days with respect to the eligible hospital during such period; and

(II) The estimated total amount of the eligible hospital’s charges during such period, not including any charges that are attributable to charity care, divided by the estimated total amount of the hospital’s charges during such period;

(iii) In computing inpatient-bed-days for the Medicaid share, an eligible hospital may not include either of the following:

(I) Estimated inpatient-bed-days attributable to individuals that may be made under Medicare Part A; or

(II) Inpatient-bed-days attributable to individuals who are enrolled with a Medicare Advantage organization under Medicare Part C;

(iv) If an eligible hospital’s charity care data necessary to calculate the portion of the formula for the Medicaid share are not available, the eligible hospital’s data on uncompensated care may be used to determine an appropriate proxy for charity care, but must include a downward adjustment to eliminate bad debt from uncompensated care data if bad debt is not otherwise differentiated from uncompensated care. Auditable data sources must be used; and

(v) If an eligible hospital’s data necessary to determine the inpatient bed-days attributable to Medicaid managed care patients are not available, that amount is deemed to equal 0. In the absence of an eligible hospital’s data necessary to compute the percentage of inpatient bed days that are not charity care as described under (B)(ii)(II) in this section, that amount is deemed to be 1.

(6) The aggregate EHR amount is determined by the State from which the eligible hospital receives its first incentive payment. If a hospital receives incentive payments from other States in subsequent years, total incentive payments received over all payment years of the program can be no greater than the aggregate EHR amount calculated by the State from which the eligible hospital received its first incentive payment.

(6) Table 165-0100-1.

(7) Table 165-0100-2.

(8) Table 165-0100-3.

[ED. NOTE: Tables referenced are available from the agency.]

Stat. Auth.: ORS 413.042

Stats. Implemented: ORS 413.042 & 414.033

Hist.: DMAP 13-2011, f. 6-29-11, cert. ef. 7-1-11; DMAP 20-2013(Temp), f. & cert. ef. 4-26-13 thru 10-23-13; DMAP 56-2013, f. & cert. ef. 10-22-13

410-165-0120

Appeals

(1) The appeals process for the Medicaid Electronic Health Record (EHR) Incentive Program is pursuant to 42 CFR 495.370 and the Oregon Health Authority’s (Authority) Provider Appeals Rules in the Oregon Administrative Rules (OAR) chapter 410, division 120.

(2) The Authority exercises its option, pursuant to 42 CFR 495.312 and 42 CFR 495.370, to have the Centers for Medicare and Medicaid Services (CMS) conduct the audits and handle any subsequent appeals, of whether eligible hospitals are meaningful EHR users.

(3) For purposes of OAR chapter 410, division 165, a provider who applies for a Medicaid EHR incentive payment may appeal a decision by the Medicaid EHR Incentive Program as outlined in the Authority’s Division of Medical Assistance Programs’ Provider Appeal Rules (OAR chapter 410, division 120). The provider’s appeal must note the specific reason for the appeal, which must be due to one or more of the following issues:

(a) An incentive payment;

(b) An incentive payment amount;

(c) A provider eligibility determination;

(d) The demonstration of adopting, implementing or upgrading; or

(e) Meaningful use eligibility other than a meaningful use eligibility issue where CMS handles the appeal, as provided in section (2) of this section.

Stat. Auth.: ORS 413.042

Stats. Implemented: ORS 413.042 & 414.033

Hist.: DMAP 13-2011, f. 6-29-11, cert. ef. 7-1-11; DMAP 20-2013(Temp), f. & cert. ef. 4-26-13 thru 10-23-13; DMAP 56-2013, f. & cert. ef. 10-22-13

410-165-0140

Oversight and Audits

(1) A provider who qualifies for a Medicaid Electronic Health Record (EHR) incentive payment under the Medicaid (EHR) Incentive Program is subject to audit or other post-payment review procedures as authorized in Oregon Administrative Rule (OAR) 943-120-1505.

(2) The Oregon Health Authority and the Department of Human Services have the authority to recover overpayments from the person or entity who received an incentive payment from the Medicaid EHR Incentive Program.

(3) As authorized in 42 CFR 495.312, the Oregon Health Authority and the Department of Human Services designate Centers for Medicare and Medicaid Services (CMS) to conduct audits on Eligible Hospitals Meaningful Use attestations.

(4) The person or entity who received a Medicaid EHR incentive overpayment must repay the amount specified within 30 calendar days from the mailing date of written notification of the overpayment as prescribed by OAR 943-120-1505.

Stat. Auth.: ORS 413.042

Stats. Implemented: ORS 413.042 & 414.033

Hist.: DMAP 13-2011, f. 6-29-11, cert. ef. 7-1-11; DMAP 20-2013(Temp), f. & cert. ef. 4-26-13 thru 10-23-13; DMAP 56-2013, f. & cert. ef. 10-22-13


Rule Caption: Amendment of HERC Prioritized List of Health Services reflecting approved modifications effective October 1, 2013

Adm. Order No.: DMAP 57-2013(Temp)

Filed with Sec. of State: 10-29-2013

Certified to be Effective: 10-29-13 thru 3-31-14

Notice Publication Date:

Rules Amended: 410-141-0520

Rules Suspended: 410-141-0520(T)

Subject: The Division is temporarily amending 410-141-0520 HERC Prioritized List of Health Services to reference the January 1, 2011–December 31, 2013, Prioritized List of Health Services effective October 1, 2013 which includes interim modifications and technical changes made for 2009 national code set.

Rules Coordinator: Sandy Cafourek—(503) 945-6430

410-141-0520

Prioritized List of Health Services

(1) The Health Evidenced Review Commission (HERC) Prioritized List of Health Services (Prioritized List) is the listing of physical and mental health services with “expanded definitions” of preventive services and the practice guidelines, as presented to the Oregon Legislative Assembly. The Prioritized List is generated and maintained by HERC. The HERC maintains the most current list on their Web site: http://www.oregon.gov/oha/herc/Pages/Prioritized-List-Pending.aspx, or for a hardcopy contact the Medical Assistance Programs within the Oregon Health Authority (OHA). This rule incorporates by reference the Centers for Medicare and Medicaid Services (CMS) approved biennial January 1, 2011–December 31, 2013 Prioritized List, including October 1, 2013 interim modifications and technical changes, expanded definitions, practice guidelines and condition treatment pairs funded through line 498.

(2) Certain mental health services are only covered for payment when provided by a Mental Health Organization (MHO), Community Mental Health Program (CMHP) or authorized Coordinated Care Organization (CCO).

(3) Substance Use Disorder (SUD) treatment services are covered for eligible OHP clients when provided by an FCHP, PCO, and CCO or by a provider who has a letter of approval from the Addictions and Mental Health Division and approval to bill Medicaid for SUD services.

Stat. Auth.: ORS 192.527, 192.528, 413.042 & 414.065

Stats. Implemented: ORS 192.527, 192.528, 414.065 & 414.727

Hist.: HR 7-1994, f. & cert. ef. 2-1-94; OMAP 33-1998, f. & cert. ef. 9-1-98; OMAP 40-1998(Temp), f. & cert. ef. 10-1-98 thru 3-1-99; OMAP 48-1998(Temp), f. & cert. ef. 12-1-98 thru 5-1-99; OMAP 21-1999, f. & cert. ef. 4-1-99; OMAP 39-1999, f. & cert. ef. 10-1-99; OMAP 9-2000(Temp), f. 4-27-00, cert. ef. 4-27-00 thru 9-26-00; OMAP 13-2000, f. & cert. ef. 9-12-00; OMAP 14-2000(Temp), f. 9-15-00, cert. ef. 10-1-00 thru 3-30-01; OMAP 40-2000, f. 11-17-00, cert. ef. 11-20-00; OMAP 22-2001(Temp), f. 3-30-01, cert. ef. 4-1-01 thru 9-1-01; OMAP 28-2001, f. & cert. ef. 8-10-01; OMAP 53-2001, f. & cert. ef. 10-1-01; OMAP 18-2002, f. 4-15-02, cert. ef. 5-1-02; OMAP 64-2002, f. & cert. ef. f. & cert. ef. 10-2-02; OMAP 65-2002(Temp), f. & cert. ef. 10-2-02 thru 3-15-0; OMAP 88-2002, f. 12-24-02, cert. ef. 1-1-03; OMAP 14-2003, f. 2-28-03, cert. ef. 3-1-03; OMAP 30-2003, f. 3-31-03 cert. ef. 4-1-03; OMAP 79-2003(Temp), f. & cert. ef. 10-2-03 thru 3-15-04; OMAP 81-2003(Temp), f. & cert. ef. 10-23-03 thru 3-15-04; OMAP 94-2003, f. 12-31-03 cert. ef. 1-1-04; OMAP 17-2004(Temp), f. 3-15-04 cert. ef. 4-1-04 thru 9-15-04; OMAP 28-2004, f. 4-22-04 cert. ef. 5-1-04; OMAP 48-2004, f. 7-28-04 cert. ef. 8-1-04; OMAP 51-2004, f. 9-9-04, cert. ef. 10-1-04; OMAP 68-2004(Temp), f. 9-14-04, cert. ef. 10-1-04 thru 3-15-05; OMAP 83-2004, f. 10-29-04 cert. ef. 11-1-04; OMAP 27-2005, f. 4-20-05, cert. ef. 5-1-05; OMAP 54-2005(Temp), f. & cert. ef. 10-14-05 thru 4-1-06; OMAP 62-2005, f. 11-29-05, cert. ef. 12-1-05; OMAP 71-2005, f. 12-21-05, cert. ef. 1-1-06; OMAP 6-2006, f. 3-22-06, cert. ef. 4-1-06; OMAP 46-2006, f. 12-15-06, cert. ef. 1-1-07; DMAP 14-2007(Temp), f. & cert. ef. 10-1-07 thru 3-28-08; DMAP 28-2007(Temp), f. & cert. ef. 12-20-07 thru 3-28-08; DMAP 8-2008, f & cert. ef. 3-27-08; DMAP 10-2008(Temp), f. & cert. ef. 4-1-08 thru 9-15-08; DMAP 23-2008, f. 6-13-08, cert. ef. 7-1-08; DMAP 31-2008(Temp), f. & cert. ef. 10-1-08 thru 3-29-09; DMAP 40-2008, f. 12-11-08, cert. ef. 1-1-09; DMAP 4-2009(Temp), f. & cert. ef. 1-30-09 thru 6-25-09; DMAP 6-2009(Temp), f. 3-26-09, cert. ef. 4-1-09 thru 9-25-09; DMAP 8-2009(Temp), f. & cert. ef. 4-17-09 thru 9-25-09; DMAP 26-2009, f. 8-3-09, cert. ef. 8-5-09; DMAP 30-2009(Temp), f. 9-15-09, cert. ef. 10-1-09 thru 3-29-10; DMAP 36-2009(Temp), f. 12-10-09 ef. 1-1-10 thru 3-29-10; DMAP 1-2010(Temp), f. & cert. ef. 1-15-10 thru 3-29-10; DMAP 3-2010, f. 3-5-10, cert. ef. 3-17-10; DMAP 5-2010(Temp), f. 3-26-10, cert. ef. 4-1-10 thru 9-1-10; DMAP 10-2010, f. & cert. ef. 4-26-10; DMAP 27-2010(Temp), f. 9-24-10, cert. ef. 10-1-10 thru 3-25-11; DMAP 43-2010, f. 12-28-10, cert. ef. 1-1-11; DMAP 4-2011, f. 3-23-11, cert. ef. 4-1-11; DMAP 24-2011(Temp), f. 9-15-11, cert. ef. 10-1-11 thru 3-26-12; DMAP 45-2011, f. 12-21-11, cert. ef. 12-23-11; DMAP 47-2011(Temp), f. 12-13-11, cert. ef. 1-1-12 thru 6-25-12; DMAP 22-2012(Temp), f. 3-30-12, cert. ef. 4-1-12 thru 9-21-12; DMAP 43-2012(Temp), f. 9-21-12, cert. ef. 9-23-12 thru 3-21-13; DMAP 11-2013, f. & cert. ef. 3-21-13; DMAP 50-2013(Temp), f. & cert. ef. 10-1-13 thru 3-30-14; DMAP 57-2013(Temp), f. & cert. ef. 10-29-13 thru 3-30-14


Rule Caption: Amends Modifications Based on Client Circumstances to Medical Transportation for Recipients of Medical Assistance Programs

Adm. Order No.: DMAP 58-2013(Temp)

Filed with Sec. of State: 10-30-2013

Certified to be Effective: 10-30-13 thru 4-28-14

Notice Publication Date:

Rules Amended: 410-136-3260

Subject: The temporary rule will align Oregon rules with federal regulations regarding providing non-emergent medical transportation.

Rules Coordinator: Sandy Cafourek—(503) 945-6430

410-136-3260

Modifications Based on Client Circumstances

(1) Brokerages may impose reasonable modifications on NEMT services when the client:

(a) Is threatening harm to the driver or others in the vehicle;

(b) Has a health condition that creates health or safety concerns to the driver or others in the vehicle;

(c) Has other behaviors or circumstances that place the driver or others in the vehicle at risk of harm;

(d) Frequently does not show up for scheduled rides;

(e) Frequently cancels the ride on the day of the scheduled ride time;

(f) Has behaviors that cause local medical providers or facilities to refuse to provide further services without imposing modifications; or

(g) Has special needs that require special accommodations.

(2) Reasonable modifications include, but are not limited to, requiring the client to:

(a) Use a specific transportation subcontractor;

(b) Travel with an attendant;

(c) Use public transportation where available;

(d) Drive themselves or locate someone to drive them and receive mileage reimbursement; or

(e) Confirm the ride with the brokerage on the day of or the day before the scheduled ride.

(3) Before requiring any modifications, the brokerage shall talk with the client about the reason for imposing a modification, explore modifications that are appropriate to the needs of the client and that address the health and safety concerns of the brokerages. The brokerage or client may include the client’s worker, PHP or CCO in the discussion. The client may include other individuals in the discussion.

(4) Brokerages may not make a reasonable modification based on the criteria in (1)(a)-(g) above that results in a denial of NEMT services to a client and must make all reasonable efforts to offer an appropriate alternative to meet the client’s needs under the circumstances.

Stat. Auth.: ORS 413.042

Stats. Implemented: ORS 413.042, 414.065

Hist: DMAP 36-2013, f. 6-27-13, cert. ef. 7-1-13; DMAP 58-2013(Temp), f. & cert. ef. 10-30-13 thru 4-28-14


Rule Caption: Align with Department of Human Services OAR chapter 461, medical eligibility rules

Adm. Order No.: DMAP 59-2013(Temp)

Filed with Sec. of State: 10-31-2013

Certified to be Effective: 11-1-13 thru 4-29-14

Notice Publication Date:

Rules Amended: 410-120-0006

Rules Suspended: 410-120-0006(T)

Subject: The General Rules Program administrative rules govern the Division’s payments for services provided to clients, and medical assistance eligibility determinations made by the Oregon Health Authority. In coordination with the Department of Human Services’ (Department) revision of medical eligibility rules in chapter 461, the Division is amending OAR 410-120-0006 to assure that the Division’s medical eligibility rule aligns with and reflects information found in the Department’s medical eligibility rules. In OAR 410-120-0006, the Division adopts in rule by reference Department eligibility rules and must update OAR 410-120-0006 in conjunction.

Rules Coordinator: Sandy Cafourek—(503) 945-6430

410-120-0006

Medical Eligibility Standards

As the state Medicaid and CHIP agency, the Oregon Health Authority (Authority) is responsible for establishing and implementing eligibility policies and procedure consistent with applicable law. As outlined in 943-001-0020; the Authority, and the Department of Human Services (Department) work together to adopt rules to assure that medical assistance eligibility procedures and determinations are consistent across both agencies.

(1) The Authority adopts and incorporates by reference the rules established in OAR Chapter 461 and in effect November 1, 2013, for all medical eligibility requirements for medical assistance when the Authority conducts eligibility determinations.

(2) Any reference to OAR Chapter 461 in Oregon Administrative Rules or contracts of the Authority are deemed to be references to the requirements of this rule and shall be construed to apply to all eligibility policies, procedures and determinations by or through the Authority.

(3) For purposes of this rule, references in OAR chapter 461 to the Department or to the Authority shall be construed to be references to both agencies.

(4) Effective on or after July 1, 2011 the Authority shall conduct medical eligibility determinations using the OAR chapter 461 rules which are in effect on the date the Authority makes the medical eligibility determination.

(5) A request for a hearing resulting from a determination under this rule, made by the Authority shall be handled pursuant to the hearing procedures set out in division 25 of OAR Chapter 461. References to “the Administrator” in division 25 of chapter 461 or “the Department” are hereby incorporated as references to the” Authority.”

Stat. Auth.: ORS 413.042

Stats. Implemented: ORS 413.042 & 414.065

Hist.: DMAP 10-2011, f. 6-29-11, cert. ef. 7-1-11; DMAP 18-2011(Temp), f. & cert. ef. 7-15-11 thru 1-11-12; DMAP 21-2011(Temp), f. 7-29-11, cert. ef. 8-1-11 thru 1-11-12; DMAP 25-2011(Temp), f. 9-28-11, cert. ef. 10-1-11 thru 1-11-12; DMAP 36-2011, f. 12-13-11, cert. ef. 1-1-12; DMAP 1-2012(Temp), f. & cert. e.f 1-13-12 thru 7-10-12; DMAP 2-2012(Temp), f. & cert. ef. 1-26-12 thru 7-10-12; DMAP 3-2012(Temp), f. & cert. ef. 1-31-12 thru 2-1-12; DMAP 4-2012(Temp), f. 1-31-12, cert. ef. 2-1-12 thru 7-10-12; DMAP 9-2012(Temp), f. & cert. ef. 3-1-12 thru 7-10-12; DMAP 21-2012(Temp), f. 3-30-12, cert. ef. 4-1-12 thru 7-10-12; DMAP 25-2012(Temp), f. & cert. ef. 5-1-12 thru 7-10-12; Administrative correction 8-1-12; DMAP 35-2012(Temp), f. & cert. ef. 7-20-12 thru 1-15-13; DMAP 45-2012(Temp), f. & cert. ef. 10-5-12 thru 1-19-13; DMAP 50-2012, f. 10-31-12, cert. ef. 11-1-12; DMAP 53-2012(Temp), f. & cert. ef. 11-1-12 thru 4-29-13; DMAP 56-2012(Temp), f. 11-30-12, cert. ef. 12-1-12 thru 4-1-13; DMAP 60-2012, f. 12-27-12, cert. ef. 1-1-13; DMAP 65-2012(Temp), f. 12-28-12, cert. ef. 1-1-13 thru 6-29-13; DMAP 2-2013(Temp), f. & cert. ef. 1-8-13 thru 6-29-13; DMAP 3-2013(Temp), f. & cert. ef. 1-30-13 thru 6-29-13; DMAP 5-2013(Temp), f. & cert. ef. 2-20-13 thru 6-29-13; DMAP 7-2013(Temp), f. & cert. ef. 3-1-13 thru 6-29-13; DMAP 12-2013, f. 3-27-13, cert. ef. 4-1-13; DMAP 17-2013, f. & cert. ef. 4-10-13; DMAP 24-2013, f. & cert. ef. 5-29-13; DMAP 32-2013, f. & cert. ef. 6-27-13; DMAP 39-2013(Temp), f. 7-26-13, cert. ef. 8-1-13 thru 1-28-14; DMAP(Temp), f. 8-21-13, cert. ef. 8-23-13 thru 1-28-14; DMAP 51-2013, f. & cert. ef. 10-1-13; DMAP 52-2013(Temp), f. & cert. ef. 10-1-13 thru 3-30-14; DMAP 55-2013(Temp), f. & cert. ef. 10-2-13 thru 3-31-14; DMAP 59-2013(Temp), f. 10-31-13, cert. ef. 11-1-13 thru 3-31-14


Rule Caption: Rules related to client appeals/hearings, provider requirements related to billing clients for non-covered services

Adm. Order No.: DMAP 60-2013

Filed with Sec. of State: 10-31-2013

Certified to be Effective: 10-31-13

Notice Publication Date: 10-1-2013

Rules Amended: 410-141-0262, 410-141-0263, 410-141-0265, 410-141-0420, 410-141-3260, 410-141-3263, 410-141-3395, 410-141-3420

Subject: Rules are amended to require providers to review with and have OHP clients sign a new OHP Client Agreement to Pay for Health Services form, DMAP 3165, or facsimile containing the elements of the form, before providing and charging clients for non-covered services. Rules are further revised to allow for use of a new Medical Assistance Service Denial Appeal and Hearing Request form, or Division approved facsimile, to be used in place of the MSC 443 and DMAP 3030 forms; change the standard for client failure to meet timely filing/actions from “circumstances beyond the control of the client’ to ‘good cause;’ state that providers shall not bill a client or submit a client billing to a Collection Agency for any amount owed by the CCO for which the client is not liable; clarify current policy and for housekeeping purposes.

Rules Coordinator: Sandy Cafourek—(503) 945-6430

410-141-0262

Prepaid Health Plan Appeal Procedures

(1) A Division of Medical Assistance Programs (Division) Member or their representative that disagrees with a Notice of Action may file a Prepaid Health Plan (PHP) level appeal or request a Division administrative hearing. Division members may not be required to go through a PHP level appeal in order to request a Division administrative hearing.

(2) The PHP must have a system in place for Division member which includes an appeal process when a Division member has requested a Division administrative hearing. For purposes of this rule, an appeal includes a request to the PHP for review of an Action upon notification from the Division.

(3) An appeal must be filed with the PHP no later than 45 calendar days from the date on the Notice of Action required under OAR 410-141-0263.

(4) If the Division member initiates an appeal directly with the PHP, it shall be documented in writing by the PHP and handled as an appeal consistent with this rule. The Division member or Division member’s representative may file an appeal with the PHP either orally or in writing and, unless he or she requests expedited resolution, must follow an oral filing with a written and signed appeal.

(5) Each PHP must adopt written policies and procedures for handling appeals that, at a minimum, meet the following requirements:

(a) Give Division members any reasonable assistance in completing forms and taking other procedural steps related to filing and resolution of an appeal or administrative hearings request. This includes, but is not limited to, providing interpreter services and toll-free numbers that have adequate Tele Typewriter (TTY)/ Telecommunications Devices for the Deaf (TTD) and interpreter capacity;

(b) Address how the PHP will accept, process and respond to such appeals, including how the PHP will acknowledge receipt of each appeal;

(c) Ensuring that Division members who receive a Notice of Action described in OAR 410-141-0263 are informed of their right to file an appeal and an administrative hearing request and how to do so;

(d) Ensuring that each appeal is transmitted timely to staff having authority to act on it;

(e) Ensuring that each appeal is investigated and resolved in accordance with these rules; and

(f) Ensuring that the individuals who make decisions on appeals are individuals:

(A) Who were not involved in any previous level of review or decision making; and

(B) Who are health care professionals who have the appropriate clinical expertise in treating the Division member’s condition or disease if an appeal of a denial is based on lack of medical appropriateness or if an appeal involves clinical issues:

(g) Include a requirement for appeals to be documented in the log to be maintained by the PHP that is in compliance with OAR 410-141-0266.

(6) The PHP shall assure Division members that appeals are handled in confidence consistent with ORS 411.320, 42 CFR 431.300 et seq, the Health Insurance Portability and Accountability Act (HIPAA) Privacy Rules, and other applicable federal and state confidentiality laws and regulations. The PHP shall safeguard the Division member’s right to confidentiality of information about the appeal as follows:

(a) PHPs shall implement and monitor written policies and procedures to ensure that all information concerning a Division member’s appeal is kept confidential consistent with appropriate use or disclosure as treatment, payment, or health care operations of the PHP, as those terms are defined in 45 CFR 164.501. The PHP and any practitioner whose authorization, treatment, services, items, quality of care, or request for payment is alleged to be involved in the appeal have a right to use this information for purposes of resolving the appeal and for purposes of maintaining the log required in OAR 410-141-0266 and for health oversight purposes by Division, without a signed release from the Division member. The administrative hearing regarding the appeal without a signed release from the Division member, pursuant to 410-120-1360(4);

(b) Except as provided in subsection (a) or as otherwise authorized by all other applicable confidentiality laws, PHPs shall ask the Division member to authorize a release of information regarding the appeal to other individuals. Before any information related to the appeal is disclosed under this subsection, the PHP shall have an authorization for release of information documented in the appeal file.

(7) The process for appeals must:

(a) Provide that oral inquiries seeking to appeal an action are treated as appeals (to establish the earliest possible filing date for the appeal) and must be confirmed in writing, unless the Division member or Division member’s representative requests expedited resolution;

(b) Provide the Division member a reasonable opportunity to present evidence and allegations of fact or law in person as well as in writing. (The PHP must inform the Division member or the Division member’s representative of the limited time available in the case of an expedited resolution);

(c) Provide the Division member and/or the Division member’s representative an opportunity, before and during the appeals process, to examine the Division member’s file, including medical records and any other documents or records to be considered during the appeals process; and

(d) Include as parties to the appeal the Division member, the Division member’s representative, or the legal representative of a deceased Division member’s estate.

(8) The PHP must resolve each appeal and provide a client notice of the appeal resolution as expeditiously as the Division member’s health condition requires and within the time frames in this section:

(a) For the standard resolution of appeals and client notices to the Division member or Division member’s representative, the PHP shall resolve the appeal and provide a client notice no later than 16 calendar days from the day the PHP receives the appeal.

(b) When the PHP has granted a request for expedited resolution of an appeal, the PHP shall resolve the appeal and provide a client notice no later than 3 working days after the PHP receives the appeal. This timeframe may be extended pursuant to subsection (c) of this section;

(c) In accordance with 42 CFR 438.408, the PHP may extend the timeframes from subsections (a) or (b) of this section by up to 14 calendar days if:

(A) The Division member or Division members representative requests the extension; or

(B) The PHP shows (to the satisfaction of the Division’s Hearings Unit upon its request) that there is need for additional information and how the delay is in the Division member’s interest;

(d) If the PHP extends the timeframes, it must, for any extension not requested by the Division member, give the Division member or Division member’s representative a written notice of the reason for the delay.

(9) For all appeals, the PHP must provide written Notice of Appeal Resolution to the Division member or their representative. If the PHP knows that there is a representative, the PHP must send a copy of the Notice to the representative. For notice on an expedited resolution, the PHP must also make reasonable efforts to provide oral notice.

(10) The written Notice of Appeal Resolution must be on a Division approved form and include the following:

(a) The results of the resolution process and the date it was completed; and

(b) For appeals not resolved wholly in favor of the Division member, the notice must also include the following information:

(A) Reasons for the resolution and a reference to the particular sections of the statutes and rules involved for each reason identified in the Notice of Appeal Resolution relied upon to deny the appeal;

(B) Unless the appeal was referred to the PHP from the Division as part of an administrative hearings process, the right to request a Division Administrative Hearing, and how to do so, which includes attaching the appropriate forms as outlined in 410-141-0263;

(C) The right to request to receive benefits while the hearing is pending, and how to make the request; and

(D) That the Division member may be held liable for the cost of those benefits if the hearing decision upholds the PHP’s Action.

(11) Unless the appeal was referred to the PHP as part of an administrative hearing process, a Division member may request a Division administrative hearing not later than 45 calendar days from the date on the Notice of Appeal Resolution. The parties to the Division administrative hearing include the PHP as well as the Division member and/or Division member’s representative, or the Representative of the deceased Division member’s estate.

(12) Each PHP shall establish and maintain an expedited review process for appeals, consistent with OAR 410-141-0265.

(13) Each PHP shall maintain records of appeals, enter appeals and their resolution into a log, and address the appeals in the context of quality improvement activity (OAR 410-141-0200) as required in OAR 410-141-0266.

(14) Continuation of benefits pending appeal:

(a) As used in this section, “timely” filing means filing on or before the later of the following:

(A) Within 10 calendar days of the PHP mailing the Notice of Action; or

(B) The intended effective date of the PHP’s proposed Action:

(b) The PHP must continue the Division member’s benefits if:

(A) The Division member or Division member’s representative files the appeal or administrative hearing request timely;

(B) The appeal or administrative hearing request involves the termination, suspension, or reduction of a previously authorized course of treatment;

(C) The services were ordered by an authorized provider;

(D) The original period covered by the original authorization has not expired; and

(E) The Division member or representative requests extension of benefits:

(c) Continuation of benefits pending administrative hearing — If, at the Division member’s request, the PHP continues or reinstates the Division member’s benefits while the appeal or administrative hearing is pending , the benefits must be continued pending administrative hearing pursuant to OAR 410-141-0264.

(15) If the final resolution of the appeal or administrative hearing is adverse to the Division member, that is, upholds the PHP’s Action, the PHP may recover the cost of the services furnished to the Division member while the appeal or administrative hearing was pending, to the extent that they were furnished solely because of the requirements of this section and in accordance with the policy set forth in 42 CFR 431.230(b).

(16) If the PHP or a Division administrative hearing decision reverses a decision to deny, limit, or delay services that were not furnished while the appeal was pending, the PHP must authorize or provide the disputed services promptly, and as expeditiously as the Division member’s health condition requires.

(17) If the PHP or the Division administrative hearing decision reverses a decision to deny authorization of services, and the Division member received the disputed services while the appeal was pending, the PHP or the Division must pay for the services in accordance with the Division policy and regulations.

(18) If the appeal was referred to the PHP from the Division as part of an administrative hearing process, the PHP must immediately (within two business days) transmit the Notice of Appeal Resolution and the complete record of the appeal to the Division Hearings Unit.

(19) If the appeal was made directly by the Division member or Representative, and if the Notice of Appeal Resolution was not favorable to the Division member, the PHP must: Retain a complete record of the appeal for not less than 45 days so that, if an administrative hearing is requested, the record can be submitted to the Division’s Hearings Unit within two business days of the Division’s request.

Stat. Auth.: ORS 413.042

Stats. Implemented: ORS 414.065

Hist.: HR 19-1996, f. & cert. ef. 10-1-96; HR 25-1997, f. & cert. ef. 10-1-97; OMAP 50-2003, f. 7-31-03 cert. ef 8-1-03; OMAP 35-2004, f. 5-26-04 cert. ef. 6-1-04; DMAP 22-2008, f. 6-13-08, cert. ef. 7-1-08; DMAP 10-2013(Temp), f. & cert. ef. 3-1-13 thru 8-27-13; DMAP 16-2013(Temp), f. & cert. ef. 4-10-13 thru 8-27-13; DMAP 46-2013, f. & cert. ef. 8-26-13; DMAP 60-2013, f. & cert. ef. 10-31-13

410-141-0263

Notice of Action by a Prepaid Health Plan

The Division of Medical Assistance Programs (Division) may have specific definitions for common terms. Please use OAR 410-141-0000, Definitions, in conjunction with this rule.

(1) When a Prepaid Health Plan (PHP) (or authorized practitioner (see definition) acting on behalf of the PHP) takes or intends to take any “action,” including but not limited to denials or limiting prior authorizations of a requested service(s) in an amount, duration, or scope that is less than requested, or reductions, suspension, discontinuation or termination of a previously authorized service, or any other action, the PHP (or authorized practitioner acting on behalf of the PHP) shall mail a written client (see definition) Notice of Action in accordance with section (2) of this rule to the Division member (see definition) within the timeframes specified in subsection (3) of this rule.

(2) The written client Notice of Action must be on a Division approved form and must be used for all denials of a requested service(s), reductions, discontinuations or terminations of previously authorized services, denials of claims payment, or other action. The client Notice of Action must meet the language and format requirements of 42 CFR 438.10(c) and (d) and shall inform the Division member of the following:

(a) Relevant information shall include, but is not limited to, the following:

(A) Date of client Notice of Action;

(B) PHP name;

(C) PCP/PCD name;

(D) The Division member’s name and ID number;

(E) Date of service or item requested or provided;

(F) Who requested or provided the item or service;

(G) Effective date of the action, if different from the date of the NOA;

(H) Whether the PHP considered other conditions as co-morbidity factors if the service was below the funding line on the OHP Prioritized List of Health Services;

(b) The action the PHP or its participating provider (see definition) has taken or intends to take;

(c) Reasons for the action, with enough specificity to clearly explain the actual reason for the denial, including but not limited to the following reasons:

(A) The item requires pre-authorization and it was not pre-authorized;

(B) The service or item is received in an emergency care setting and does not qualify as an Emergency Service under the prudent layperson standard;

(C) The person was not a Division member at the time of the service or is not a Division member at the time of a requested service; and

(D) The provider is not on the PHP’s panel and prior approval was not obtained (if such prior authorization would be required under the Oregon Health Plan rules);

(d) A reference to the particular sections of the statutes and rules involved for each reason identified in the Notice of Action pursuant to subsection (b) of this section, in compliance with the notice requirements in ORS 183.415(2)(c);

(e) The Division member’s right to file an appeal with the PHP and how to exercise that right as required in OAR 410-141-0262;

(f) The Division member’s right to request a Division administrative hearing and how to exercise that right. A copy of the following forms must be attached to the Notice of Action:

(A) Hearing Request form, (DHS 443), and the Notice of Hearing Rights, (DMAP 3030), or

(B) The Medical Assistance Service Denial Appeal and Hearing Request form, DMAP 1234, or approved facsimile.

(g) The circumstances under which expedited appeal resolution is available and how to request it;

(h) The Division member’s right to have benefits continue pending resolution of the appeal, how to request that benefit(s) be continued, and the circumstances under which the Division member may be required to pay the costs of these services; and

(i) The telephone number to contact the PHP for additional information.

(3) The PHP or practitioner acting on behalf of the PHP must mail the Notice of Action within the following time frames:

(a) For termination, suspension, or reduction of previously authorized OHP covered services (see definition), the following time frames apply:

(A) The notice must be mailed at least 10 calendar days before the date of action, except as permitted under subsections (B) or (C) of this section;

(B) The PHP (or authorized practitioner acting on behalf of the PHP) may mail a notice not later than the date of action if:

(i) The PHP or practitioner receives a clear written statement signed by the Division member that he or she no longer wishes services or gives information that requires termination or reduction of services and indicates that he or she understands that this must be the result of supplying the information;

(ii) The Division member has been admitted to an institution where he or she is ineligible for covered services from the PHP;

(iii) The Division member’s whereabouts are unknown and the post office returns PHP or practitioner’s mail directed to him or her indicating no forwarding address;

(iv) The PHP establishes the fact that another State, territory, or commonwealth has accepted the Division member for Medicaid services;

(v) A change in the level of medical or dental care is prescribed by the Division member’s PCP or PCD; or

(vi) The date of action will occur in less than 10 calendar days, in accordance with 42 CFR 483.12(a)(5)(ii), related to discharges or transfers and long-term care facilities:

(C) The PHP may shorten the period of advance notice to 5 calendar days before the date of the action if the PHP has facts indicating that an action should be taken because of probable fraud by the Division member. Whenever possible, these facts should be verified through secondary sources:

(b) For denial of payment, at the time of any action affecting the claim;

(c) For standard prior authorizations that deny a requested service or that authorize a service in an amount, duration, or scope that is less than requested, the PHP must provide Notice of Action as expeditiously as the Division member’s health condition requires and within 14 calendar days following receipt of the request for service, except that:

(A) The PHP may have a possible extension of up to 14 additional calendar days if the Division member or the provider requests the extension; or if the PHP justifies (to the Division upon request) a need for additional information and how the extension is in the Division member’s interest;

(B) If the PHP extends the timeframe, in accordance with subsection (A) of this section, it must give the Division member written notice of the reason for the decision to extend the timeframe and inform the Division member of their right to file a grievance if he or she disagrees with that decision. The PHP must issue and carry out its prior authorization determination as expeditiously as the Division member’s health condition requires and no later than the date the extension expires;

(d) For prior authorization decisions not reached within the timeframes specified in subsection (c) of this section, (which constitutes a denial and is thus an adverse action), on the date that the timeframes expire;

(e) For expedited prior authorizations, within the timeframes specified in OAR 410-141-0265.

[Publications: Publications referenced are available from the agency.]

Stat. Auth.: ORS 413.042 & 414.065

Stats. Implemented: ORS 414.065

Hist.: HR 19-1996, f. & cert. ef. 10-1-96; HR 25-1997, f. & cert. ef. 10-1-97; OMAP 39-1999, f. & cert. ef. 10-1-99; OMAP 26-2000, f. 9-28-00, cert. ef. 10-1-00; OMAP 50-2003, f. 7-31-03 cert. ef 8-1-03; OMAP 35-2004, f. 5-26-04 cert. ef. 6-1-04; OMAP 46-2005, f. 9-9-05, cert. ef. 10-1-05; DMAP 22-2008, f. 6-13-08, cert. ef. 7-1-08; DMAP 45-2009, f. 12-15-09, cert. ef. 1-1-10; DMAP 42-2010, f. 12-28-10, cert. ef. 1-1-11; DMAP 60-2013, f. & cert. ef. 10-31-13

410-141-0265

Request for Expedited Appeal or Expedited Administrative Hearing

(1) Each PHP shall establish and maintain an expedited review process for appeals, when the PHP determines (upon request from the Division of Medical Assistance Programs (Division) member) or the provider indicates (in making the request on a Division member’s behalf or supporting the DMAP member’s request) that taking the time for a standard resolution could seriously jeopardize the Division member’s life, health, or ability to attain, maintain or regain maximum function.

(2) The PHP must ensure that punitive action is not taken against a provider who requests an expedited resolution or supports a Division member’s appeal.

(3) If the PHP provides an expedited appeal, but denies the services or items requested in the expedited appeal, the PHP shall inform the Division member of the right to request an expedited Administrative Hearing and send the member a Division approved Notice of Appeal Resolution, Hearing Request and Information forms as outlined in OAR 410-141-0263 with the Notice of Appeal Resolution.

(4) If the PHP denies a request for expedited resolution on appeal, it must:

(a) Transfer the appeal to the time frame for standard resolution in accordance with OAR 410-141-0262;

(b) Make reasonable efforts to give the Division member prompt oral notice of the denial, and follow-up within 2 calendar days with a written notice.

(5) A Division member who believes that taking the time for a standard resolution of a request for an Administrative Hearing could seriously jeopardize the Division member’s life or health or ability to attain, maintain or regain maximum function may request an expedited Administrative Hearing.

(6) The PHP shall submit relevant documentation to the Division’s Medical Director within, as nearly as possible, 2 working days for a decision as to the necessity of an expedited Administrative Hearing. The Division’s Medical Director shall decide within, as nearly as possible, 2 working days from the date of receiving the medical documentation applicable to the request, whether the Division member is entitled to an expedited Administrative Hearing.

(7) If the Division’s Medical Director denies a request for expedited Administrative Hearing, the Division must:

(a) Handle the request for Administrative Hearing in accordance with OAR 410-141-0264; and

(b) Make reasonable efforts to give the Division member prompt oral notice of the denial, and follow-up within 2 calendar days with a written notice.

[ED. NOTE: Forms referenced are available from the agency.]

Stat. Auth.: ORS 409.110, 413.042 & 414.065

Stats. Implemented: ORS 414.065

Hist.: HR 19-1996, f. & cert. ef. 10-1-96; HR 25-1997, f. & cert. ef. 10-1-97; OMAP 39-1999, f. & cert. ef. 10-1-99; OMAP 50-2003, f. 7-31-03 cert. ef 8-1-03; OMAP 35-2004, f. 5-26-04 cert. ef. 6-1-04; DMAP 22-2008, f. 6-13-08, cert. ef. 7-1-08; DMAP 60-2013, f. & cert. ef. 10-31-13

410-141-0420

Managed Care Prepaid Health Plan Billing and Payment under the Oregon Health Plan

The Division of Medical Assistance Programs (Division) may have specific definitions for common terms. Please use OAR 410-141-0000, Definitions, in conjunction with this rule.

(1) Providers must submit all billings for Oregon Health Plan (OHP) clients to Prepaid Health Plans (PHPs) and to the Division within four (4) months and twelve (12) months, respectively, of the date of service, subject to other applicable Division billing rules. Providers must submit billings to PHPs within the four (4) month time frame except in the following cases:

(a) Pregnancy;

(b) Eligibility issues such as retroactive deletions or retroactive enrollments;

(c) Medicare is the primary payer;

(d) Other cases that could have delayed the initial billing to the PHP (which does not include failure of provider to certify the Division member’s (see definition) eligibility); or

(e) Third Party Liability (TPL). Pursuant to 42 CFR 136.61, subpart G: Indian Health Services and the amended Public Law 93-638 under the Memorandum of Agreement that Indian Health Service and 638 Tribal Facilities are the payer of last resort and is not considered an alternative liability or TPL.

(2) Providers must be enrolled with the Division to be eligible for Division fee-for-service (FFS) payments. Mental health providers, except Federally Qualified Health Centers (FQHC), must be approved by the Local Mental Health Authority (LMHA) and the Addictions and Mental Health (AMH) Division before enrollment with the Division or to be eligible for PHP payment for services. Providers may be retroactively enrolled, in accordance with OAR 410-120-1260, Provider Enrollment.

(3) Providers, including mental health providers (see definition), must be enrolled with the Division either as a Medicaid provider or an encounter-only provider prior to submission of encounter data to ensure the servicing provider is not excluded per federal and State standard as defined in OAR 407-120-0300.

(4) Providers shall verify, before rendering services, which Division member is eligible for the Medical Assistance Program on the date of service using the Division tools and optionally the PHP’s tools, as applicable and that the service to be rendered is covered under the Oregon Health Plan Benefit Package of covered services. Providers shall also identify the party responsible for covering the intended service and seek pre-authorizations from the appropriate payer before rendering services. Before providing a non-covered service, the provider must complete, and have the member sign, a DMAP 3165, or facsimile, as described in OAR 410-120-1280.

(5) PHPs are responsible for payment of all capitated services. Such services should be billed directly to the PHP, unless the PHP or the Division specifies otherwise. PHPs may require providers to obtain preauthorization to deliver certain capitated services.

(6) Payment by the PHP to participating providers for capitated services is a matter between the PHP and the participating provider, except as follows:

(a) Pre-authorizations:

(A) PHPs shall have written procedures for processing pre-authorization requests received from any provider. The procedures shall specify time frames for:

(i) Date stamping pre-authorization requests when received;

(ii) Determining within a specific number of days from receipt whether a pre-authorization request is valid or non-valid;

(iii) The specific number of days allowed for follow up on pended preauthorization requests to obtain additional information;

(iv)The specific number of days following receipt of the additional information that a redetermination must be made;

(v) Providing services after office hours and on weekends that require preauthorization;

(vi) Sending notice of the decision with appeal rights to the Division member when the determination is made to deny the requested service as specified in 410-141-0263.

(B) PHPs shall make a determination on at least 95% of valid preauthorization requests, within two working days of receipt of a preauthorization or reauthorization request related to urgent services; alcohol and drug services; and/or care required while in a skilled nursing facility. Preauthorization for prescription drugs must be completed and the pharmacy notified within 24 hours. If a preauthorization for a prescription cannot be completed within the 24 hours, the PHP must provide for the dispensing of at least a 72-hour supply if the medical need for the drug is immediate. PHP shall notify providers of such determination within 2 working days of receipt of the request;

(C) For expedited prior authorization requests in which the provider indicates, or the PHP determines, that following the standard timeframe could seriously jeopardize the Division member’s life or health or ability to attain, maintain, or regain maximum function:

(i) The PHP must make an expedited authorization decision and provide notice as expeditiously as the member’s health condition requires and no later than three working days after receipt of the request for service;

(ii) The PHP may extend the three working days time period by up to 14 calendar days if the Division member requests an extension, or if the PHP justifies to the Division a need for additional information and how the extension is in the member’s interest.

(D) For all other preauthorization requests, PHPs shall notify providers of an approval, a denial or a need for further information within 14 calendar days of receipt of the request. PHPs must make reasonable efforts to obtain the necessary information during that 14-day period. However, the PHP may use an additional 14 days to obtain follow-up information, if the PHP justifies (to the Division upon request) the need for additional information and how the delay is in the interest of the Division member. If the PHP exends the timeframe, it shall give the Division member written notice of the reason for the extension, as outlined in OAR 410-141-0263. The PHP shall make a determination as the Division member’s health condition requires, but no later than the expiration of the extension.

(b) Claims payment:

(A) PHPs shall have written procedures for processing claims submitted for payment from any source. The procedures shall specify time frames for:

(i) Date stamping claims when received;

(ii) Determining within a specific number of days from receipt whether a claim is valid or non-valid;

(iii) The specific number of days allowed for follow up of pended claims to obtain additional information;

(iv) The specific number of days following receipt of additional information that a determination must be made; and

(v) Sending notice of the decision with appeal rights to the Division member when the determination is made to deny the claim.

(B) PHPs shall pay or deny at least 90% of valid claims within 45 calendar days of receipt and at least 99% of valid claims within 60 calendars days of receipt. PHPs shall make an initial determination on 99% of all claims submitted within 60 calendar days of receipt;

(C) PHPs shall provide written notification of PHP determinations when such determinations result in a denial of payment for services, as outlined in 410-141-0263.

(D) PHPs shall not require providers to delay billing to the PHP;

(E) PHPs shall not require Medicare be billed as the primary insurer for services or items not covered by Medicare, nor require non-Medicare approved providers to bill Medicare;

(F) PHPs shall not deny payment of valid claims when the potential TPR is based only on a diagnosis, and no potential TPR has been documented in the Division member’s clinical record;

(G) PHPs shall not delay nor deny payments because a co-payment was not collected at the time of service.

(c) FCHPs, PCOs, and MHOs are responsible for payment of Medicare coinsurances and deductibles up to the Medicare or PHP’s allowable for covered services the Division member receives within the PHP, for authorized referral care, and for urgent care services or emergency services the Division member receives from non-participating providers (see definition). FCHPs, PCOs, and MHOs are not responsible for Medicare coinsurances and deductibles for non-urgent or non-emergent care Division members receive from non-participating providers;

(d) FCHPs and PCOs shall pay transportation, meals and lodging costs for the Division member and any required attendant for out-of-state services (as defined in General Rules, chapter 410, division 120) that the FCHP and PCO has arranged and authorized when those services are available within the state, unless otherwise approved by the Division;

(e) PHPs shall be responsible for payment of covered services (see definition) provided by a non-participating provider which was not pre-authorized if the following conditions exist:

(A) It can be verified that the participating provider (see definition) ordered or directed the covered services to be delivered by a non-participating provider; and

(B) The covered service was delivered in good faith without the pre-authorization; and

(C) It was a covered service that would have been pre-authorized with a participating provider if the PHP’s referral protocols had been followed;

(D) The PHP shall be responsible for payment to non-participating providers (providers enrolled with the Division that do not have a contract with the PHP) for covered services that are subject to reimbursement from the PHP, the amount specified in OAR 410-120-1295. This rule does not apply to providers that are Type A or Type B hospitals, as they are paid in accordance with ORS 414.727.

(7) Other services:

(a) Division members enrolled with PHPs may receive certain services on a Division FFS basis. Such services are referred to as non-capitated services (see definition);

(b) Certain services must be authorized by the PHP or the Community Mental Health Program (CMHP) for some mental health services, even though such services are then paid by the Division on a Division FFS basis. Before providing services, providers should verify a Division member’s eligibility via the web portal or AVR. For some mental health services, providers will need to contact the CMHP directly. In addition, the provider may call the PHP to obtain information about coverage for a particular service or pre-authorization requirements;

(c) Services authorized by the PHP or CMHP are subject to the rules and limitations of the appropriate Division administrative rules and supplemental information, including rates and billing instructions;

(d) Providers shall bill the Division directly for non-capitated services in accordance with billing instructions contained in the Division administrative rules and supplemental information;

(e) The Division shall pay at the Medicaid FFS rate in effect on the date the service is provided subject to the rules and limitations described in the relevant rules, contracts, billing instructions and Division administrative rules and supplemental information;

(f) The Division shall not pay a provider for provision of services for which a PHP has received a capitation payment unless otherwise provided for in OAR 410-141-0120;

(g) When an item or service is included in the rate paid to a medical institution, a residential facility or foster home, provision of that item or service is not the responsibility of the Division, AMH, nor a PHP except as provided for in Division administrative rules and supplemental information (e.g., capitated services that are not included in the nursing facility all-inclusive rate);

(h) FCHPs and PCOs that contract with FQHCs and RHCs shall negotiate a rate of reimbursement that is not less than the level and amount of payment which the FCHP or PCO would make for the same service(s) furnished by a provider, who is not an FQHC nor RHC, consistent with the requirements of BBA 4712(b)(2).

(8) Coverage of services through the Oregon Health Plan Benefit Package of covered services is limited by OAR 410-141-0500, excluded services and limitations for OHP clients.

(9) OHP clients who are enrolled with a PCM receive services on a FFS basis:

(a) PCMs are paid a per client-per month payment to provide Primary Care Management Services, in accordance with OAR 410-141-0410, Primary Care Manager Medical Management;

(b) PCMs provide primary care access, and management services for preventive services, primary care services, referrals for specialty services, limited inpatient hospital services and outpatient hospital services. The Division payment for these PCM managed services is contingent upon PCCM authorization;

(c) All PCM managed services are covered services that shall be billed directly to the Division in accordance with billing instructions contained in the Division administrative rules and supplemental information;

(d) The Division shall pay at the Division FFS rate in effect on the date the service is provided subject to the rules and limitations described in the appropriate Division administrative rules and supplemental information.

(10) All OHP clients who are enrolled with a PCO receive inpatient hospital services on a Division FFS basis:

(a) May receive services directly from any appropriately enrolled Division provider;

(b) All services shall be billed directly to the Division in accordance with FFS billing instructions contained in the Division administrative rules and supplemental information;

(c) The Division shall pay at the Division FFS rate in effect on the date the service is provided subject to the rules and limitations described in the appropriate Division administrative rules and supplemental information.

(11) OHP clients who are not enrolled with a PHP receive services on a Division FFS basis:

(a) Services may be received directly from any appropriate enrolled Division provider;

(b) All services shall be billed directly to the Division in accordance with billing instructions contained in the Division administrative rules and supplemental information;

(c) The Division shall pay at the Division FFS rate in effect on the date the service is provided subject to the rules and limitations described in the appropriate Division administrative rules and supplemental information.

[Publications: Publications referenced are available from the agency.]

Stat. Auth.: ORS 413.042 & 414.065

Stats. Implemented: ORS 414.065

Hist.: HR 31-1993, f. 10-14-93, cert. ef. 2-1-94; HR 7-1994, f. & cert. ef. 2-1-94; HR 17-1995, f. 9-28-95, cert. ef. 10-1-95; HR 19-1996, f. & cert. ef. 10-1-96; HR 25-1997, f. & cert. ef. 10-1-97; OMAP 21-1998, f. & cert. ef. 7-1-98; OMAP 39-1999, f. & cert. ef. 10-1-99; OMAP 26-2000, f. 9-28-00, cert. ef. 10-1-00; OMAP 15-2001, f. 3-30-01, cert. ef. 4-1-01; OMAP 52-2001, f. & cert. ef. 10-1-01; OMAP 57-2002, f. & cert. ef. 10-1-02; OMAP 4-2003, f. 1-31-03, cert. ef. 2-1-03; OMAP 61-2003, 9-5-03, cert. ef. 10-1-03; OMAP 23-2004(Temp), f. & cert. ef. 3-23-04 thru 8-15-04; OMAP 33-2004, f. 5-26-04, cert. ef. 6-1-04; OMAP 37-2004(Temp), f. 5-27-04 cert. ef. 6-1-04 thru 11-15-04; OMAP 47-2004, f. 7-22-04 cert. ef. 8-1-04; OMAP 27-2005, f. 4-20-05, cert. ef. 5-1-05; OMAP 46-2005, f. 9-9-05, cert. ef. 10-1-05; OMAP 23-2006, f. 6-12-06, cert. ef. 7-1-06; OMAP 53-2006(Temp), f. 12-28-06, cert. ef. 1-1-07 thru 6-29-07; DMAP 9-2007, f. 6-14-07, cert. ef. 6-29-07; DMAP 45-2009, f. 12-15-09, cert. ef. 1-1-10; DMAP 16-2010, f. 6-11-10, cert. ef. 7-1-10; DMAP 42-2010, f. 12-28-10, cert. ef. 1-1-11; DMAP 29-2011, f. 10-19-11, cert. ef. 10-20-11; DMAP 48-2011(Temp), f. 12-23-11, cert. ef. 1-1-12 thru 6-25-12; Administrative correction, 8-1-12; DMAP 60-2013, f. & cert. ef. 10-31-13

410-141-3260

Grievance System: Grievances, Appeals and Contested Case Hearings

(1) This rule applies to requirements related to the grievance system, which includes appeals, contested case hearings, and grievances. For purposes of this rule and OAR 410-141-3261 through 410-141-3264, references to member means a member, member’s representative and the representative of a deceased member’s estate.

(2) The CCO must establish and have a Division approved process and written procedures, for the following:

(a) Member rights to appeal and request a CCO’s review of an action;

(b) Member rights to request a contested case hearing on a CCO action under the Administrative Procedures Act; and

(c) Member rights to file a grievance for any matter other than an appeal or contested case hearing;

(d) An explanation of how CCOs shall accept, process, and respond to appeals, hearing requests, and grievances;

(e) Compliance with grievance system requirements as part of the state quality strategy and to monitor and enforce consumer rights and protections within the Oregon Integrated and Coordinated Health Care Delivery System and ensure consistent response to complaints of violations of consumer right and protections.

(3) Upon receipt of a grievance or appeal, the CCO must:

(a) Acknowledge receipt to the member;

(b) Give the grievance or appeal to staff with the authority to act upon the matter;

(c) Obtain documentation of all relevant facts concerning the issues;

(d) Ensure that staff making decisions on the grievance or appeal are:

(A) Not involved in any previous level of review or decision-making; and

(B) Health care professionals, as defined in OAR 410-120-0000, with appropriate clinical expertise in treating the member’s condition or disease if the grievance or appeal involves clinical issues or if the member requests an expedited review.

(4) The CCO must analyze all grievances, appeals, and hearings in the context of quality improvement activity pursuant to OAR 410-141-3200 and 410-141-3260.

(5) CCOs must keep all healthcare information concerning a member’s request confidential, consistent with appropriate use or disclosure as the terms treatment, payment, or CCO health care operations, are defined in 45 CFR 164.501.

(6) The following pertains to release of a member’s information:

(a) The CCO and any provider whose authorizations, treatments, services, items, quality of care, or requests for payment are involved in the grievance, appeal or hearing may use this information without the member’s signed release for purposes of:

(A) Resolving the matter; or

(B) Maintaining the grievance or appeals log.

(b) If the CCO needs to communicate with other individuals or entities, not listed in subsection (a), to respond to the matter, the CCO must obtain the member’s signed release and retain the release in the member’s record.

(7) The CCO must provide members with any reasonable assistance in completing forms and taking other procedural steps related to filing grievances, appeals, or hearing requests. Reasonable assistance includes, but is not limited to:

(a) Assistance from qualified community health workers, qualified peer wellness specialists or personal health navigators to participate in processes affecting the member’s care and services;

(b) Free interpreter services;

(c) Toll-free phone numbers that have adequate TTY/TTD and interpreter capabilities; and

(d) Reasonable accommodation or policy and procedure modifications as required by any disability of the member.

(8) The CCO and its participating providers may not:

(a) Discourage a member from using any aspect of the grievance, appeal, or hearing process;

(b) Encourage the withdrawal of a grievance, appeal, or hearing request already filed; or

(c) Use the filing or resolution of a grievance, appeal, or hearing request as a reason to retaliate against a member or to request member disenrollment.

(9) In all CCO administrative offices and in those physical, behavioral, and oral health offices where the CCO has delegated response to the appeal, hearing request or grievance, the CCO must have the following forms available:

(a) OHP Complaint Form (OHP 3001);

(b) Appeal forms;

(c) Hearing request form, (DHS 443) and Notice of Hearing Rights (DMAP 3030); or

(d) The Medical Assistance Service Programs Denial Appeal and Hearing Request form (DMAP 1234), or approved facsimile.

(10) A member’s provider:

(a) Acting on behalf of and with written consent of the member, may file an appeal;

(b) May not act as the member’s authorized representative for requesting a hearing or filing a grievance.

(11) The CCO and its participating providers must cooperate with the Department of Human Services Governor’s Advocacy Office, the Authority’s Ombudsman and hearing representatives in all activities related to member appeals, hearing requests, and grievances including providing all requested written materials.

(12) If the CCO delegates the grievance and appeal process to a subcontractor, the CCO must:

(a) Ensure the subcontractor meets the requirements consistent with this rule and OAR 410-141-3261 through 410-141-3264;

(b) Monitor the subcontractor’s performance on an ongoing basis;

(c) Perform a formal compliance review at least once a year to assess performance, deficiencies, or areas for improvement; and

(d) Ensure the subcontractor takes corrective action for any identified areas of deficiencies that need improvement.

(13) CCO’s must maintain yearly logs of all appeals and grievances for seven calendar years with the following requirements:

(a) The logs must contain the following information pertaining to each member’s appeal or grievance:

(A) The member’s name, ID number, and date the member filed the grievance or appeal;

(B) Documentation of the CCO’s review, resolution, or disposition of the matter, including the reason for the decision and the date of the resolution or disposition;

(C) Notations of oral and written communications with the member; and

(D) Notations about appeals and grievances the member decides to resolve in another way if the CCO is aware of this.

(b) For each calendar year, the logs must contain the following aggregate information:

(A) The number of actions; and

(B) A categorization of the reasons for and resolutions or dispositions of appeals and grievances.

(14) The CCO must review the log monthly for completeness and accuracy, which includes but is not limited to timeliness of documentation and compliance with procedures.

(15) A member or a member’s provider may request an expedited resolution of an appeal or a contested case hearing if the member or provider believes taking the standard time of resolution could seriously jeopardize the member’s:

(a) Life, health, mental health or dental health; or

(b) Ability to attain, maintain or regain maximum function.

(16) A member who may be entitled to continuing benefits may request and receive continuing benefits in the same manner and same amount while an appeal or contested case hearing is pending:

(a)To be entitled to continuing benefits, the member must complete a hearing request or request for appeal, requesting continuing benefits, no later than:

(A) The tenth day following the date of the notice or the notice of appeal resolution; and

(B) The effective date of the action proposed in the notice, if applicable.

(b) In determining timeliness under section (3)(a) of this rule, delay for good cause, as defined in OAR 137-002-0528, is not counted;

(c) The benefits must be continued until:

(A) A final appeal resolution resolves the appeal, unless the member requests a hearing with continuing benefits, no later than ten days following the date of the notice of appeal resolution;

(B) A final order resolves the contested case;

(C) The time period or service limits of a previously authorized service have been met; or

(D) The member withdraws the request for hearing.

(17) The CCO shall review and report to the Authority complaints that raise issues related to racial or ethnic background, gender, religion, sexual orientation, socioeconomic status, culturally or linguistically appropriate service requests, disability status and other identity factors for consideration in improving services for health equity.

(18) If a CCO receives a complaint or grievance related to a member’s entitlement of continuing benefits in the same manner and same amount during the transition of transferring from one CCO to another CCO for reasons defined in OAR 410-141-3080 (15) the CCO shall log the complaint/grievance and work with the receiving/sending CCO to ensure continuity of care during the transition

Stat. Auth.: ORS 413.032, 414.615, 414.625, 414.635, 414.651

Stats. Implemented: ORS 414.610 – 414.685

Hist.: DMAP 16-2012(Temp), f. & cert. ef. 3-26-12 thru 9-21-12; DMAP 37-2012, f. & cert. ef. 8-1-12; DMAP 54-2012(Temp), f. & cert. ef. 11-1-2 thru 4-29-13; DMAP 22-2013, f. & cert. ef. 4-26-13; DMAP 60-2013, f. & cert. ef. 10-31-13

410-141-3263

Notice of Action

(1) A CCO must provide a member with a notice of action when the CCO’s decision about a health service constitutes an action. The notice of action must:

(a) Be written in language sufficiently clear that a layperson could understand the notice and make an informed decision about appealing the action and requesting a hearing;

(b) Comply with the Authority’s formatting and readability standards;

(c) The notice must include but is not limited to the following:

(A) Date of the notice;

(B) CCO’s name and telephone number;

(C) Name of the member’s PCP, PCD, or behavioral health professional, as applicable;

(D) Member’s name and member ID number;

(E) Service requested and whether the CCO is denying, terminating, suspending or reducing a service or payment;

(F) Date of the service or date the member requested the service;

(G) Name of the provider who performed or requested the service;

(H) Effective date of the action if different from the date of the notice;

(I) Whether the CCO considered other conditions as co-morbidity factors if the service was below the funding line on the OHP Prioritized List of Health Services;

(J) Clearly and thoroughly explain specific reasons for the action and a reference to the specific sections of the statutes and rules pertaining to each reason;

(K) Member’s right to file an appeal with the CCO or request a contested case hearing;

(L) An explanation of circumstances under which the member may request expedited resolution of an appeal, and how to request one; and

(M) A statement that the member has the right to request to receive the services that are being denied pending resolution of the appeal and that the member may be responsible for the cost of those services if the outcome of the appeal upholds the CCO’s action;

(d) The Notice of Action must be on a Division approved form.

(2) The CCO must include the appropriate forms based on the Division approved Notice of Action, as outlined in OAR 410-141-3260, to the notice.

(3) For actions affecting previously authorized services, the CCO must mail the notice at least 10 calendar days before the date of action with the exception of circumstances described in section (4) of this rule.

(4) The CCO may mail the notice no later than the date of action if:

(a) The CCO or provider has information confirming the death of the member;

(b) The member sends the CCO a signed statement stating the member no longer wants the service;

(c) The CCO can verify that the member is in an institution where the member is no longer eligible for OHP services;

(d) The CCO is unaware of the member’s whereabouts; the post office returns the mail indicating no forwarding address; and the Authority or Department of Human Services has no other address;

(e) The CCO verifies another state, territory, or commonwealth has accepted the member for Medicaid services;

(f) The member’s PCP, PCD, or behavioral health professional has prescribed a change in the level of health services; or

(g) The date of action shall occur in less than 10 calendar days when the CCO:

(A) Has facts indicating probable fraud by the member, and the CCO has certified those facts, if possible, through a secondary resource; or

(B) Denies payment for a claim.

(5) For actions affecting services not previously authorized, the CCO must send the notice as expeditiously as the member’s health condition requires but no later than 14 calendar days following the date of receipt of the request for service.

(6) For actions affecting services not previously authorized and for which the CCO grants expedited review, the CCO must send the notice as expeditiously as the member’s health condition requires but no later than three business days after receipt of the request for service.

(7) In accordance with 42 CFR 438.408, the CCO may extend the timeframes from (5) above by up to 14 calendar days, if:

(a) The Division member or Division member’s representative requests the extension; or

(b) The CCO shows (to the satisfaction of the Division’s Hearings Unit upon it request) that there is need for additional information and how the delay is in the Division member’s interest.

(8) If the CCO extends the timeframes, it must, for any extension not requested by the Division member, give the Division member and Division member’s representative, a written notice of the reason for the delay.

Stat. Auth.: ORS 414.032, 414.615, 414.625, 414.635, 414.651

Stats. Implemented: ORS 414.610 – 685 OL 2011, Ch 602 Sec. 13, 14, 16, 17, 62, 64 (2), 65, HB

Hist.: DMAP 16-2012(Temp), f. & cert. ef. 3-26-12 thru 9-21-12; DMAP 37-2012, f. & cert. ef. 8-1-12; DMAP 60-2013, f. & cert. ef. 10-31-13

410-141-3395

Member Protection Provisions

(1) In the event of a finding of impairment by OHA or of a termination of certification as a CCO or of the CCO contract, members of the CCO shall be offered disenrollment from the CCO and enrollment in accordance with OHA rule.

(2) For the purpose of this section only, and only in the event of a finding of impairment by OHA or of a termination of certification or of the CCO contract, any covered health care service furnished within the state by a provider to a member of a CCO shall be considered to have been furnished pursuant to a contract between the provider and the CCO with whom the member was enrolled when the services were furnished.

(3) Each contract between a CCO and a provider of health services shall provide that if the CCO fails to pay for covered health services as set forth in the contract, the member is not liable to the provider for any amounts owed by the CCO.

(4) If the contract between the contracting provider and the CCO has not been reduced to writing or fails to contain the provisions required by this rule, the member is not liable to the contracting provider for any amounts owed by the CCO.

(5) No contracting provider or agent, trustee or assignee of the contracting provider shall bill a member, send a member’s bill to a Collection Agency, or maintain a civil action against a member to collect any amounts owed by the CCO for which the member is not liable to the contracting provider in this rule and under 410-120-1280.

(6) Nothing in this section impairs the right of a provider to charge, collect from, and attempt to collect from or maintain a civil action against a member for any of the following:

(a) Deductible, copayment or coinsurance amounts;

(b) Health services not covered by the CCO, if a valid DMAP 3165, or facsimile, signed by the client, has been completed as described in OAR 410-120-1280; or

(c) Health services rendered after the termination of the contract between the CCO and the provider, unless the health services were rendered during the confinement in an inpatient facility and the confinement began prior to the date of termination or unless the provider has assumed post-termination treatment obligations under the contract. Before providing a non-covered service, the provider must complete a DMAP 3165, or facsimile, as described in OAR 410-120-1280.

Stat. Auth.: ORS 413.042, 414.615, 414.625, 414.635 & 414.651

Stats. Implemented: ORS 414.610 - 414.685

Hist.: DMAP 16-2012(Temp), f. & cert. ef. 3-26-12 thru 9-21-12; DMAP 37-2012, f. & cert. ef. 8-1-12; DMAP 60-2013, f. & cert. ef. 10-31-13

410-141-3420

Billing and Payment

(1) Subject to other applicable Division billing rules, providers must submit all billings for CCO members following the timeframes in (a) and (b) below:

(a) Submit billings within 12 months of the date of service in the following cases:

(A) Member pregnancy;

(B) Eligibility issues such as retroactive deletions or retroactive enrollments;

(C) Medicare is the primary payer, except where the CCO is responsible for the Medicare reimbursement;

(D) Other cases that could have delayed the initial billing to the CCO (which does not include failure of provider to certify the member’s eligibility); or

(E) Third Party Liability (TPL). Pursuant to 42 CFR 136.61, subpart G: Indian Health Services and the amended Public Law 93-638 under the Memorandum of Agreement that Indian Health Service and 638 Tribal Facilities are the payer of last resort and is not considered an alternative liability or TPL.

(b) Submit bills within four months of the date of service for all other cases.

(2) Providers must be enrolled with the Authority’s Division of Medical Assistance Programs to be eligible for fee-for-service (FFS) payments. Mental health providers, except Federally Qualified Health Centers (FQHC), must be approved by the Local Mental Health Authority (LMHA) and the Authority’s Addictions and Mental Health (AMH) Division before enrollment with the Authority or to be eligible for CCO payment for services. Providers may be retroactively enrolled, in accordance with OAR 410-120-1260 (Provider Enrollment).

(3) Providers, including mental health providers, must be enrolled with the Authority as a Medicaid provider or an encounter-only provider prior to submission of encounter data to ensure the encounter is accepted.

(4) Providers shall verify, before providing services, that the member is eligible for coordinated care services on the date of service. Providers shall use the Authority tools and the CCO’s tools, as applicable, to determine if the service to be provided is covered under the member’s Oregon Health Plan Benefit Package of covered services. Providers shall also identify the party responsible for covering the intended service and seek pre-authorizations from the appropriate payer before providing services. Before providing a non-covered service, the provider must complete a DMAP 3165, or facsimile, signed by the client, as described in OAR 141-120-1280.

(5) CCOs shall pay for all covered coordinated care services. These services must be billed directly to the CCO, unless the CCO or the Authority specifies otherwise. CCOs may require providers to obtain preauthorization to deliver certain coordinated care services.

(6) Payment by the CCO to participating providers for coordinated care services is a matter between the CCO and the participating provider, except as follows:

(a) CCOs shall have procedures for processing pre-authorization requests received from any provider. The procedures shall specify time frames for:

(A) Date stamping pre-authorization requests when received;

(B) Determining within a specific number of days from receipt whether a pre-authorization request is valid or non-valid;

(C) The specific number of days allowed for follow up on pended preauthorization requests to obtain additional information;

(D)The specific number of days following receipt of the additional information that a redetermination must be made;

(E) Providing services after office hours and on weekends that require preauthorization;

(F) Sending notice of the decision with appeal rights to the member when the determination is a denial of the requested service as specified in OAR 410-141-3263.

(b) CCOs shall make a determination on at least 95% of valid preauthorization requests, within two working days of receipt of a preauthorization or reauthorization request related to urgent services; alcohol and drug services; or care required while in a skilled nursing facility. Preauthorization for prescription drugs must be completed and the pharmacy notified within 24 hours. If a preauthorization for a prescription cannot be completed within the 24 hours, the CCO must provide for the dispensing of at least a 72-hour supply if there is an immediate medical need for the drug. CCOs shall notify providers of the determination within 2 working days of receipt of the request;

(c) For expedited prior authorization requests in which the provider indicates, or the CCO determines, that following the standard timeframe could seriously jeopardize the member’s life or health or ability to attain, maintain, or regain maximum function:

(A) The CCO must make an expedited authorization decision and provide notice as expeditiously as the member’s health or mental health condition requires and no later than three working days after receipt of the request for service;

(B) The CCO may extend the three working day time period no more than 14 calendar days if the member requests an extension, or if the CCO justifies to the Authority a need for additional information and how the extension is in the member’s best interest.

(d) For all other preauthorization requests, CCOs shall notify providers of an approval, a denial or the need for further information within 14 calendar days of receipt of the request, as outlined in 410-141-3263, CCOs must make reasonable efforts to obtain the necessary information during the 14-day period. However, the CCO may use an additional 14 days to obtain follow-up information, if the CCO justifies (to the Authority upon request) the need for additional information and how the delay is in the interest of the member. The CCO shall make a determination as the member’s health or mental health condition requires, but no later than the expiration of the extension.

(7) CCOs shall have written procedures for processing payment claims submitted from any source. The procedures shall specify time frames for:

(a) Date stamping claims when received;

(b) Determining within a specific number of days from receipt whether a claim is valid or non-valid;

(c) The specific number of days allowed for follow up of pended claims to obtain additional information;

(d) The specific number of days following receipt of additional information that a determination must be made; and

(e) Sending notice of the decision with appeal rights to the member when the determination is made to deny the claim;

(f) CCOs shall pay or deny at least 90% of valid claims within 45 calendar days of receipt and at least 99% of valid claims within 60 calendars days of receipt. CCOs shall make an initial determination on 99% of all claims submitted within 60 calendar days of receipt;

(g) CCOs shall provide written notification of CCO determinations when the determinations result in a denial of payment for services as outlined in 410-141-3263;

(h) CCOs may not require providers to delay billing to the CCO;

(i) CCOs may not require Medicare be billed as the primary insurer for services or items not covered by Medicare, or require non-Medicare approved providers to bill Medicare;

(j) CCOs may not deny payment of valid claims when the potential TPR is based only on a diagnosis, and no potential TPR has been documented in the member’s clinical record;

(k) CCOs may not delay or deny payments because a co-payment was not collected at the time of service.

(8) CCOs shall pay for Medicare coinsurances and deductibles up to the Medicare or CCOs allowable for covered services the member receives within the CCO, for authorized referral care, and urgent care services or emergency services the member receives from non-participating providers. CCOs may not pay for Medicare coinsurances and deductibles for non-urgent or non-emergent care members receive from non-participating providers.

(9) CCOs shall pay transportation, meals and lodging costs for the member and any required attendant for services that the CCO has arranged and authorized when those services are not available within the state, unless otherwise approved by the Authority.

(10) CCOs shall pay for covered services provided by a non-participating provider which was not pre-authorized if the following conditions exist:

(a) It can be verified that the participating provider ordered or directed the covered services to be delivered by a non-participating provider; and

(b) The covered service was delivered in good faith without the pre-authorization; and

(c) It was a covered service that would have been pre-authorized with a participating provider if the CCO’s referral procedures had been followed;

(d) The CCO shall pay non-participating providers (providers enrolled with the Authority that do not have a contract with the CCO) for covered services that are subject to reimbursement from the CCO, in the amount specified in OAR 410-120-1295. This rule does not apply to providers that are Type A or Type B hospitals;

(e) CCOs shall reimburse hospitals for services provided on or after January 1, 2012 using Medicare Severity DRG for inpatient services and Ambulatory Payment Classification (APC) for outpatient services or other alternative payment methods which incorporate the most recent Medicare payment methodologies for both inpatient and outpatient services established by CMS for hospital services; and alternative payment methodologies, including but not limited to pay-for-performance, bundled payments and capitation. An alternative payment methodology does not include reimbursement payment based on percentage of billed charges. This requirement does not apply to Type A or Type B hospitals as referenced in ORS 442.470. CCO shall attest annually to the Authority, in a manner to be prescribed, to CCO’s compliance with these requirements.

(11) Members may receive certain services on a Fee for Service (FFS) basis:

(a) Certain services must be authorized by the CCO or the Community Mental Health Program (CMHP) for some mental health services, even though the services are then paid by the Authority on a FFS basis. Before providing services, providers must verify a member’s eligibility using the web portal or AVR;

(b) Services authorized by the CCO or CMHP are subject to the rules and limitations of the appropriate Authority administrative rules and supplemental information, including rates and billing instructions;

(c) Providers shall bill the Authority directly for FFS services in accordance with billing instructions contained in the Authority administrative rules and supplemental information;

(d) The Authority shall pay at the Medicaid FFS rate in effect on the date the service is provided subject to the rules and limitations described in the relevant rules, contracts, billing instructions;

(e) The Authority may not pay a provider for provision of services for which a CCO has received a CCO payment unless otherwise provided for in rule;

(f) When an item or service is included in the rate paid to a medical institution, a residential facility or foster home, provision of that item or service is not the responsibility of the Authority or a CCO except as provided in Authority administrative rules and supplemental information (e.g., coordinated care services that are not included in the nursing facility all-inclusive rate);

(g) CCOs that contract with FQHCs and RHCs shall negotiate a rate of reimbursement that is not less than the level and amount of payment which the CCO would pay for the same service furnished by a provider, who is not an FQHC nor RHC, consistent with the requirements of BBA 4712(b)(2).

(12) Coverage of services through the Oregon Health Plan Benefit Package of covered services is limited by OAR 410-141-0500, excluded services and limitations for OHP clients.

Stat. Auth.: ORS 414.032, 414.615, 414.625, 414.635, 414.651

Stats. Implemented: ORS 414.610 – 685 OL 2011, Ch 602 Sec. 13, 14, 16, 17, 62, 64 (2), 65, HB 3650

Hist.: DMAP 16-2012(Temp), f. & cert. ef. 3-26-12 thru 9-21-12; DMAP 37-2012, f. & cert. ef. 8-1-12; DMAP 38-2013(Temp), f. 7-8-13, cert. ef. 7-9-13 thru 1-5-14; DMAP 60-2013, f. & cert. ef. 10-31-13


Rule Caption: Related to client appeals/hearings, and provider requirements related to billing clients for non-covered services

Adm. Order No.: DMAP 61-2013

Filed with Sec. of State: 10-31-2013

Certified to be Effective: 11-1-13

Notice Publication Date: 10-1-2013

Rules Amended: 410-120-1280, 410-120-1400, 410-120-1860

Subject: Rules are amended to require providers to review with and have OHP clients sign a new OHP Client Agreement to Pay for Health Services form, DMAP 3165, or facsimile containing the elements of the DMAP 3165, before providing and charging clients for non-covered services. Rules are further revised to allow for use of a new Medical Assistance Service Denial Appeal and Hearing Request form, or Division approved facsimile, to be used in place of the MSC 443 and DMAP 3030 forms; change the standard for client failure to meet timely filing/actions from “circumstances beyond the control of the client’ to ‘good cause;’ more directly link that failure to comply with policies outlined in 410-120-1280 may be cause for provider sanctions; and to make clarity and housekeeping revisions.

Rules Coordinator: Sandy Cafourek—(503) 945-6430

410-120-1280

Billing

(1) A provider enrolled with the Authority or providing services to a client in a CCO or PHP under the Oregon Health Plan (OHP) must not seek payment, from the client for any services covered by Medicaid fee-for-service or through contracted health care plans:

(a) A client cannot be billed for missed appointments. A missed appointment is not considered to be a distinct Medicaid service by the federal government and as such is not billable to the client or the Division;

(b) A client cannot be billed for services or treatments that have been denied due to provider error (e.g., required documentation not submitted, prior authorization not obtained, etc.).

(2) For Medicaid covered services the provider must not bill the Division more than the provider’s usual charge (see definitions) or the reimbursement specified in the applicable Division Program rules.

(3) Providers shall only bill a client or a financially responsible relative or representative of that client in the following situations:

(a) For any applicable coinsurance, copayments and deductibles expressly authorized in OAR chapter 410, division 120, OAR chapter 410, division 141, or any other individual Division Program rules;

(b) The client did not inform the provider of their OHP coverage, enrollment in a prepaid health plan (PHP) or coordinated care organization (CCO), or third party insurance coverage at the time of or after a service was provided, therefore, the provider could not bill the appropriate payer for reasons including, but not limited to, the lack of prior authorization, or the time limit to submit the claim for payment has passed. The provider must verify eligibility, pursuant to OAR 410-120-1140, and document attempts to obtain coverage information prior to billing the client;

(c) The client became eligible for benefits retroactively but did not meet all of the other criteria required to receive the service);

(d) A third party payer made payments directly to the client for services provided;

(e) The client has a limited benefit package: Citizen Alien Waived Emergency Medical Program (CWM) may be billed for services that are not benefits of those programs, refer to OAR 410-120-1210 for coverage. The provider must document that the client was informed in advance that the service or item would not be part of their benefit coverage by the Division. A DMAP 3165 is not required for these services;

(f) The client has requested a continuation of benefits during the contested case hearing process and the final decision was not in favor of the client. The client is responsible for any charges incurred for the denied service, on or after the effective date on the Notice of Action or Notice of Appeal Resolution. The provider must complete the DMAP 3165 pursuant to section (3)(h) of this rule before providing these services;

(g) In exceptional circumstances, a client may decide to privately pay for a covered service. In this situation, the provider may bill the client if the provider informs the client in advance of all of the following:

(A) The requested service is a covered service, and the appropriate payer (the Division, PHP, CCO or third party payer) would pay the provider in full for the covered service; and

(B) The estimated cost of the covered service, including all related charges, the amount that the appropriate payer would pay for the service, and that the provider cannot bill the client for an amount greater than the amount the appropriate payer would pay; and

(C) That the client knowingly and voluntarily agrees to pay for the covered service;

(D) The provider documents in writing, signed by the client or the client’s representative, the provider gave the client the information described in (3)(g)(A-C); the client had an opportunity to ask questions, obtain additional information and consult with the client’s caseworker or client representative; and the client agreed to privately pay for the service by signing an agreement incorporating all of the information described above. The client must be given a copy of the signed agreement. A provider shall not submit a claim for payment for covered services to the Division or to the client’s PHP, CCO or third party payer that is subject to such agreement.

(h) A provider may bill a client for services that are not covered by the Division, PHP, or CCO (see definition of non-covered services). Before providing the non-covered service, the client must sign the provider-completed Agreement to Pay (DMAP 3165), or a facsimile containing all of the information and elements of the DMAP 3165, as shown in Table 3165 of this rule. The completed DMAP 3165, or facsimile, is valid only if the estimated fee does not change and the service is scheduled within 30 days of the client’s signature. Providers must make a copy of the completed DMAP 3165, or facsimile, available to the Division or applicable PHP or CCO upon request.

(4) Code Set requirements:

(a) Federal Code Set requirements (45 CFR 162) apply to all Medicaid Code Set requirements, including the use of diagnostic or procedure codes for prior authorization, claims submissions and payments. Code Set has the meaning established in 45 CFR 162.103 and it includes the codes and the descriptors of the codes. Federal Code Set requirements are mandatory and the Division lacks any authority to delay or alter their application or effective dates as established by the U.S. Department of Health and Human Services;

(b) The Division will adhere to the Code Set requirements in 45 CFR 162.1000 — 162.1011;

(c) Periodically, the Division will update its provider rules and tables to conform to national codes. In the event of an alleged variation between a Division-listed code and a national code, the Division will apply the national code in effect on the date of request or date of service;

(d) Only codes with limitations or requiring prior authorization are noted in rules. National Code Set issuance alone should not be construed as coverage, or a covered service by the Division;

(e) The Division adopts by reference the National Code Set revisions, deletions, and additions issued and published by the American Medical Association (Current Procedural Terminology — CPT) and on the CMS website (Healthcare Common Procedural Coding System — HCPCS). This code adoption should not be construed coverage, or a covered service by the Division.

(5) Claims:

(a) Upon submission of a claim to the Division for payment, the provider agrees that it has complied with all Division Program rules. Submission of a claim, however, does not relieve the provider from the requirement of a signed provider agreement;

(b) A provider enrolled with the Division must bill using the Authority assigned provider number, in addition to the National Provider Identification (NPI) number, if the NPI is available, pursuant to 410-120-1260;

(c) The provider must not bill the Division more than the provider’s usual charge (see definitions) or the reimbursement specified in the applicable Division Program rules;

(d) Must be submitted on the appropriate form as described in the individual Division Program rules or electronically in a manner authorized in OAR chapter 943, division 120;

(e) Must be for services provided within the provider’s licensure or certification;

(f) Must be submitted after (unless specified otherwise in the Division’s individual Program rules):

(A) Delivery of service; or

(B) Dispensing, shipment or mailing of the item.

(g) It is the responsibility of the provider to submit true and accurate information when billing the Division. Use of a billing provider does not abrogate the performing provider’s responsibility for the truth and accuracy of submitted information;

(h) A claim is considered a valid claim only if all required data is entered on or attached to the claim form. See the appropriate provider rules and supplemental information for specific instructions and requirements;

(i) A provider or its contracted agency (including billing providers) shall not submit or cause to be submitted:

(A) Any false claim for payment;

(B) Any claim altered in such a way as to result in a payment for a service that has already been paid;

(C) Any claim upon which payment has been made or is expected to be made by another source unless the amount paid or to be paid by the other party is clearly entered on the claim form;

(D) Any claim for furnishing specific care, item(s), or service(s) that have not been provided.

(j) The provider is required to submit an Individual Adjustment Request, or to refund the amount of the overpayment, on any claim where the provider identifies an overpayment made by the Division;

(k) A provider who, after having been previously warned in writing by the Division or the Department of Justice about improper billing practices, is found to have continued such improper billing practices and has had an opportunity for a contested case hearing, shall be liable to the Division for up to triple the amount of the Division established overpayment received as a result of such violation.

(6) Diagnosis code requirement:

(a) A primary diagnosis code is required on all claims, using the HIPAA nationally required diagnosis Code Set, unless specifically excluded in individual Division Program rules;

(b) All diagnosis codes are required to the highest degree of specificity;

(c) Hospitals are always required to bill using the 5th digit, in accordance with methodology used in the Medicare Diagnosis Related Groups.

(7) Procedure code requirement:

(a) For claims requiring a procedure code the provider must bill as instructed in the appropriate Division Program rules and must use the appropriate HIPAA procedure Code Set such as CPT, HCPCS, ICD-9-CM, ADA CDT, NDC, established according to 45 CFR 162.1000 to 162.1011, which best describes the specific service or item provided;

(b) For claims that require the listing of a diagnosis or procedure code as a condition of payment, the code listed on the claim form must be the code that most accurately describes the client’s condition and the service(s) provided. Providers must use the ICD-9-CM diagnosis coding system when a diagnosis is required unless otherwise specified in the appropriate individual Division Program rules. Hospitals must follow national coding guidelines;

(c) When there is no appropriate descriptive procedure code to bill the Division, the provider must use the code for “unlisted services.” Instructions on the specific use of unlisted services are contained in the individual provider rules. A complete and accurate description of the specific care, item, or service must be documented on the claim;

(d) Where there is one CPT, CDT or HCPCS code that according to CPT, CDT and HCPCS coding guidelines or standards, describes an array of services the provider must bill the Division using that code rather than itemizing the services under multiple codes. Providers must not “unbundled” services in order to increase the Division payment.

(8) Third party Liability (TPL):

(a) Federal law requires that state Medicaid agencies take all reasonable measures to ensure that in most instances the Division will be the payer of last resort;

(b) Providers must make reasonable efforts to obtain payment first from other resources. For the purposes of this rule “reasonable efforts” include determining the existence of insurance or other resources on each date of service by:

(A) Using an insurance database such as Electronic Verification System (EVS) available to the provider;

(B) Using the Automated Voice Response (AVR) or secure provider web portal on each date of service and at the time of billing.

(c) Except as noted in (8) (d) (A through E) below, when third party coverage is known to the provider, prior to billing the Division the provider must:

(A) Bill the TPL; and

(B) Except for pharmacy claims billed through the Division’s point-of-sale system the provider must have waited 30 days from submission date of a clean claim and have not received payment from the third party; and

(C) Comply with the insurer’s billing and authorization requirements; and

(D) Appeal a denied claim when the service is payable in whole or in part by an insurer.

(d) In accordance with federal regulations the provider must bill the TPL prior to billing the Division, except under the following circumstances:

(A) The covered health service is provided by an Intermediate Care Facility for Individuals with Intellectual Disabilities (ICF/ID);

(B) The covered health service is provided by institutional services for the mentally and emotionally disturbed;

(C) The covered health services are prenatal and preventive pediatric services;

(D) Services are covered by a third party insurer through an absent parent where the medical coverage is administratively or court ordered;

(E) When another party may be liable for an injury or illness (see definition of Liability Insurance), the provider may bill the insurer or liable party or place a lien against a settlement or the provider may bill the Division. The provider may not both place a lien against a settlement and bill the Division. The provider may withdraw the lien and bill the Division within 12 months of the date of service. If the provider bills the Division the provider must accept payment made by the Division as payment in full.

(e) The provider must not return the payment made by the Division in order to accept payment from a liability settlement or liability insurer or place a lien against that settlement:

(A) In the circumstances outlined in (8)(d)(A through E) above, the provider may choose to bill the primary insurance prior to billing the Division. Otherwise, the Division will process the claim and, if applicable, will pay the Division allowable rate for these services and seek reimbursement from the liable third party insurance plan;

(B) In making the decision to bill the Division the provider should be cognizant of the possibility that the third party payer may reimburse the service at a higher rate than the Division, and that, once the Division makes payment no additional billing to the third party is permitted by the provider.

(f) The provider may bill the Division directly for services that are never covered by Medicare or another insurer on the appropriate form identified in the relevant provider rules. Documentation must be on file in the provider’s records indicating this is a non-covered service for purposes of Third Party Resources. See the individual provider rules for further information on services that must be billed to Medicare first;

(g) Providers are required to submit an Individual Adjustment Request showing the amount of the third party payment or to refund the amount received from another source within 30 days of the date the payment is received. Failure to submit the Individual Adjustment Request within 30 days of receipt of the third party payment or to refund the appropriate amount within this time frame is considered concealment of material facts and grounds for recovery and/or sanction:

(A) When a provider receives a payment from any source prior to the submission of a claim to the Division, the amount of the payment must be shown as a credit on the claim in the appropriate field;

(B) Any provider who accepts third party payment for furnishing a service or item to a Division client after having billed the Division, shall:

(i) Submit an Individual Adjustment Request indicating the amount of the third party payment. Follow instructions in the individual Division Program rules and supplemental billing; or

(ii) When the provider has already accepted payment from the Division for the specific service or item, the provider shall make direct payment of the amount of the third party payment to the Division. The check to repay the Division shall include the reason the payment is being made and either:

(I) An Individual Adjustment Request which identifies the original claim, name and number of the client, date of service and item(s) or service(s) for which the repayment is made; or

(II) A copy of the Remittance Advice showing the original Division payment.

(C) Any provider who accepts payment from a client, or client’s representative, and is subsequently paid for the service by the Division, shall reimburse the client, or their representative, the full amount of their payment.

(h) The Division reserves the right to make a claim against any third party payer after making payment to the provider of service. The Division may pursue alternate resources following payment if it deems this a more efficient approach. Pursue alternate resources includes, but is not limited to, requesting the provider to bill the third party and to refund the Division in accordance with this rule;

(i) For services rendered to a Medicare and Medicaid dual eligible client, the Division may request the provider to submit a claim for Medicare payment and the provider must honor that request. Under federal regulation, a provider agrees not to charge a beneficiary (or the state as the beneficiary’s subrogee) for services for which a provider failed to file a timely claim (42 CFR 424) with Medicare despite being requested to do so;

(j) If Medicare is the primary payer and Medicare denies payment, Medicare appeals must be timely pursued and Medicare denial must be obtained prior to submitting the claim for payment to Division. Medicare denial on the basis of failure to submit a timely appeal may result in the Division reducing from the amount of the claim any amount the Division determines could have been paid by Medicare.

(9) Full use of alternate resources:

(a) The Division will generally make payment only when other resources are not available for the client’s medical needs. Full use must be made of reasonable alternate resources in the local community;

(b) Except as provided in subsection (10) of this rule, alternate resources may be available:

(A) Under a federal or state worker’s compensation law or plan;

(B) For items or services furnished by reason of membership in a prepayment plan;

(C) For items or services provided or paid for directly or indirectly by a health insurance plan or as health benefits of a governmental entity, such as:

(i) Armed Forces Retirees and Dependents Act (CHAMPVA);

(ii) Armed Forces Active Duty and Dependents Military Medical Benefits Act (CHAMPUS); and

(iii) Medicare Parts A and B.

(D) To residents of another state under that state’s Title XIX or state funded medical assistance programs; or

(E) Through other reasonably available resources.

(10) Exceptions:

(a) Indian Health Services or Tribal Health Facilities. Pursuant to 42 CFR 136.61 subpart G and the Memorandum of Agreement in OAR 310-146-0000, Indian Health Services facilities and tribal facilities operating under Public Law 93, Section 638 agreement are payers of last resort, and are not considered an alternate resource or TPL;

(b) Veterans Administration. Veterans who are also eligible for Medicaid benefits are encouraged to utilize Veterans’ Administration facilities whenever possible. Veterans’ benefits are prioritized for service related conditions and as such are not considered an alternate or TPL.

(11) Table 120-1280 – TPR codes.

(12) Table – OHP Client Agreement to Pay for Health Services, DMAP 3165.

[ED. NOTE: Tables referenced are available from the agency.]

Stat. Auth.: ORS 413.042

Stats. Implemented: ORS 414.025, 414.065 & 414.085

Hist.: PWC 683, f. 7-19-74, ef. 8-11-74; PWC 803(Temp), f. & ef. 7-1-76; PWC 812, f. & ef. 10-1-76; AFS 5-1981, f. 1-23-81, ef. 3-1-81, Renumbered from 461-013-0050, 461-013-0060, 461-013-0090 & 461-013-0020; AFS 47-1982, f. 4-30-82, & AFS 52-1982, f. 5-28-82, ef. 5-1-82 for providers located in the geographical areas covered by the branch offices of North Salem, South Salem, Dallas, Woodburn, McMinnville, Lebanon, Albany and Corvallis, ef. 6-30-82 for remaining AFS branch offices; AFS 117-1982, f. 12-30-82, ef. 1-1-83; AFS 42-1983, f. 9-2-83, ef. 10-1-83; AFS 45-1983, f. 9-19-83, ef. 10-1-83; AFS 6-1984(Temp), f. 2-28-84, ef. 3-1-84; AFS 36-1984, f. & ef. 8-20-84; AFS 24-1985, f. 4-24-85, cert. ef. 6-1-85; AFS 33-1986, f. 4-11-86, ef. 6-1-86; AFS 43-1986, f. 6-13-86, ef. 7-1-86; AFS 57-1986, f. 7-25-86, ef. 8-1-86; AFS 14-1987, f. 5-31-87, ef. 4-1-87; AFS 38-1988, f. 5-17-88, cert. ef. 6-1-88; HR 2-1990, f. 2-12-90, cert. ef. 3-1-90, Renumbered from 461-013-0140, 461-013-0150, 461-013-0175 & 461-013-0180; HR 19-1990, f. & cert. ef. 7-9-90; HR 41-1991, f. & cert. ef. 10-1-91; HR 32-1993, f. & cert. ef. 11-1-93, Renumbered from 410-120-0040, 410-120-0260, 410-120-0280, 410-120-0300 & 410-120-0320; HR 31-1994, f. & cert. ef. 11-1-94; HR 5-1997, f. 1-31-97, cert. ef. 2-1-97; HR 21-1997, f. & cert. ef. 10-1-97; OMAP 20-1998, f. & cert. ef. 7-1-98; OMAP 10-1999, f. & cert. ef. 4-10-99; OMAP 31-1999, f. & cert. ef. 10-1-99; OMAP 35-2000, f. 9-29-00, cert. ef. 10-1-00; OMAP 30-2001, f. 9-24-01, cert. ef 10-1-01; OMAP 23-2002, f. 6-14-02 cert. ef. 8-1-02; OMAP 42-2002, f. & cert. ef. 10-1-02; OMAP 73-2002, f. 12-24-02, cert. ef. 1-1-03; OMAP 3-2003, f. 1-31-03, cert. ef. 2-1-03; OMAP 62-2003, f. 9-8-03, cert. ef.10-1-03; OMAP 10-2004, f. 3-11-04, cert. ef. 4-1-04; OMAP 10-2005, f. 3-9-05, cert. ef. 4-1-05; OMAP 39-2005, f. 9-2-05, cert. ef. 10-1-05; OMAP 67-2005, f. 12-21-05, cert. ef. 1-1-06; OMAP 15-2006, f. 6-12-06, cert. ef. 7-1-06; OMAP 45-2006, f. 12-15-06, cert. ef. 1-1-07; DMAP 34-2008, f. 11-26-08, cert. ef. 12-1-08; DMAP 39-2010, f. 12-28-10, cert. ef. 1-1-11; DMAP 49-2012, f. 10-31-12, cert. ef. 11-1-12; DMAP 61-2013, f. 10-31-13, cert. ef. 11-1-13

410-120-1400

Provider Sanctions

(1) The Authority recognizes two classes of provider sanctions, mandatory and discretionary, outlined in (3) and (4) respectively.

(2) Except as otherwise noted, the Authority will impose provider sanctions at the discretion of the Authority Director or the Administrator of the Division whose budget includes payment for the services involved.

(3) The Division of Medical Assistance Programs (Division) will impose mandatory sanctions and suspend the provider from participation in Oregon’s medical assistance programs:

(a) When a provider of medical services has been convicted (as that term is defined in 42 CFR 1001.2) of a felony or misdemeanor related to a crime, or violation of Title XVIII, XIX, or XX of the Social Security Act or related state laws;

(b) When a provider is excluded from participation in federal or state health care programs by the Office of the Inspector General of the U.S. Department of Health and Human Services or from the Medicare (Title XVIII) program of the Social Security Act as determined by the Secretary of Health and Human Services. The provider will be excluded and suspended from participation with Division for the duration of exclusion or suspension from the Medicare program or by the Office of the Inspector General;

(c) If the provider fails to disclose ownership or control information required under 42 CFR 455.104 that is required to be reported at the time the provider submits a provider enrollment application or when there is a material change in the information that must be reported, or information related to business transactions required to be provided under 42 CFR 455.105 upon request of federal or state authorities.

(4) The Division may impose discretionary sanctions when the Division determines that the provider fails to meet one or more of the Division’s requirements governing participation in its medical assistance programs. Conditions that may result in a discretionary sanction include, but are not limited to, when a provider has:

(a) Been convicted of fraud related to any federal, state, or locally financed health care program or committed fraud, received kickbacks, or committed other acts that are subject to criminal or civil penalties under the Medicare or Medicaid statutes;

(b) Been convicted of interfering with the investigation of health care fraud;

(c) Been convicted of unlawfully manufacturing, distributing, prescribing, or dispensing a controlled substance;

(d) By actions of any state licensing authority for reasons relating to the provider’s professional competence, professional conduct, or financial integrity either:

(A) Had his or her health care license suspended or revoked, or has otherwise lost such license; or

(B) Surrendered his or her license while a formal disciplinary proceeding is pending before such licensing authority.

(e) Been suspended or excluded from participation in any federal or state health care program for reasons related to professional competence, professional performance, or other reason;

(f) Billed excessive charges (i.e., charges in excess of the usual charge); furnished items or services substantially in excess of the Division client’s needs or in excess of those services ordered by a medical provider or in excess of generally accepted standards or of a quality that fails to meet professionally recognized standards;

(g) Failed to furnish medically necessary services as required by law or contract with the Division if the failure has adversely affected (or has a substantial likelihood of adversely affecting) the Division client;

(h) Failed to disclose required ownership information;

(i) Failed to supply requested information on subcontractors and suppliers of goods or services;

(j) Failed to supply requested payment information;

(k) Failed to grant access or to furnish as requested, records, or grant access to facilities upon request of the Division or the State of Oregon’s Medicaid Fraud Unit conducting their regulatory or statutory functions;

(l) In the case of a Hospital, failed to take corrective action as required by the Division, based on information supplied by the Quality Improvement Organization to prevent or correct inappropriate admissions or practice patterns, within the time specified by the Division;

(m) Defaulted on repayment of federal or state government scholarship obligations or loans in connection with the provider’s health profession education. The Division:

(A) Must have made a reasonable effort to secure payment;

(B) Must take into account access of beneficiaries to services; and

(C) Will not exclude a community’s sole physician or source of essential specialized services.

(n) Repeatedly submitted a claim with required data missing or incorrect:

(A) When the missing or incorrect data has allowed the provider to:

(i) Obtain greater payment than is appropriate;

(ii) Circumvent prior authorization requirements;

(iii) Charge more than the provider’s usual charge to the general public;

(iv) Receive payments for services provided to persons who were not eligible;

(v) Establish multiple claims using procedure codes that overstate or misrepresent the level, amount or type of health care provided.

(B) Does not comply with the requirements of OAR 410-120-1280.

(o) Failed to develop, maintain, and retain in accordance with relevant rules and standards adequate clinical or other records that document the medical appropriateness, nature, and extent of the health care provided;

(p) Failed to develop, maintain, and retain in accordance with relevant rules and standards adequate financial records that document charges incurred by a client and payments received from any source;

(q) Failed to develop, maintain and retain adequate financial or other records that support information submitted on a cost report;

(r) Failed to follow generally accepted accounting principles or accounting standards or cost principles required by federal or state laws, rules, or regulations;

(s) Submitted claims or written orders contrary to generally accepted standards of medical practice;

(t) Submitted claims for services that exceed that requested or agreed to by the client or the responsible relative or guardian or requested by another medical provider;

(u) Breached the terms of the provider contract or agreement. This includes failure to comply with the terms of the provider certifications on the medical claim form;

(v) Rebated or accepted a fee or portion of a fee or charge for a the Division client referral; or collected a portion of a service fee from the client, and billed the Division for the same service;

(w) Submitted false or fraudulent information when applying for a the Division assigned provider number, or failed to disclose information requested on the provider enrollment application;

(x) Failed to correct deficiencies in operations after receiving written notice of the deficiencies from the Division;

(y) Submitted any claim for payment for which payment has already been made by the Division or any other source unless the amount of the payment from the other source is clearly identified;

(z) Threatened, intimidated or harassed clients or their relatives in an attempt to influence payment rates or affect the outcome of disputes between the provider and the Division;

(aa) Failed to properly account for a Division client’s Personal Incidental Funds; including but not limited to using a client’s Personal Incidental Funds for payment of services which are included in a medical facility’s all-inclusive rates;

(bb) Provided or billed for services provided by ineligible or unsupervised staff;

(cc) Participated in collusion that resulted in an inappropriate money flow between the parties involved, for example, referring clients unnecessarily to another provider;

(dd) Refused or failed to repay, in accordance with an accepted schedule, an overpayment established by the Division;

(ee) Failed to report to Division payments received from any other source after the Division has made payment for the service;

(ff) Failure to comply with the requirements listed in OAR 410-120-1280, Billing.

(5) A provider who has been excluded, suspended or terminated from participation in a federal or state medical program, such as Medicare or Medicaid, or whose license to practice has been suspended or revoked by a state licensing board, shall not submit claims for payment, either personally or through claims submitted by any billing agent/service, billing provider or other provider, for any services or supplies provided under the medical assistance programs, except those services or supplies provided prior to the date of exclusion, suspension or termination.

(6) Providers must not submit claims for payment to the Division for any services or supplies provided by a person or provider entity that has been excluded, suspended or terminated from participation in a federal or state medical program, such as Medicare or Medicaid, or whose license to practice has been suspended or revoked by a state licensing board, except for those services or supplies provided prior to the date of exclusion, suspension or termination.

(7) When the provisions of subsections (5) or (6) are violated, the Division may suspend or terminate the billing provider or any individual performing provider within said organization who is responsible for the violation(s).

Stat. Auth.: ORS 413.042

Stats. Implemented: ORS 414.019, 414.025 & 414.065

Hist.: AFS 47-1982, f. 4-30-82 & AFS 52-1982, f. 5-28-82, ef. 5-1-82 for providers located in the geographical areas covered by the branch offices of North Salem, South Salem, Dallas, Woodburn, McMinnville, Lebanon, Albany and Corvallis, ef. 6-30-82 for remaining AFS branch offices; AFS 42-1983, f. 9-2-83, ef. 10-1-83; HR 2-1990, f. 2-12-90, cert. ef. 3-1-90, Renumbered from 461-013-0095; HR 32-1993, f. & cert. ef. 11-1-93, Renumbered from 410-120-0600; OMAP 39-2005, f. 9-2-05, cert. ef. 10-1-05; OMAP 15-2006, f. 6-12-06, cert. ef. 7-1-06; DMAP 61-2013, f. 10-31-13, cert. ef. 11-1-13

410-120-1860

Contested Case Hearing Procedures

(1) These rules apply to all contested case hearings provided by the Division of Medical Assistance Programs (Division) involving a client’s health care benefits, except as otherwise provided in OAR 410-141-0263. The hearings are conducted in accordance with the Attorney General’s model rules at 137-003-0501 and following. When the term “agency” is used in the Attorney General’s model rules, it shall refer to the Division for purposes of this rule Except for 137-003-0528(1)(a), the method described in 137-003-0520(8)-(10) is used in computing any period of time prescribed in this division of rules (OAR 410 division 120) applicable to timely filing of client requests for hearing. Due to operational conflicts, the procedures needing revision and the expense of doing so, 137-003-0528(1)(a), which allows hearing requests to be treated as timely based on the date of postmark, does not apply to Division contested cases.

(2) Medical provider appeals and administrative reviews involving the Division are governed by OAR 410-120-1560 through 410-120-1600.

(3) Complaints and appeals for clients requesting or receiving medical assistance from a Coordinated Care Organization (CCO) or Prepaid Health Plan (PHP) shall be governed exclusively by the procedures in OARs 410-141-3260 to 410-141-3262 and 410-141-0260 to 410-141-0262. This rule describes the procedures applicable when those clients request and are eligible for a Division contested case hearing.

(4) Contested Case Hearing Requests:

(a) A client has the right to a contested case hearing in the following situations upon the timely completion of a request for a hearing:

(A) The Authority acts to deny client services, payment of a claim, or to terminate, discontinue or reduce a course of treatment, or issues related to disenrollment in a CCO or PHP; or

(B) The right of a client to request a contested case hearing is otherwise provided by statute or rule, including OAR 410-141-0264 when a client of a PHP or 410-141-0364 when a client of a CCO may request a state hearing.

(b) To be timely, a request for a hearing is complete when the Division receives the Division approved appeal and hearing forms not later than the 45th day following the date of the decision notice;

(c) In the event a request for hearing is not timely, the Division will determine whether the client showed there was good cause, as defined in OAR 137-003-0501(7) for their failure to timely file the hearing request. In determining whether to accept a late hearing request, the Division requires the request to be supported by a written statement that explains why the request for hearing is late. The Division may conduct such further inquiry as the Division deems appropriate. If the Division finds that the client has good cause for late filing, the Division will refer the case to the OAH for a contested case hearing. The following factual disputes will be referred to the OAH for a hearing:

(A) Whether the hearing request was received timely;

(B) Whether the client received the notice of action;

(C) The information included in the client’s statement of good cause.

(d) In the event the claimant has no right to a contested case hearing on an issue, the Division may enter an order accordingly. The Division may refer a hearing request to the Office of Administrative Hearings for a hearing on the question of whether the claimant has a right to a contested case hearing;

(e) A client who requests a hearing shall be referred to as a claimant. The parties to a contested case hearing are the claimant and, if the claimant has requested a hearing about a decision of a CCO or PHP, the claimant’s CCO or PHP;

(f) A client may be represented by any of the persons identified in ORS 183.458. A CCO or PHP that is a corporation may be represented by any of the persons identified in ORS 410.190.

(5) Expedited hearings:

(a) A claimant who feels his or her medical or dental problem cannot wait for the normal review process may be entitled to an expedited hearing;

(b) Expedited hearings are requested using Authority Form 443 or other Division approved appeal and/or hearing request forms;

(c) Division staff will request all relevant medical documentation and present the documentation obtained in response to that request to the Division Medical Director or the Medical Director’s designee for review. The Division Medical Director or the Medical Director’s designee will decide if the claimant is entitled to an expedited hearing within, as nearly as possible, two working days from the date of receiving the documentation applicable to the request;

(d) An expedited hearing will be allowed, if the Division Medical Director or the Medical Director’s designee, determines that the claimant has a medical condition which is an immediate, serious threat to claimant’s life or health and claimant has been denied a medical service.

(6) Informal conference:

(a) The Division hearing representative and the claimant, and their legal representative if any, may have an informal conference, without the presence of the Administrative law Judge (ALJ), to discuss any of the matters listed in OAR 137-003-0575. The informal conference may also be used to:

(A) Provide an opportunity for the Division and the claimant to settle the matter;

(B) Provide an opportunity to make sure the claimant understands the reason for the action that is subject of the hearing request;

(C) Give the claimant and the Division an opportunity to review the information that is the basis for that action;

(D) Inform the claimant of the rules that serve as the basis for the contested action;

(E) Give the claimant and the Division the chance to correct any misunderstanding of the facts;

(F) Determine if the claimant wishes to have any witness subpoenas issued for the hearing; and

(G) Give the Division an opportunity to review its action.

(b) The claimant may, at any time prior to the hearing date, request an additional informal conference with the Authority representative, which may be granted if the Authority representative finds, in his or her sole discretion, that the additional informal discussion will facilitate the hearing process or resolution of disputed issues;

(c) The Division may provide to the claimant the relief sought at any time before the Final Order is served;

(d) Any agreement reached in an informal conference shall be submitted to the ALJ in writing or presented orally on the record at the hearing.

(7) A claimant may withdraw a hearing request at any time. The withdrawal is effective on the date it is received by the Division or the ALJ, whichever is first. The ALJ will send a Final Order confirming the withdrawal to the claimant’s last known address. The claimant may cancel the withdrawal up to the tenth calendar day following the date such an order is effective.

(8) Contested case hearings are closed to non-participants in the hearing; however, a client may choose to have another person present.

(9) Proposed and Final Orders:

(a) In a contested case, an ALJ assigned by the Office of Administrative Hearings will serve a proposed order on all parties and the Division, unless, prior to the hearing, the Division notifies the ALJ that a final order may be served. The proposed order issued by the ALJ will become a final order if no exceptions are filed within the time specified in subsection (b) unless the Division notifies the parties and the ALJ that the Division will issue the final order;

(b) If the ALJ issues a proposed order, a party adversely affected by the proposed order may file exceptions to the proposed order or present argument for the Division’s consideration:

(A) The exceptions must be in writing and reach the Division not later than 10 working days after date the proposed order is issued by the ALJ;

(B) After receiving the exceptions, if any, the Division may adopt the proposed order as the final order or may prepare a new order. Prior to issuing the final order, the Authority will issue an amended proposed order.

(10) A hearing request is dismissed by order when neither the party nor the party’s legal representative, if any, appears at the time and place specified for the hearing. The order is effective on the date scheduled for the hearing. The Division will cancel the dismissal order on request of the party upon the party being able to show good cause, as defined in OAR 137-003-0501(7), as to why they were unable to attend the hearing and unable to request a postponement.

(11) The final order is effective immediately upon being signed or as otherwise provided in the order. A final order resulting from the claimant’s withdrawal of the hearing request is effective the date the claimant withdraws. When claimant fails to appear for the hearing and the hearing request is dismissed by final order, the effective date of the order is the date of the scheduled hearing.

(12) All contested case hearing decisions are subject to judicial review under ORS 183.482 in the Court of Appeals.

[ED. NOTE: Forms referenced are available from the agency.]

Stat. Auth.: ORS 183.341 & 413.042

Stats. Implemented: ORS 183.411 - 183.470, 414.025, 414.055 & 414.065

Hist.: AFS 47-1982, f. 4-30-82 & AFS 52-1982, f. 5-28-82, ef. 5-1-82 for providers located in the geographical areas covered by the branch offices of North Salem, South Salem, Dallas, Woodburn, McMinnville, Lebanon, Albany and Corvallis, ef. 6-30-82 for remaining AFS branch offices; AFS 13-1984(Temp), f. & ef. 4-2-84; AFS 37-1984, f. 8-30-84, ef. 9-1-84; HR 2-1990, f. 2-12-90, cert. ef. 3-1-90, Renumbered from 461-013-0053; HR 19-1990, f. & cert. ef. 7-9-90; HR 35-1990(Temp), f. & cert. ef. 10-15-90; HR 32-1990, f. 9-24-90, cert. ef. 10-1-90; HR 41-1990, f. & cert. ef. 11-26-90; HR 11-1991(Temp), f. & cert. ef. 3-1-91; HR 34-1991, f. & cert. ef. 8-26-91; HR 32-1993, f. & cert. ef. 11-1-93, Renumbered from 410-120-0760; HR 7-1996, f. 5-31-96 & cert. ef. 6-1-96; HR 5-1997, f. 1-31-97, cert. ef. 2-1-97; OMAP 41-2000, f. & cert. ef. 12-1-00; OMAP 39-2005, f. 9-2-05, cert. ef. 10-1-05; DMAP 6-2012(Temp), f. & cert. ef. 2-1-12 thru 7-4-12; DMAP 28-2012, f. 6-21-12, cert. ef. 7-1-12; DMAP 49-2012, f. 10-31-12, cert. ef. 11-1-12; DMAP 61-2013, f. 10-31-13, cert. ef. 11-1-13


Rule Caption: Rules related to Substance Use Disorder Residential Treatment Managed Care Enrollment Process and Procedures

Adm. Order No.: DMAP 62-2013(Temp)

Filed with Sec. of State: 10-31-2013

Certified to be Effective: 11-1-13 thru 4-30-14

Notice Publication Date:

Rules Adopted: 410-141-0065, 410-141-3065

Subject: The Division intends to amend the above rules to clarify the Substance Use Disorder Residential Treatment Services managed care enrollment process and procedures. All other revisions are to clarify current policy or for housekeeping purposes.

Rules Coordinator: Sandy Cafourek—(503) 945-6430

410-141-0065

Fully Capitated Health Plan or Physician Care Organization (FCHP or PCO) Enrollment Requirements for Individuals Receiving Residential Substance Use Disorder (SUD) Treatment Services

This rule implements and further describes how the Oregon Health Authority (Authority) will administer its authority under 410-141-0060 for purposes of making enrollment decisions and 410-141-0080 for purposes of making disenrollment decisions for the adult and adolescent individuals receiving residential SUD treatment services;

(1) The Authority has determined that, to the maximum extent possible, all individuals should be enrolled at the next available enrollment date following eligibility, redetermination, or upon review by the Authority, unless disenrollment is authorized by the Authority in accordance with this section, OAR 410-141-0050 and 410-141-0080

(2) If the Authority determines that disenrollment should occur, the FCHP or PCO will continue to be responsible for providing covered services until the disenrollment date established by the Authority, which shall provide for an adequate transition to the next responsible FCHP or PCO when applicable.

(3) It is not unusual for individuals to receive residential SUD treatment services outside of their residential or home county and outside of the FCHP or PCO’s delivery service area. Receiving residential SUD treatment is considered a temporary absence from the individual’s residential or home county and does not represent a change of residence or a change in enrollment when the individual is reasonably likely to return to the FCHP or PCO’s delivery service area at the end of the residential treatment stay.

(4) If the individual is enrolled in a FCHP or PCO on the same day the individual is admitted to the residential treatment services, the managed care organization shall be responsible for the covered services during that placement even if the location of the facility is outside of the FCHP or PCO’s service area;

(5) The individual is presumed to continue to be enrolled in the FCHP or PCO with which the individual was most recently enrolled. An admission to a residential SUD facility is deemed a temporary placement and does not constitute a change of residence for the purposes of FCHP or PCO enrollment and does not constitute a basis for disenrollment from the FCHP or PCO, notwithstanding OAR 410-141-0080(2)(b)(F). If the Authority determines that an individual was disenrolled for reasons not consistent with these rules, the Authority will re-enroll the individual with the appropriate FCHP or PCO and assign an enrollment date that provides for continuous FCHP or PCO coverage with the appropriate FCHP or PCO. If the individual was enrolled in a different FCHP or PCO in error, the Authority will disenroll the individual and recoup the capitation payments.

(6) If the individual is enrolled in a FCHP or PCO after the first day of an admission to a residential SUD treatment service facility, the individual will be retro effectively disenrolled from the FCHPO or PCO, and capitation will be recouped. The date of enrollment shall be effective the next available enrollment date following discharge from the residential FCHP or PCO treatment service facility.

Stat. Auth.: ORS 414.042

Stats. Implemented: ORS 414.042

Hist.: DMAP 62-2013(Temp), f. 10-31-13, cert. ef. 11-1-13 thru 4-30-14

410-141-3065

Coordinated Care Organization (CCO) Enrollment Requirements for Individuals Receiving Residential Substance Abuse Disorder (SUD) Treatment Services

This rule implements and further describes how the Oregon Health Authority (Authority) will administer its authority under 410-141-3060 for purposes of making enrollment decisions and 410-141-3080 for purposes of making disenrollment decisions for adult and adolescent individuals receiving residential SUD treatment services;

(1) The Authority has determined that, to the maximum extent possible, all individuals should be enrolled at the next available enrollment date following eligibility, redetermination, or upon review by the Authority. Unless disenrollment is authorized by the Authority in accordance with this section, OAR 410-141-3050 or 410-141-3080. If the Authority determines that disenrollment should occur, the CCO will continue to be responsible for providing covered services until the disenrollment date established by the Authority, which shall provide for an adequate transition to the next responsible managed care organization when applicable.

(2) It is not unusual for individuals to receive residential SUD treatment services outside of their residential/home county and outside of the coordinated care organization’s delivery service area. Receiving residential SUD treatment is considered a temporary absence from the individual’s residential/home-county and does not represent a change of residence or a change in enrollment when the individual is reasonably likely to return to the coordinated care organization’s delivery service area at the end of the residential treatment stay.

(3) If the individual is enrolled in a coordinated care organization on the same day the individual is admitted to the residential treatment services, the CCO shall be responsible for the covered services during that placement even if the location of the facility is outside of the CCO’s service area; The individual is presumed to continue to be enrolled in the CCO with which the individual was most recently enrolled. An admission to a residential SUD facility is deemed a temporary placement and does not constitute a change of residence for the purposes of CCO enrollment and does not constitute a basis for disenrollment from the CCO, notwithstanding OAR 410-141-3080. If the Authority determines that an individual was disenrolled for reasons not consistent with these rules, the Authority will re-enroll the individual with the appropriate CCO and assign an enrollment date that provides for continuous CCO coverage with the appropriate CCO. If the individual was enrolled in a different CCO in error, the Authority will disenroll the individual from that CCO and recoup the capitation payments.

(4) If the individual is enrolled in a CCO after the first day of an admission to a residential SUDs treatment service facility, the individual will be retro disenrolled from the CCO, and any capitation payment will be recouped. The date of enrollment shall be effective the next available enrollment date following discharge from the residential SUD treatment service facility.

Stat. Auth.: ORS 414.042

Stats. Implemented: ORS 414.042

Hist.: DMAP 62-2013(Temp), f. 10-31-13, cert. ef. 11-1-13 thru 4-30-14


Rule Caption: Describe program requirements for Behavior Rehabilitation Services Program

Adm. Order No.: DMAP 63-2013

Filed with Sec. of State: 11-14-2013

Certified to be Effective: 1-1-14

Notice Publication Date: 10-1-2013

Rules Adopted: 410-170-0000, 410-170-0010, 410-170-0020, 410-170-0030, 410-170-0040, 410-170-0050, 410-170-0060, 410-170-0070, 410-170-0080, 410-170-0090, 410-170-0100, 410-170-0110, 410-170-0120

Subject: Administrative rules need to be put in place for the Behavior Rehabilitation Services (BRS) Program, as no rules currently exist. These rules describe the general program requirements for the BRS Program, prior authorization process, Services and Placement Related Activities, BRS Contractor and BRS Provider requirements, reimbursement rates, and compliance and oversight activities.

Rules Coordinator: Sandy Cafourek—(503) 945-6430

410-170-0000

Effective Date and Administration of the BRS Program

(1) OAR 410-170-0000 through 410-170-0120 are effective on January 1, 2014.

(2) All BRS contractor’s and BRS provider’s programs must meet the requirements in the BRS program general rules (OAR 410-170-0000 through 410-170-0120). Additional agency-specific BRS program rules for the Department of Human Services are contained in 413-090-0055 through 413-090-0090, and for the Oregon Youth Authority are contained in 416-335-0000 through 416-335-0100.

(3) All references to federal and state laws and regulations referenced in these rules are those in place on November 13, 2013, and the agency-specific BRS program rules that are effective on January 1, 2014.

(4) Delegation of Authority: The Oregon Health Authority may delegate authority to another agency or a unit of government to carry out some of its obligations under these rules.

Stat. Auth.: ORS 183.355, 413.042 & 414.065

Stats. Implemented: ORS 414.065

Hist.: DMAP 63-2013, f. 11-14-13, cert. ef. 1-1-14

410-170-0010

Purpose

The purpose of the Behavior Rehabilitation Services (BRS) Program is to remediate the BRS client’s debilitating psychosocial, emotional and behavioral disorders by providing such services as behavioral intervention, counseling, and skills-training. These rules describe the general program requirements for the BRS program, prior authorization process, services and placement related activities, BRS contractor and BRS provider requirements, reimbursement rates, and compliance and oversight activities.

Stat. Auth.: ORS 413.042, 414.065

Stats. Implemented: ORS 414.065

Hist.: DMAP 63-2013, f. 11-14-13, cert. ef. 1-1-14

410-170-0020

Definitions

The following definitions apply to terms used in OAR 410-170-0000 through 410-170-0120.

(1) Agency means the state agency that has a contract with the BRS contractor to provide services and placement related activities to the BRS client, and provides prior authorization for the BRS client to receive services and placement related activities pursuant to the BRS program general rules and, as applicable, agency-specific BRS program rules. The agency will be one of the following state agencies: the Department of Human Services, the Oregon Health Authority, or the Oregon Youth Authority.

(2) Approved provider parent means an individual who a BRS contractor, a BRS provider, or OYA has approved to provide services or placement related activities to the BRS client in the home of that individual. Approved provider parents who provide services are considered direct care staff, and must meet those qualifications in OAR 410-170-0030(4).

(3) Behavior Rehabilitation Services (BRS) program is a program that provides services and placement related activities to the BRS client to address their debilitating psychosocial, emotional and behavioral disorders in a community placement utilizing either a residential care model or therapeutic foster care model.

(4) Billable care day means each calendar day the BRS client is in the direct care of the BRS provider at 11:59 p.m. or meets the requirements in OAR 410-170-0110.

(5) BRS client means the person who has prior authorization from an agency to receive services or placement related activities through the BRS program in accordance with the BRS program general rules, and as applicable agency-specific BRS program rules.

(6) BRS contractor means the entity contracted with an agency to be responsible for providing services and placement related activities to the BRS client. The BRS contractor may also be the BRS provider if it provides direct services and placement related activities to the BRS client.

(7) BRS provider means a facility, institution, corporate entity, or other organization that provides direct services and placement related activities to the BRS client.

(8) BRS type of care means the type of program model, services, placement related activities, staffing requirements and qualifications which are necessary to meet the medical and other needs of the BRS client.

(9) Caseworker means the individual who coordinates the services and placement related activities for the BRS client with the BRS contractor and BRS provider.

(10) Child or children means a person or persons under 18 years of age.

(11) Children’s health insurance program (CHIP) means the federal and state funded portion of the Oregon Health Plan (OHP) established by Title XXI of the Social Security Act and administered by the Authority.

(12) Designated LPHA means a licensed practitioner of the healing arts, who has a contract with, is approved by, or is employed by the agency to make a determination on the medical appropriateness of the BRS program for the BRS client.

(13) DHS or Department means the Department of Human Services, Child Welfare.

(14) Direct care staff means an individual who is employed by or who has a contract or an agreement with the BRS provider, and is responsible for assisting social service staff in providing individual and group counseling, skills-training and therapeutic interventions, and monitoring and managing the BRS client’s behavior to provide a safe, structured living environment that is conducive to treatment.

(15) Initial service plan (ISP) means the initial written individualized services plan, developed by the BRS contractor or BRS provider, identifying the services that must be provided to the BRS client during the first 45 days in its BRS program or until the master service plan is written. Additional requirements are described in OAR 410-170-0070.

(16) Licensed practitioner of the healing arts (LPHA) means a physician or other practitioner licensed in the State of Oregon who is authorized within the scope of his or her practice, as defined under state law, to diagnose and treat individuals with physical or mental disabilities, or psychosocial, emotional and behavioral disorders.

(17) Master service plan (MSP) means the written individualized services plan, developed by the BRS contractor or BRS provider, identifying the services that must be provided to the BRS client in its BRS program. Additional requirements are described in OAR 410-170-0070.

(18) Medicaid means the federal and state funded portion of the medical assistance programs established by Title XIX of the Social Security Act, as amended, administered in Oregon by the Authority.

(19) OHA or Authority means the Oregon Health Authority. The Authority is the agency established in ORS Chapter 413 that administers the funds for Titles XIX and XXI of the Social Security Act. It is the single state agency for the administration of the medical assistance program under ORS chapter 414. For purposes of these rules, the agencies under the authority of the Authority are the Public Health Division, the Addictions and Mental Health Division, and the Division of Medical Assistance Programs.

(20) OYA means the Oregon Youth Authority.

(21) Physical restraint means the act of restricting the BRS client’s voluntary movement as an emergency measure to manage and protect the BRS client or others from injury when no alternate actions are sufficient to manage the BRS client’s behavior. Physical restraint does not include temporarily holding a BRS client to assist him or her or assure his or her safety, such as preventing a child from running onto a busy street.

(22) Placement related activities means the BRS contractor’s or BRS provider’s activities related to the operation of the program and the care of the BRS client as set forth in the BRS program general rules, applicable agency-specific BRS program rules, the contract or agreement with the agency or the BRS contractor, and applicable federal and state licensing and regulatory requirements. Placement related activities may include but are not limited to providing the BRS client with: food, clothing, shelter, daily supervision, access to educational, cultural and recreational activities; and case management. Room and board is not funded by Medicaid or CHIP.

(23) Private child-caring agency is defined by the definitions in ORS 418.205, and means a “child-caring agency” that is not owned, operated, or administered by any governmental agency or unit:

(a) A child-caring agency means an agency or organization providing:

(A) Day treatment for disturbed children;

(B) Adoption placement services;

(C) Residential care, including but not limited to foster care or residential treatment for children;

(D) Outdoor youth programs (defined at OAR 413-215-0911); or

(E) Other similar services for children;

(b) A child-caring agency does not include residential facilities or foster care homes certified or licensed by the Department under ORS 443.400 to 443.455, 443.830 and 443.835 for children receiving developmental disability services.

(24) Proctor parent means an approved provider parent who is certified by OYA and a private child-caring agency in accordance with the applicable provisions in OAR 416-530-0000 through 416-530-0200 and 416-550-0000 through 416-550-0080, and who is employed by or who has a contract or agreement with the private child-caring agency to provide some services and placement related activities to the BRS client in the individual’s home.

(25) Program coordinator or program director means an individual employed by or contracted with the BRS provider, and is responsible for supervising staff, providing overall direction to the BRS provider, planning and coordinating program activities and delivery of services and placement related activities, and ensuring the safety and protection of the BRS client and the BRS provider’s staff.

(26) Public child-caring agency means, for purposes of this rule, an agency or institution operated by a governmental agency or unit other than DHS, OYA, or OHA, which provides care to the BRS client in a residential community setting.

(27) Residential care model means that services and placement related activities are provided to the BRS client in a residential community setting and not in the home of an approved provider parent.

(28) Respite care means a formal planned arrangement to relieve an approved provider parent’s responsibilities by an individual temporarily assuming responsibility for the care and supervision of the BRS client in the home of the respite provider or approved provider parent. Respite care must be less than 14 consecutive days.

(29) Seclusion means the involuntary confinement of a BRS client to an area or room from which the BRS client is physically prevented from leaving.

(30) Services means the treatment provided to the BRS client in a BRS provider’s program, including but not limited to treatment planning, individual and group counseling, skills-training, and parent training.

(31) Social service staff means an individual employed by or contracted with the BRS provider, and is responsible for case management and the development of the ISP or MSP for the BRS client; individual, group and family counseling; individual and group skills-training; assisting the direct care staff in providing appropriate treatment to the BRS client; coordinating services with other agencies; and documenting the BRS client’s treatment progress.

(32) Therapeutic foster care model means services and placement related activities are provided to the BRS client who resides in the home of an approved provider parent.

(33) Total daily rate means the total amount of the service payment and placement related activities payment for a billable care day.

(34) Young adult means a person aged 18 through 20 years.

Stat. Auth.: ORS 413.042, 414.065

Stats. Implemented: ORS 414.065

Hist.: DMAP 63-2013, f. 11-14-13, cert. ef. 1-1-14

410-170-0030

BRS Contractor and BRS Provider Requirements

(1) Conditions of BRS contractor and BRS provider participation. The BRS contractor must ensure that itself and its BRS providers meet the following minimum requirements:

(a) Have the necessary current and valid licenses, approvals or certifications required by federal or state law or regulations for the entity and its staff to operate a BRS program;

(b) Have a license to operate a private child-caring agency or be approved by the Department of Human Services’ Office of Licensing and Regulatory Oversight to operate a public child-caring agency;

(c) Comply with all federal and state laws and regulations required to be a licensed or an approved foster care agency under OAR 413-215-0301 to 413-215-0396 or residential care agency under OAR 413-215-0501 to 413-215-0586 and, if the BRS client is a person age 18 or older, comply with the licensing or approval requirements that would apply if the BRS client was a child;

(d) Comply with the provider enrollment requirements in OAR 410-120-1260;

(e) Comply with the requirements in OAR 410-120-1380(1)(c)(J) for excluding individuals and entities from being subcontractors if they are found on the listed exclusion list(s); and

(f) Have a contract or agreement with an agency, or as applicable a BRS contractor, to provide services and placement related activities to the BRS client.

(2) Compliance with Federal and State Law. The BRS contractor must, and must ensure its BRS providers, comply with all applicable federal and state laws and regulations pertaining to the provision of Medicaid services under the Medicaid Act, Title XIX, 42 USC 1396 et seq. and the BRS program, including but not limited to all applicable provisions in OAR 410-120-0000 through 410-120-1980.

(3) Confidentiality of BRS client information:

(a) Confidentiality Generally: The BRS contractor must not, and ensure its BRS providers do not, use or disclose any information concerning a BRS client for any purpose not directly connected with the administration of the BRS contractor’s or BRS provider’s program or as otherwise permitted by law, except with the written consent of the agency, or if the agency is not the BRS client’s guardian, on the written consent of the person or persons authorized by law to consent to such use or disclosure. The BRS contractor must, and must require its employees and BRS providers to, comply with all appropriate federal and state laws, rules and regulations regarding the confidentiality of records related to the BRS client;

(b) HIPAA Compliance and Medical Privacy. The BRS contractor must, and ensure its BRS providers, comply with all applicable confidentiality requirements in the Health Insurance Portability and Accountability Act (HIPAA) of 1996 (Public Law 104-191, August 21, 1996) and its implementing regulations in 45 CFR 160 and 164 et. seq., and all applicable confidentiality requirements in state statutes and administrative rules, including but not limited to ORS 179.505 and OAR chapter 410, division 120;

(c) Maintenance of Written Records: The BRS contractor must, and ensure its BRS providers, appropriately secure all records and files related to BRS clients to prevent access by unauthorized persons or entities;

(d) Disclosure to the agency, Authority or other governmental oversight or licensing entities:

(A) The BRS contractor must, and ensure its BRS providers, promptly provide access to any information or written documentation in its possession related to the BRS client or its BRS program upon the request of the agency for any reason; and

(B) The BRS contractor must, and ensure its BRS providers, promptly provide access to any information or written documentation in its possession related to the BRS client or its BRS program that is necessary for the purpose of evaluating, overseeing or auditing the BRS contractor’s program upon the request of the Authority or other governmental oversight or licensing entities.

(4) Staff Qualifications. The BRS contractor must ensure that its BRS program, either operated by itself or by its BRS provider, has a program coordinator, social service staff, and direct care staff who meet and maintain the following minimum qualifications:

(a) No less than 50% of the direct care staff for a BRS provider must have a Bachelor’s degree from an accredited college or university. A combination of formal education and experience with children or young adults may be substituted for a Bachelor’s degree. Direct care staff must be under the direction of a qualified social service staff member or a program coordinator;

(b) Direct care staff, social service staff, and the program coordinator, who directly work with BRS clients, must:

(A) Receive a minimum of 28 hours of initial training prior to or within 30 days of employment or certification on the following topics: BRS services documentation, mandatory reporting of child abuse, program policies and expectations, gender- and cultural-specific services, behavior and crisis management, medication administration, discipline and restraint policies, and suicide prevention. Any direct care staff, social service staff, or program coordinator who has not yet completed this initial training prior to employment or certification, must be supervised by a person who has completed this training when having direct contact with BRS clients; and

(B) Receive a minimum of 16 hours of training annually on the following topics: skills-training that supports evidence-based or promising practices, and other subjects relevant to the responsibilities of providing services and placement related activities to the BRS client; and

(C) Have and maintain cardiopulmonary resuscitation (CPR) and first aid certification;

(c) The program coordinator or program director must have a Bachelor’s degree from an accredited college or university, preferably with major study in psychology, sociology, social work, social sciences, or a closely allied field, and two years of experience in the supervision and management of a residential facility for the care and treatment of children or young adults;

(d) Social service staff must have a Master’s degree from an accredited college or university with major study in social work or a closely allied field and one year of experience in the care and treatment of children or young adults; or have a Bachelor’s degree with major study in social work, psychology, sociology or a closely allied field and two years of experience in the care and rehabilitation of children or young adults.

(5) Fitness Determination:

(a) The BRS contractor and BRS provider must ensure that its employees, volunteers, contractors, vendors, approved provider parents, or other persons providing services or placement related activities to BRS clients, comply with all applicable criminal record and child abuse background checks and any fitness determination process required by federal or state law or regulation;

(b) The BRS contractor and the BRS provider must ensure that its employees, volunteers, contractors, vendors, approved provider parents, or other persons providing services or placement related activities to BRS clients, who have not yet successfully completed the requirements in section (5)(a) of this rule, are supervised by a person who has successfully met these requirements when having direct contact with BRS clients;

(c) Except in cases where more stringent legal requirements apply, the BRS contractor and BRS provider must ensure that its employees, volunteers, contractors, vendors, approved provider parents, or other persons providing services or placement related activities to BRS clients, report to it any arrests or court convictions, any known allegation of child abuse or neglect, and any other circumstance that could reasonably affect a fitness determination within one business day. The BRS contractor and BRS provider must report this information to the agency on the same day it receives the information.

(6) Mandatory Reporting:

(a) The BRS contractor and BRS provider must comply with the child abuse reporting laws in ORS 419B.010 through 419B.050;

(b) The BRS contractor and BRS provider must require any staff member, including employees, volunteers, subcontractors, approved provider parents, or other persons providing services or placement related activities to BRS clients, to immediately make a report or cause a report to be made under ORS 419B.015 anytime the staff member has reasonable cause to believe that any child with whom the staff member comes in contact has suffered abuse, as defined by 419B.005(1), or that any person with whom the staff member comes in contact has abused a child;

(c) The BRS contractor and BRS provider must train their staff regarding child abuse reporting requirements;

(d) The BRS contractor must ensure that its BRS provider complies with the requirements of this section.

(7) Communication:

(a) The BRS contractor must ensure that its BRS program, either operated by itself or by its BRS provider, maintains a system for immediate and on-going communication amongst program staff regarding the whereabouts, status and condition of the BRS clients in its program;

(b) The BRS contractor must ensure that direct care staff and social service staff have access to a BRS client’s information to the extent it is relevant to providing the BRS client with services and placement related activities;

(c) The BRS contractor must provide, or ensure that its BRS provider provides, immediate verbal notification to the caseworker and the agency (if an additional contact person is designated) when there is a communication outage at the program, and must provide an alternative means by which the program may be contacted, if possible.

(8) Staffing Requirements:

(a) Supervision of BRS clients: The BRS contractor must ensure that its BRS program, either operated by itself or by its BRS provider, meets and maintains appropriate staffing levels to ensure supervision of the BRS clients in its program at all times (24 hours a day, 7 days a week), including taking steps to ensure that a BRS client is supervised while temporarily outside of the program. The BRS provider must not leave a BRS client unsupervised, except in cases where there is a service plan for the BRS client to be out of the BRS provider’s direct supervision;

(b) Therapeutic Foster Care Model:

(A) The Authority’s or the Department’s BRS contractors. The BRS contractor must ensure that its BRS program, either operated by itself or by its BRS provider, meets and maintains the following adult to child ratios in its therapeutic foster care homes:

(i) Shelter Evaluation and Assessment and Independent Living Services:

(I) A maximum of 3 BRS clients shall be placed in the home of an approved provider parent;

(II) A maximum of 5 children (including both BRS clients and non-BRS clients) and young adults (BRS clients only) shall live in an approved provider parent home with two parents;

(III) A maximum of 4 children (including both BRS clients and non-BRS clients) and young adults (BRS clients only) shall live in an approved provider parent home with one parent; and

(IV) No more than two children (including both BRS clients and non-BRS clients) under the age of three shall live in an approved provider parent home;

(ii) Intensive Community Care, Therapeutic Foster Care, and Enhanced Therapeutic Foster Care:

(I) A maximum of 2 BRS clients shall be placed in the home of an approved provider parent;

(II) A maximum of 5 children (including both BRS clients and non-BRS clients) and young adults (BRS clients only) shall live in an approved provider parent home with two parents;

(III) A maximum of 4 children (including both BRS clients and non-BRS clients) and young adults (BRS clients only) shall live in an approved provider parent home with one parent; and

(IV) No more than two children (including both BRS clients and non-BRS clients) under the age of three shall live in an approved provider parent home;

(iii) Notwithstanding section (8)(b)(A)(i) and (ii) of this rule, the BRS contractor or BRS provider may exceed these limits on the maximum number of children and young adults who shall live in a home when the approved provider parent is providing respite care;

(B) OYA’s BRS contractors. The BRS contractor must ensure that its BRS program, either operated by itself or by its BRS provider, meets and maintains the adult to child or young adult ratios described in OYA-specific BRS program rules for therapeutic foster care homes;

(c) Residential Care Model: The BRS contractor must ensure that its BRS program, either operated by itself or by its BRS provider, meets and maintains the following direct care staff to BRS client ratios for the BRS type of care it provides in its residential care BRS program:

(A) Shelter Assessment and Evaluation, Intensive Community Care, and Independent Living Service: During scheduled school days, weekends and non-scheduled school days, the program must:

(i) Have 1 direct care staff member for every 7 BRS clients onsite between 7 a.m. and 3 p.m.;

(ii) Have 1 direct care staff member for every 4.7 BRS clients onsite between 3 p.m. and 11 p.m.; and

(iii) Have 1 direct care staff member for every 9.3 BRS clients onsite between 11 p.m. and 7 a.m.;

(B) Community Step-Down, Independent Living Program, and BRS Basic Residential and Rehabilitation Services:

(i) During scheduled school days, the program must:

(I) Have 1 direct care staff member for every 7 BRS clients onsite between 7 a.m. and 3 p.m.;

(II) Have 1 direct care staff member for every 4.7 BRS clients onsite between 3 p.m. and 11 p.m.;

(III) Have 1 direct care staff member for every 9.3 BRS clients onsite between 11 p.m. and 7 a.m.; and

(ii) During weekends and non-scheduled school days, the program must:

(I) Have 1 direct care staff member for every 4.7 BRS clients onsite between 7 a.m. and 3 p.m.;

(II) Have 1 direct care staff member for every 4.7 BRS clients onsite between 3p.m. and 11 p.m.;

(III) Have 1 direct care staff member for every 9.3 BRS clients onsite between 11 p.m. and 7 a.m.;

(C) Intensive Rehabilitation Residential Services, BRS Residential, BRS Enhanced, and Short-Term Stabilization Program:

(i) During scheduled school days, the program must:

(I) Have 1 direct care staff member for every 7 BRS clients onsite between 7 a.m. and 3 p.m.;

(II) Have 1 direct care staff member for every 2.8 BRS clients onsite between 3 p.m. and 11 p.m.;

(III) Have 1 direct care staff member for every 9.3 BRS clients onsite between 11 p.m. and 7 a.m.; and

(ii) During weekends and non-scheduled school days, the program must:

(I) Have 1 direct care staff member for every 4.7 BRS clients onsite between 7 a.m. and 3 p.m.;

(II) Have 1 direct care staff member for every 2.8 BRS clients onsite between 3 p.m. and 11 p.m.;

(III) Have 1 direct care staff member for every 9.3 BRS clients onsite between 11 p.m. and 7 a.m.;

(d) For purposes of calculating the number of direct care staff under section (8)(c) of this rule only, a social service staff member or program coordinator may be included if that staff member is specifically scheduled to and actually provides direct supervision to BRS clients onsite during the relevant time period;

(e) Under section (8)(c) of this rule only, in the event that no BRS clients are onsite at the program due to home visits or other planned absences, the BRS contractor and BRS provider must ensure that its program has the resources and procedures in place to serve the BRS client who may need to return to the program prior to the scheduled return date;

(f) In the event a BRS client is temporarily admitted to a hospital (other than to a psychiatric hospital) but is still enrolled in the BRS provider’s program, the BRS contractor and BRS provider must ensure that its program works with the caseworker, and the family when appropriate, to develop a plan approved by the agency for supervision during the BRS client’s hospitalization;

(g) The BRS contractor may, or allow its BRS provider to, request prior written agency approval for its BRS program to deviate from the ratios described in section (8)(b) and (c) of this rule or agency-specific BRS program rules. If the agency grants a waiver, this shall only apply to BRS program ratio requirements specified in these rules and agency-specific BRS program rules. The BRS contractor and BRS provider must comply with any ratio requirements applicable under federal or state licensing requirements or approvals;

(9) Physical Facility. The BRS contractor must ensure that its BRS program, either operated by itself or by its BRS provider, do the following:

(a) Provide an environment suitable for the treatment of a BRS client, which meets all applicable safety, health and general environment standards required for a residential community setting, if services are provided to the BRS client in a residential care model, or in the home of an approved provider parent certified by the BRS provider, if services are provided to the BRS client in a therapeutic foster care model;

(b) Provide separate bedrooms for children and persons 18 years or older, except in cases where the child shares a bedroom with a young adult who is the child’s parent and caregiver or where there is written approval from the Department of Human Services’ Office of Licensing and Regulatory Oversight Coordinator and the agency;

(c) Provide separate bedrooms for BRS clients who have inappropriate sexual behaviors identified in their service plan and BRS clients who do not have those behaviors identified in their service plan, unless there is written approval from the agency;

(d) Provide that BRS clients, who have inappropriate sexual behaviors identified in their service plan, occupy a bedroom either individually or in a group of three or more BRS clients who have inappropriate sexual behaviors identified in their service plan, unless there is written approval from the agency;

(e) Provide separate bedrooms for BRS clients and other members of the household unless there is written approval from the agency;

(f) Provide separate bedrooms or dormitories for females and males;

(g) Provide physical separation of BRS clients served in its BRS program from persons housed in a detention facility or youth correction facility;

(h) Provide that at least one door in each bedroom is unlocked at all times;

(i) Provide that at least one door in each dormitory is unlocked at all times, unless the BRS contractor or BRS provider receives prior written agency approval to lock all dormitory doors for eight hours at night; and

(j) Provide a means of egress for BRS clients to leave the facility.

(10) BRS providers and BRS contractors are not required to comply with (9)(b) and (c) of this rule if they provide services or placement related activities in a dormitory setting.

(11) BRS Program Policies and Procedures:

(a) The BRS contractor must ensure that its BRS program, either operated by itself or by its BRS provider, has the following written policies and procedures, which have been reviewed and approved by the agency:

(A) Admission criteria and standards to accept a BRS client into its program;

(B) Staff training policies and procedures, including child abuse reporting expectations under ORS 419B.005, 419B.010 and 419B.015;

(C) Policies and procedures related to reviewing referrals to its program and notification of admission decisions;

(D) A behavior management system policy designed to consistently encourage appropriate behaviors by the BRS client in a non-punitive manner;

(E) A behavioral rehabilitation program model that uses evidence-based or promising practices whenever possible and the curriculum, policies, and procedures which implement that model;

(F) Policies regarding the BRS client’s and family’s rights, including but not limited to the search and seizure of the BRS client’s person, property, and mail; visitation and communication; and discharges initiated by the BRS client;

(G) A grievance policy describing the process through which the BRS client, and, if applicable, the BRS client’s parent, guardian or legal custodian may present grievances to the BRS provider about its operation and a process to resolve issues;

(H) A suicide prevention policy and procedure that describes how the BRS provider must respond in the event a BRS client exhibits self-injurious, self-harm or suicidal behavior. This policy must describe warning signs of suicide; emergency protocol and contacts; training requirements for staff, including suicide prevention training and suicide risk assessment tool training; procedures for determining implementation of additional supervision precautions and for determining removal of additional supervision precautions; suicide risk assessment procedures on the day of intake; documentation requirements for suicide ideation, self-harm, and special observation precautions to ensure immediate communication to all staff; a process for tracking suicide behavioral patterns; and a “post-intervention” plan with identified resources;

(I) A seclusion and physical restraint policy that describes when such interventions may be used in compliance with applicable federal and state laws and regulations, including but not limited to requirements for licensed or approved public or private child-caring agencies and agency-specific BRS program rules. Physical restraint or seclusion shall only be used as a last resort, and shall not be used for discipline, punishment, convenience of personnel, or as a substitute for activities, treatment or training. The policy must describe how staff are trained and monitored and who may perform such interventions;

(J) A medication management policy which complies with applicable licensing requirements and agency-specific BRS program rules. At minimum, the policy must describe:

(i) How and where medications are stored and dispensed; and

(ii) How the BRS provider must notify the caseworker if the BRS client refuses prescribed medications for more than 7 days or refuses a medication that has been identified by any LPHA as requiring an immediate report for health care reasons;

(K) A quality improvement policy and procedures that monitor the operation of the BRS program to ensure compliance with all applicable laws and regulations, including but not limited to tracking service hours, monitoring the timeliness of reporting requirements, and monitoring the quality of service delivery;

(b) The BRS contractor must ensure that its BRS program, either operated by itself or by its BRS provider, reviews and updates its policies and procedures as listed in section (9)(a) of this rule biannually, and has any updated policies and procedures reviewed and approved by the agency;

(c) The BRS contractor must ensure that its BRS program, either operated by itself or by its BRS provider, complies with, and maintains documentation of its compliance, with all policies and procedures described in section (9)(a) of this rule, and with any modifications to their policies and procedures that are required by the agency.

(12) Documentation Requirements:

(a) The BRS contractor and BRS provider must:

(A) Comply with all documentation requirements in OAR 410-120-1360, BRS program general rules and agency-specific BRS program rules;

(B) Use forms reviewed and approved by the agency to document the following if required: the ISP, the assessment and evaluation report, the MSP, the MSP 90 day updates, the daily and weekly log for service hours, and the invoice form;

(C) Maintain current documentation of its staff’s compliance with applicable training, qualifications, and licensing requirements, which must be readily available for on-site review by the caseworker, agency, and other appropriate licensing or oversight entity;

(D) Create, maintain and update an individualized case file for each BRS client either in hard copy or electronically, including but not limited to service documentation (service plans, weekly service type and hour records, and discreet service notes), which must be readily available for on-site review by the BRS provider’s direct care staff and social service staff, the caseworker, the agency, and the appropriate licensing or oversight entity;

(E) Ensure that all documentation about the BRS client is written in terms that are easily understood by all persons involved in service planning and delivery, including but not limited to the service plans, progress notes and reports, assessments, and incident reports; and

(F) Ensure that all documentation (paper or electronic) identifies any corrections made, including the original information, what was corrected or changed, the date of the correction, and who made the correction. White out, eraser tape, electronic deletions or other means of eradicating information to make corrections on documentation may not be used;

(b) Incident Reports: The BRS contractor must ensure that its BRS program, either operated by itself or by its BRS provider, creates and maintains a record of all incidents and crisis interventions on a form approved by the agency, including but not limited to use of seclusion and physical restraint, a risk to the status or custody of the BRS client, or other incidents likely to cause complaints, generate safety, programmatic or other serious concerns, or come to the attention of the media or law enforcement.

(A) Incident reports must contain the following information:

(i) Name of the BRS client;

(ii) The date, location, and type of incident or crisis intervention;

(iii) The duration of any seclusions or physical restraints employed in the context of the incident;

(iv) Name of staff involved in the incident or crisis intervention, including the names of any witnesses;

(v) Description of the incident or crisis intervention, including precipitating factors, preventative efforts employed, and description of circumstances during the incident;

(vi) Physical injuries to the BRS client or others resulting from the incident or crisis intervention, including information regarding any follow-up medical care or treatment;

(vii) Documentation showing that any necessary reports were made to the appropriate agency, any other entity required by law to be notified, and, as applicable the BRS client’s parent, guardian or legal custodian;

(viii) Documentation indicating the date that a copy of the incident report was sent to the caseworker;

(ix) Actions or interventions taken by program staff;

(x) Any follow-up recommendations for the BRS client or staff;

(xi) Any follow-up or investigation conducted by the BRS contractor or BRS provider’s supervisory staff and administrative personnel, DHS, OHA, OYA or other entities; and

(xii) The BRS contractors or BRS provider’s review of the incident or crisis intervention.

(B) The BRS contractor must ensure that its BRS program, either operated by itself or by its BRS provider, provides immediate verbal notification to the caseworker, the agency’s designated contact, and as applicable the appropriate licensing entity of the following types of incidents: incidents posing a risk to the status or custody of the BRS client, and any other incidents that are of a nature serious enough to raise safety, programmatic, or other serious concerns. Verbal notification must be followed up by the submission of a written incident report to the individuals or entities described in this section within 1 business day. Compliance with this notification requirement does not satisfy child abuse reporting requirements under ORS 419B.005 to 419B.045;

(C) The BRS contractor must ensure that its BRS program, either operated by itself or by its BRS provider, provides a written incident report within 5 business days to the caseworker regarding any use of seclusion or physical restraint on a BRS client;

(D) At the end of each month, the BRS contractor must ensure that its BRS program, either operated by itself or by its BRS provider, sends copies of all incident reports for that month, not previously submitted under section (12)(b)(B) of this rule, to the designated agency contact;

(c) The BRS contractor and BRS provider must promptly provide documentation to the agency upon request or by the deadline specified in a written request, whichever is sooner. The BRS contractor’s or BRS provider’s failure to provide the agency with the requested documentation by the agency’s deadline may result in the agency pursuing any one or a combination of the sanctions or remedies against the BRS contractor described in OAR 410-170-0120 or agency-specific BRS rules.

(13) Overnight Absences: The BRS contractor must ensure that its program, either operated by itself or by its BRS provider, receives prior written approval from the caseworker whenever the BRS client will be sleeping outside of its program for any reason (such as home visits, camping trips, court appearances, hospital admissions, or detention) excluding cases of emergency:

(a) Initial approval shall be completed at intake and will include information from the caseworker documenting any special instructions such as:

(A) Conditions under which an overnight absence from the program would be approved;

(B) Home visit resources that are acceptable;

(C) Any required notifications to the community: victim, court, special interest group, or law enforcement;

(D) Approved and non-approved contacts during absences, as applicable; and

(E) Approved and non-approved activities, as applicable;

(b) After initial approval by the caseworker, the BRS contractor must ensure that its BRS program, either operated by itself or by its BRS provider, notifies the caseworker of each upcoming overnight visit at least 2 business days prior to the visit, and provides the following information:

(A) Dates of visit;

(B) Type of visit or activity;

(C) Location of visit or activity; and

(D) Explanation of how any special conditions or requirements will be addressed;

(c) The BRS contractor and BRS provider shall not permit the BRS client to leave the state or country without prior written approval by the agency.

(14) Publicly-Operated Community Residences. The BRS contractor must ensure that its BRS program, either operated by itself or by its BRS provider, that provides services and placement related activities in a publicly-operated community residence does not serve more than 16 residents, unless it receives prior written approval from the Authority with a determination that it is not an institution for mental diseases (see definitions in 42 CFR 435.1010).

(15) The BRS contractor’s Supervision of the BRS Provider:

(a) The BRS contractor is responsible for monitoring and ensuring that its BRS providers comply with all applicable laws and regulations related to the BRS program. The Authority and agency may pursue any sanctions, remedies, or recovery of an overpayment as described in OAR 410-170-0120 or agency-specific BRS rules against the BRS contractor for failing to monitor and ensure its BRS providers are in compliance with all applicable laws and regulations related to the BRS program;

(b) The BRS contractor is solely responsible for any and all obligations owed to its BRS provider under its subcontract or agreement;

(16) The BRS Contractor’s Supervision of the Approved Provider Parent:

(a) The BRS contractor must, or must ensure that its BRS provider, monitors and ensures that its approved provider parents comply with all applicable laws and regulations related to the BRS program. The Authority and agency may pursue any sanctions, remedies, or recovery of an overpayment described in OAR 410-170-0120 or agency-specific BRS rules against the BRS contractor for failing to monitor and ensure its approved provider parents are in compliance with all applicable laws and regulations related to the BRS program;

(b) The BRS contractor must, or ensure that its BRS provider:

(A) Recruits, trains, reimburses, and supports the approved provider parent in providing services or placement related activities to the BRS client;

(B) Visits the approved provider parent’s home a minimum of one time each month for the purposes of supervision, monitoring, training and support;

(C) Provides at minimum the following support services to the approved provider parent:

(i) Twenty-four hour back-up services: The BRS contractor must, or ensure that its BRS provider, have staff available to provide the approved provider parent with back-up services at all times (24 hours per day, 7 days a week), which includes on-call services, consultation, and direct crisis counseling. Approved provider parents must be given the contact details (names and phone numbers) of the program staff that are available to provide these back-up services;

(ii) Forty eight hours of respite care: The BRS contractor must provide, or ensure that its BRS provider provides, the approved provider parent with the opportunity to receive 48 hours per month of time away from approved provider parent responsibilities. Daytime supervision and night-time monitoring equivalent to that provided by the approved provider parent must be arranged and provided to the BRS client during that time;

(c) The BRS contractor, or as applicable the BRS provider, is solely responsible for any and all obligations owed to the approved provider parent under its subcontract or agreement.

(17) Conflict of Interest: The BRS contractor must, or ensure that its BRS provider, notifies the agency in writing when a current employee or newly hired employee is also an employee of the agency. The BRS contractor must, or ensure that its BRS provider, submits the notification to the contract administrator and the agency’s contracts unit and shall include the name of the employee and their job description. The agency must review the employment situation for any actual or potential conflicts of interest as identified under ORS chapter 244.

Stat. Auth.: ORS 413.042 & 414.065

Stats. Implemented: ORS 414.065

Hist.: DMAP 63-2013, f. 11-14-13, cert. ef. 1-1-14

410-170-0040

Prior Authorization for the BRS Program; Appeal Rights

(1) The BRS program requires prior authorization from the agency in accordance with the Authority’s rules, the general BRS program rules and applicable agency-specific BRS program rules. A referral by a LPHA or agency to the Authority for prior authorization of the BRS program is not a prior authorization.

(2) Prior Authorization Criteria for the BRS program:

(a) The Authority shall provide prior authorization for the BRS program to a person who:

(A) Is enrolled in the Oregon Health Plan (OHP), is eligible for Oregon’s Medicaid or CHIP program, and is eligible for Early and Periodic Screening, Diagnosis and Treatment (EPSDT) Services, according to the procedures established by the Authority;

(B) Has a determination by a designated LPHA that the BRS program is medically appropriate to meet his or her medical needs;

(C) Is not receiving residential mental health or residential developmental disability services from another governmental unit or entity;

(D) Is a child or young adult; and

(E) Does not have a current prior authorization for the BRS program for the requested time period from OYA or the Department;

(b) OYA or the Department may provide prior authorization for the BRS program for a person that meets the requirements in its agency-specific BRS program rules.

(3) In order to meet the requirement in section (2)(a)(B) of this rule, the designated LPHA must determine that the BRS program is medically appropriate because the person:

(a) Has a primary mental, emotional or behavioral disorder, or developmental disability that prevents the person from functioning at a developmentally appropriate level in the person’s home, school or community;

(b) Demonstrates severe emotional, social and behavioral problems, including but not limited to: drug and alcohol abuse; anti-social behaviors requiring close supervision, intervention and structure; sexual behavioral problems; or behavioral disturbances;

(c) Requires out-of-home behavioral rehabilitation treatment in order to restore or develop the person’s appropriate functioning at a developmentally appropriate level in the person’s home, school or community;

(d) Is able to benefit from the BRS program at a developmentally-appropriate level;

(e) Does not have active suicidal, homicidal, or serious aggressive behaviors; and

(f) Does not have active psychosis or psychiatric instability.

(4) The Authority may also request that the designated LPHA determine the BRS type of care that is medically appropriate for the person. The designated LPHA must make that determination based on the following factors, including but not limited to the:

(a) Severity of the person’s psychosocial, emotional and behavior disorders;

(b) Intensity and type of services that would be appropriate to treat the person;

(c) Type of setting or treatment model that would be most beneficial to the person;

(d) Least restrictive and intensive setting based on the person’s treatment history, degree of impairment, current symptoms and the extent of family and other supports; and

(e) Behavior management needs of the person.

(5) The agency is not required to provide prior authorization or to make payment for services or placement related activities under the following circumstances:

(a) The person was not eligible for the BRS program at the time services or placement related activities were provided;

(b) The documentation is not adequate to determine the type, medical appropriateness, or frequency and duration of services;

(c) The services or placement related activities billed or provided are not consistent with the information submitted when the prior authorization was requested;

(d) The services or placement related activities billed are not consistent with those provided;

(e) The services or placement related activities were not provided within the timeframe specified on the notice of prior authorization;

(f) The BRS program is not covered under the person’s medical assistance package;

(g) The services or placement related activities were not authorized or provided in compliance with the BRS program general rules, agency-specific BRS program rules, or applicable DMAP General Rules (OAR 410-120-0000 to 410-120-1920);

(h) The person does not meet the prior authorization requirements as stated above;

(i) The BRS contractor or BRS provider was not eligible to receive reimbursement through the BRS program at the time the services or placement related activities were provided; or

(j) The person’s needs could be better met through another system of care, the individual is eligible for services under that system of care; the individual has been given notice of that eligibility; and the services necessary to support a successful transition to the alternate system of care have been provided.

(6) Retroactive Eligibility and Authorization:

(a) In those instances when the BRS client is made retroactively eligible for the BRS program, the agency may grant prior authorization if:

(A) The BRS contractor or BRS provider received preliminary approval from the agency prior to admitting the BRS client into its program while the prior authorization process was pending;

(B) The BRS client met all prior authorization criteria and eligibility requirements on the date that the services and placement related activities were provided;

(C) The BRS provider delivered the services and placement related activities in accordance with all applicable BRS program general rules and agency-specific BRS program rules; and

(D) Prior authorization was retroactively approved by the agency within 5 business days from the date that the BRS client was admitted into the BRS provider’s program;

(b) Prior authorization after 5 business days from the date the BRS client was admitted into the BRS contractor’s or BRS provider’s program requires documentation that prior authorization could not have been obtained within those 5 business days.

(7) Prior authorization is valid for the time period specified on the agency’s prior authorization notice, but is not to exceed 12 months from the date on the notice, unless the BRS client is no longer eligible for a medical assistance program that covers the BRS program, in which case the authorization shall terminate on the date coverage ends.

(8) The BRS contractor is responsible for ensuring that there is a prior authorization from the agency for the BRS client in advance of providing the services or placement related activities for the applicable time period unless section (6) of this rule applies.

(9) If a person is denied prior authorization for the BRS program under section (2)(a) of this rule, OAR 413-090-0075(1)(a), or OAR 416-335-0040(1)(a), the person is entitled to notice and contested hearing rights under OAR 410-120-1860 and 410-120-1865. The contested case hearing shall be held by the Authority.

Stat. Auth.: ORS 413.042 & 414.065

Stats. Implemented: ORS 414.065

410-170-0050

Program Referrals and Admission to BRS Provider

(1) After the BRS client has received prior authorization for the BRS program, the agency shall refer the BRS client for admission to one or more BRS contractors or BRS providers that provide the appropriate BRS type of care.

(2) The agency shall provide the BRS contractor, or as applicable the BRS provider, with the following documents in the BRS client’s referral packet:

(a) Information identifying the person or entity with legal authority over the BRS client, which may be the BRS client’s parent, guardian or legal custodian;

(b) Any prior evaluations, assessments, or other documents that provide background information about the BRS client or that support the need for the BRS client’s current level of services; and

(c) The caseworker’s case plan describing necessary services or similar planning form for the BRS client.

(3) The BRS contractor, or as applicable the BRS provider, must make admission decisions for the BRS client based on its agency-approved written admission criteria unless provided with written authorization from the agency to accept a BRS client who does not meet its admission criteria.

(4) The BRS contractor, or as applicable the BRS provider, shall not deny an eligible BRS client admission to its program if a vacancy exists within the program at the time of referral and the BRS client meets its agency-approved admission criteria, unless it receives written approval from the referring agency.

(5) The BRS contractor must not, and ensure its BRS providers do not, deny an eligible BRS client admission to its program for any of the following reasons:

(a) The presence or absence of family members to support the placement;

(b) The race, religion, sexual orientation, color, or national origin of the BRS client involved;

(c) The BRS client’s place of residence; or

(d) The absence of an identified after-care resource.

(6) The BRS contractor must, or must ensure its BRS provider, notifies the caseworker of its admission decision within 5 business days of receiving the BRS client’s referral packet, unless an earlier timeframe is required in agency-specific BRS rules. If the BRS provider denies admission to the BRS client, then it must provide the caseworker with a written explanation.

(7) The BRS contractor must, or must ensure its BRS provider, maintains documentation (either electronically or in hard copy) of all its admission decisions for BRS clients referred by an agency or BRS contractor, which includes the following:

(a) The name of the BRS client referred;

(b) The date the referral was received;

(c) The reason the referral was accepted or denied; and

(d) The date the referral was responded to in writing.

(8) Intake Procedures:

(a) On the day that the BRS client is physically admitted to the BRS contractor’s or BRS provider’s program, its staff must provide the BRS client and, as applicable, the BRS client’s parent, guardian or legal custodian, with copies of the following policies:

(A) Behavior management system policy;

(B) Grievance policy;

(C) BRS client’s and family’s rights policies, including but not limited to visitation and communication policies and the policies regarding the search and seizure of the BRS client’s person, property, and mail;

(D) Discharge polices, including but not limited to a discharge initiated by the BRS client;

(E) Seclusion and physical restraint policies;

(F) Suicide prevention policy and procedures; and

(G) Medication management policy;

(b) The BRS contractor must ensure its program, either operated by itself or by its BRS provider, maintains signed documentation indicating that the BRS client and, as applicable, the BRS client’s parent, guardian or legal custodian received and understood the information described in section (8)(a) of this rule;

(c) If any of the policies described in section (8)(a) of this rule are individualized for a particular BRS client and differ from the program’s standard documented practices, these variations shall be explained and documented, and included in or attached to the BRS client’s service plan;

(d) If the BRS client’s parent, guardian or legal custodian is unavailable at the time of admission, the BRS contractor must ensure its program, either operated by itself or by its BRS provider, documents in the BRS client’s case file that it has forwarded this information to the BRS client’s parent, guardian or legal custodian by facsimile, mail or electronic mail within 48 hours of the BRS client’s admission to the program;

(e) The agency is responsible for notifying the BRS contractor or BRS provider of any changes to the information described in section (2) of this rule. In addition, the agency must provide the BRS contractor or BRS provider with the following information;

(A) Applicable written authorizations by the BRS client or the BRS client’s parent, guardian or legal custodian consenting to the BRS client’s participation in the BRS program;

(B) If applicable, the prepaid health plan or coordinated care organization in which the BRS client is enrolled;

(C) The BRS client’s current medical information, medication regime, and other medical needs; and

(D) If applicable, the BRS client’s school information, parental contact information, or similar types of information.

Stat. Auth.: ORS 413.042 & 414.065

Stats. Implemented: ORS 414.065

Hist.: DMAP 63-2013, f. 11-14-13, cert. ef. 1-1-14

410-170-0060

Discharge from the BRS Contractor or BRS Provider

(1) Discharge initiated by the BRS client:

(a) The BRS client’s participation in the BRS program is voluntary. The BRS contractor must, or ensure its BRS provider, develops and follows a process that allows the BRS client to provide no more than 3 business days advance notice of his or her decision to leave the BRS contractor’s or BRS provider’s program. If the BRS client wants to be discharged from the program, the BRS client is only required to provide the BRS contractor or BRS provider with 3 business days advance notice;

(b) If the BRS client wants to be discharged from the program, the BRS client must give the BRS contractor or BRS provider notice that complies with the policy described above. After receiving that notice, the BRS contractor or BRS provider must provide immediate verbal notification within 1 business day to the caseworker and the agency’s designated contact and, if applicable, the BRS client’s parent, guardian or legal custodian to allow for alternate placement arrangements. The BRS contractor or BRS provider must provide written notification to the caseworker and the agency’s designated contact within 1 business day of its verbal notification.

(2) Planned discharge initiated by the BRS contractor, BRS provider, or the agency:

(a) Initiated by the BRS contractor or BRS provider:

(A) The BRS contractor or BRS provider must notify the caseworker in writing as soon as reasonably practicable regarding its intent to initiate the planned discharge of the BRS client from its program;

(B) Following notification, the BRS contractor or BRS provider and caseworker shall meet to discuss the case. If a discharge date can be agreed upon, the BRS client shall be discharged on that date. If they cannot agree, the caseworker shall remove the BRS client from the program within 30 days from the original written notice to the caseworker, resulting in the BRS client’s planned discharge;

(b) Initiated by the agency:

(A) The BRS client’s caseworker must notify the BRS contractor or BRS provider in writing as soon as reasonably practicable regarding the agency’s intent to initiate the planned discharge of the BRS client from its program;

(B) Following notification, the caseworker and the BRS contractor or BRS provider must meet to discuss the case. If a discharge date can be agreed upon, the BRS client must be discharged on that date. If they cannot agree, the caseworker may remove the BRS client from the program resulting in the BRS client’s planned discharge.

(3) Emergency Discharge:

(a) Initiated by the BRS contractor or BRS provider:

(A) The BRS contractor or BRS provider may request the immediate discharge of a BRS client from its program if, after contact with the agency staff, there is mutual agreement that the BRS client is a clear and immediate danger to self or others. In such situations, the caseworker must consider the notification a priority and respond to the BRS contractor or BRS provider as soon as practicable but no later than one business day;

(B) The BRS contractor or BRS provider and caseworker must discuss the BRS client’s continuation in, temporary removal or discharge from the program;

(b) Initiated by the agency: The agency may immediately remove the BRS client from the BRS contractor’s or BRS provider’s program for any reason, resulting in the BRS client’s emergency discharge;

(c) Initiated by the parent or guardian: A parent or guardian with appropriate legal authority, as determined by the agency, may immediately remove the BRS client from the BRS contractor’s or BRS provider’s program, resulting in the BRS client’s emergency discharge.

(4) Discharge from a particular program does not impact a BRS client’s prior authorization for the BRS program generally. A BRS client may be referred to another BRS contractor or BRS provider or request re-referral to the same program, as long as the prior authorization remains valid and the BRS client remains eligible for the BRS program.

(5) Temporary Removal: The agency may temporarily remove the BRS client for any reason without resulting in a discharge from the BRS contractor’s or BRS provider’s program.

(6) Storage of the BRS client’s personal property:

(a) The BRS contractor or BRS provider must store property belonging to the BRS client in its program for up to 30 days in a secure location following discharge, when the BRS client exits the program without his or her property;

(b) The BRS contractor or BRS provider must contact the BRS client’s caseworker as soon as possible to make arrangements for the property to be retrieved. If the property has not been retrieved by the 15th day following discharge, the BRS contractor or BRS provider must contact the caseworker once more in order to remind them of the need to retrieve the property by the 30th day.

Stat. Auth.: ORS 413.042 & 414.065

Stats. Implemented: ORS 414.065

Hist.: DMAP 63-2013, f. 11-14-13, cert. ef. 1-1-14

410-170-0070

BRS Service Planning

(1) Initial Service Plan (ISP):

(a) The BRS contractor or BRS provider must:

(A) Ensure that a social service staff member completes a written ISP within two business days of the BRS client’s admission to its program;

(B) Provide an opportunity for the following individuals to participate in developing the BRS client’s ISP, including but not limited to: the BRS client, the BRS client’s family, social service staff, the BRS client’s caseworker and any other significant persons involved with the BRS client;

(C) Obtain and maintain the signatures of all participants or documentation that the individuals listed in section (1)(a)(B) of this rule were provided with the opportunity to participate in developing the ISP;

(D) Obtain written approval of the ISP prior to its implementation from the caseworker and, as applicable and appropriate, the BRS client and the BRS client’s parent, guardian or legal custodian; and

(E) Provide the services identified in the ISP during the first 45 days in the BRS provider’s program or until the MSP is written;

(b) The BRS contractor or BRS provider must ensure that the ISP is individualized, developmentally appropriate, and based on a thorough assessment of the BRS client’s referral information, and include at minimum the following:

(A) A plan to address specific behaviors identified in the referral information including the intervention to be used;

(B) A plan for any overnight home visits;

(C) The anticipated discharge date;

(D) The anticipated type of placement at discharge;

(E) A plan to address any needs identified in the referral information;

(F) Existing orders for medication and any prescribed treatments for medical conditions, mental health conditions, or substance abuse;

(G) Any type of behavior management system that will be used as an intervention; and

(H) Specific behavior management needs.

(2) Assessment and Evaluation Report (AER):

(a) The BRS contractor or BRS provider must:

(A) Ensure that a social service staff member conducts a comprehensive assessment of the BRS client and completes a written AER; and

(B) Submit the written AER to the caseworker within 30 days of the BRS client’s admission to its program;

(b) The BRS contractor or BRS provider must ensure that the AER includes information about the BRS client with regard to the following domains:

(A) Legal custody and basis for custody;

(B) Medical information including prescribed medications and dosages;

(C) Family information including specific cultural factors;

(D) Mental health information;

(E) Alcohol and drug use both current and historical;

(F) Educational needs;

(G) Vocational needs;

(H) Social living skills; and

(I) Placement plans including home visits, anticipated discharge date, and placement resources;

(c) The BRS contractor or BRS provider must ensure that the AER describes the following:

(A) Identified problems, reason for referral or placement, and pertinent historical information;

(B) The BRS client’s behaviors, response to current services, and strengths and assets;

(C) Significant incidents or interventions or both;

(D) The behavior management level needed for the BRS client, specifically any behavior management needs greater than usual for its program;

(E) Identification of any service goals; and

(F) Identified needs by assessment and history.

(d) Abbreviated AERs:

(A) Upon the request of the caseworker, the BRS contractor or BRS provider must submit an abbreviated AER regarding the BRS client’s current status by the deadline stated in the written request;

(B) If a BRS client is transferred to the current BRS program from another BRS program and the BRS client’s most recent AER is less than 90 days old, the current BRS contractor or BRS provider may submit an abbreviated AER to the caseworker within 30 days of the BRS client’s transfer to its program;

(C) The BRS contractor or BRS provider must ensure an abbreviated AER includes at minimum the information in section (2)(b)(A) of this rule and any other specific information requested by the caseworker. If the information is available, the BRS contractor or BRS provider must also include the information in section (2)(b)(B) through (D) of this rule;

(3) Master Service Plan (MSP):

(a) The BRS contractor or BRS provider must:

(A) Ensure that a social service staff member completes a written individualized MSP within 45 days of the BRS client’s admission to its program;

(B) Provide the opportunity for the individuals listed in section (1)(a)(B) of this rule to participate in developing the BRS client’s MSP;

(C) Obtain and maintain the signatures of all participants or documentation that the individuals listed in section (1)(a)(B) of this rule were provided with the opportunity to participate in developing the MSP;

(D) Obtain written approval of the MSP prior to its implementation from the caseworker and, as applicable and appropriate, the BRS client and the BRS client’s parent, guardian or legal custodian; and

(E) Provide the services identified in the MSP;

(b) The BRS contractor or BRS provider must ensure that the MSP includes goals that are measurable and attainable within a specified time frame, and address at minimum the following domains where need is indicated by the BRS client’s assessment and history:

(A) Legal custody and basis for custody;

(B) Medical information including medications and dosages;

(C) Family information including specific cultural factors;

(D) Mental health information;

(E) Alcohol and drug use both current and historical;

(F) Educational needs;

(G) Vocational needs;

(H) Social living skills;

(I) Placement plans including home visits, anticipated discharge date, and placement resources;

(J) Other needs identified in the BRS client’s AER that do not fall in one of the other identified domains above; and

(K) Completion criteria individualized for each BRS client. Completion is defined by progress in acquiring pro-social behaviors, attitudes, and beliefs while in the program, and not engaging in behavior that seriously jeopardizes the safety of staff and other program participants;

(c) The BRS contractor or BRS provider must ensure that the MSP is individualized and developmentally appropriate, and includes:

(A) Specifically stated and prioritized service goals for the BRS client that include the caseworker’s recommendations and goals that the BRS client wants to achieve;

(B) Specific interventions and services its program shall provide to address each goal, including the use of a behavior management system as an intervention and any behavior management needs that are greater than usual for the program;

(C) Staff responsible for providing the identified services;

(D) Specifically stated behavioral criteria for evaluating the achievement of goals;

(E) A timeframe for the completion of goals;

(F) The method used to monitor the BRS client’s progress towards completing goals and the person responsible for monitoring progress; and

(G) Aftercare and transition goals and planning;

(d) The BRS contractor or BRS provider must identify in the MSP those needs identified in a BRS client’s AER that will be addressed by an outside provider and identify that provider. The BRS contractor or BRS provider must also facilitate the BRS client’s access to other providers whenever needs identified in the AER cannot be met within the scope of the services offered by its program;

(e) The BRS contractor or BRS provider must also describe in the MSP any plan for the BRS client to participate in overnight home visits, including but not limited to documenting when the home visits are to occur, identifying the frequency of the visits (up to a maximum of 8 days per month), and describing how the visits relate to the BRS client’s goals identified in the MSP. The BRS contractor or BRS provider must make every attempt to schedule home visits so that they do not conflict with services. Any deviation from the approved home visit plan requires prior written approval from the agency.

(4) Master Service Plan 90 Day Updates:

(a) The BRS contractor or BRS provider must:

(A) Ensure that a social service staff member reviews and updates in writing the BRS client’s MSP no later than 90 days from the date the MSP was first finalized or the last time it was updated, and every 90 days thereafter. Social service staff must review the MSP, and update it in writing if necessary, earlier whenever additional information becomes available that suggests that other services should be provided;

(B) Provide the opportunity for the individuals listed in section (1)(a)(B) of this rule to participate in developing the BRS client’s MSP updates;

(C) Obtain and maintain the signatures of all participants or documentation that the individuals listed in section (1)(a)(B) of this rule were provided with the opportunity to participate in developing the MSP updates;

(D) Obtain written approval of an updated MSP prior to its implementation from the caseworker and, as applicable and appropriate, the BRS client and the BRS client’s parent, guardian or legal custodian; and

(E) Provide the services identified in the most recent MSP update;

(b) The BRS contractor or BRS provider must ensure that the written update to the MSP is individualized and developmentally appropriate, and includes at minimum the following:

(A) The BRS client’s progress towards achieving service goals;

(B) The BRS client’s performance on the behavior management system;

(C) The BRS client’s performance on any individualized plans developed to address specific behaviors;

(D) Any modifications to services based on the BRS client’s new behaviors or identified needs;

(E) Any changes regarding recommendations, the discharge date, or aftercare and transition plans; and

(F) A summary of incidents involving the BRS client that have occurred since the last time the MSP was updated.

(5) Aftercare and Transition Plan (ATP):

(a) The BRS contractor or BRS provider must:

(A) Ensure that a social service staff member develops and completes a written ATP at least 30 days prior to or as close as possible to the BRS client’s planned discharge;

(B) Provide the opportunity for the individuals listed in section (1)(a)(B) of this rule and members of the service planning team to participate in developing the BRS client’s written ATP;

(C) Obtain and maintain the signatures of all participants or documentation that the individuals listed in section (1)(a)(B) of this rule and members of the service planning team were provided with the opportunity to participate in developing the written ATP;

(D) Provide a copy of the written ATP to the individuals described in section (1)(a)(B) of this rule and members of the service planning team; and

(E) Obtain written approval of the written ATP from the caseworker and, as applicable and appropriate, the BRS client and the BRS client’s parent, guardian or legal custodian;

(b) The BRS contractor or BRS provider must ensure that the written ATP describe how the BRS client will successfully transition from its program to the community, specifically addressing the period of 90 days after discharge from its program. The BRS contractor or BRS provider must ensure that the written ATP includes, at minimum, the following:

(A) Identification of the BRS client’s individual needs and unmet goals;

(B) Identification of the aftercare services and supports outside of its program that will be available for the 90-day time period;

(C) Identification of the person or entity responsible for providing the aftercare services; and

(D) Schedule for regular telephone contact by BRS provider staff with the BRS client and, as applicable, the BRS client’s family, caseworker or other identified significant persons;

(c) The BRS contractor or BRS provider shall not be required to provide an initial and final written ATP under the following circumstances:

(A) The agency, legal guardian, or custodian removes the BRS client from the program with little or no advance notice and in a manner not in accordance with the existing ATP;

(B) The BRS client is discharged from the program on an emergency basis due to the BRS client’s behavior, runaway status without a plan to return to the program, or transfer to another program or higher level of care; or

(C) The BRS client initiates an immediate voluntary discharge from the program.

(6) Discharge Summary: The BRS contractor or BRS provider must ensure that a social service staff member completes and provides a written discharge summary to the caseworker within 15 days following the BRS client’s planned or actual discharge from its program. The discharge summary must include the BRS client’s progress towards service goals.

(7) Aftercare Summary: The BRS contractor or BRS provider must ensure that a social service staff member completes and provides a written aftercare summary to the caseworker within 120 days following the BRS client’s discharge from its program. An aftercare summary is not required if the BRS provider was not required to complete an ATP. The aftercare summary must summarize the BRS client’s status and progress on the ATP for the 90 days following the BRS client’s discharge from the BRS provider, including but not limited to the BRS client’s adjustment to the community and any further recommendations.

(8) Notwithstanding sections (5) through (7) of this rule, the BRS contractor or BRS provider is not required to complete an ATP, discharge summary and aftercare summary for the BRS clients receiving services and placement related activities in the following BRS types of care:

(a) Shelter, Assessment and Evaluation;

(b) Intensive Community Care; and

(c) Independent Living Service.

(9) Independent Living Program: A BRS contractor or BRS provider that provides services and placement related activities in an Independent Living Program:

(a) Is not required to complete an ISP, AER, ATP, and aftercare summary for the BRS clients in its program, notwithstanding sections (1), (2) and (5) through (7) of this rule; and

(b) Must complete an MSP, the MSP updates and a discharge summary for the BRS clients in its program consistent with the requirements in sections (3) and (4) of this rule, and the additional requirements for a master service plan — transition and the master service plan — transition updates as described in OAR 416-335-0060.

(10) Short-Term Stabilization Program: A BRS contractor or BRS provider that provides services and placement related activities in a Short-Term Stabilization Program:

(a) Is not required to complete an ISP and aftercare summary for the BRS clients in its program, notwithstanding sections (1) and (7) of this rule;

(b) Must complete an AER for the BRS clients in its program consistent with the requirements in section (2) of this rule, except in cases where the BRS client is not expected to remain in its program for more than 30 days;

(c) Must complete an ATP for the BRS clients in its program consistent with the requirements in section (5) of this rule except for those in section (5)(b)(D), and must complete the additional requirements for an aftercare and transition plan — stabilization in OAR 416-335-0070 for BRS clients who are being discharged home or into a non-BRS foster care placement; and

(d) Must complete a MSP and the MSP updates for the BRS clients in its program consistent with the requirements in sections (3) and (4) of this rule, and the additional requirements for a master service plan — stabilization and the master service plan — stabilization updates as described in OAR 416-335-0070.

(11) Documentation: The BRS contractor or BRS provider must ensure that all BRS service plans described in this rule are developed and maintained in the BRS client’s case file in accordance with the timeframes and criteria in this rule, unless otherwise exempted.

Stat. Auth.: ORS 413.042 & 414.065

Stats. Implemented: ORS 414.065

Hist.: DMAP 63-2013, f. 11-14-13, cert. ef. 1-1-14

410-170-0080

Services

(1) The BRS contractor or BRS provider must provide services to the BRS client in accordance with the BRS client’s ISP or MSP.

(2) All services must be structured and directly supervised by the BRS contractor or BRS provider’s staff.

(3) Types of Services:

(a) Crisis counseling: The BRS contractor or BRS provider provides the BRS client with counseling on a 24-hour basis in order to stabilize the BRS client’s behavior until the problem can be resolved or assessed and treated by a qualified mental health professional or licensed medical practitioner;

(b) Individual and group counseling: The BRS contractor or BRS provider provides face-to-face individual or group counseling sessions to the BRS client which are designed to remediate the problem behaviors identified in the BRS client’s ISP or MSP;

(c) Milieu therapy: The BRS contractor or BRS provider provides the BRS client with structured activities and planned interventions designed to normalize psycho-social development, promote safety, stabilize environment, and assist in responding in developmentally appropriate ways. The program’s staff must monitor the BRS client in these activities, which include developmental, recreational, academic, rehabilitative, or other productive work. Milieu therapy occurs in concert with one of the other types of services;

(d) Parent training: Direct care staff or social service staff provide planned activities or interventions (face-to-face or by telephone) to the BRS client’s family or identified aftercare resource family. Parent training is designed to assist the family in identifying the specific needs of the BRS client, to support the BRS client’s efforts to change, and to improve and strengthen parenting knowledge or skills indicated in the ISP or MSP as being necessary for the BRS client to return home or to another community living resource;

(e) Skills-training: The BRS contractor or BRS provider provides the BRS client with planned, curriculum-based individual or group sessions designed to improve specific areas of functioning in the BRS client’s daily living as identified in the ISP or MSP. Skills-training may be designed to develop appropriate social and emotional behaviors, improve peer and family relationships, improve self-care, encourage conflict resolution, reduce aggression, improve anger control, and reduce or eliminate impulse and conduct disorders;

(4) The BRS contractor or BRS provider must:

(a) Provide a combination of services necessary to comply with the BRS client’s ISP or MSP and the requirements in OAR 410-170-0090 for the appropriate BRS type of care;

(b) Create and maintain written documentation describing the services provided to each BRS client which includes at a minimum the following information:

(A) Name of the BRS client;

(B) Date of service;

(C) Name and position of the staff member providing the service to the BRS client;

(D) Length of time staff spent providing the service to the BRS client;

(E) Description of the service provided; and

(F) Description of the BRS client’s participation in the service;

(c) Create and maintain a written weekly record in each BRS client’s case file with the total number of service hours provided each day to the BRS client and a breakdown of the number of hours spent providing each particular type of service described in section (3) of this rule; and

(d) Ensure that that social service staff review the documentation described in this section each week for quality, content, and appropriateness with the BRS client’s ISP or MSP.

Stat. Auth.: ORS 413.042 & 414.065

Stats. Implemented: ORS 414.065

Hist.: DMAP 63-2013, f. 11-14-13, cert. ef. 1-1-14

410-170-0090

BRS Types of Care

The BRS types of care are as follows:

(1) Shelter Assessment and Evaluation, Intensive Community Care, Independent Living Service, Community Step-Down, and Independent Living Program:

(a) The BRS contractor or BRS provider may use either a residential care model or therapeutic foster care model for these BRS types of care;

(b) The BRS client is placed in these BRS types of care to identify deficiencies and develop necessary skills;

(c) The BRS contractor or BRS provider providing one of these BRS types of care must ensure that a minimum of six hours of services are available per week to each BRS client as follows;

(A) One hour of individual counseling or individual skills-training provided by social service staff; and

(B) Five hours of any combination of individual or group counseling, crisis counseling, skills-training, or parent training.

(2) Therapeutic Foster Care, BRS Proctor and Multidimensional Treatment Foster Care:

(a) The BRS contractor or BRS provider must use a therapeutic foster care model for these BRS types of care;

(b) The BRS client placed in these BRS types of care requires structure, behavior management, and support services to develop the skills necessary to be successful in a less restrictive environment;

(c) The BRS contractor or BRS provider providing one of these BRS types of care must ensure that a minimum of 11 hours of services are available per week to each BRS client as follows:

(A) Two hours of individual counseling or individual skills-training, one of which is provided by social service staff; and

(B) Nine hours of any combination of individual or group counseling, crisis counseling, skills-training, or parent training.

(3) BRS Proctor Day Treatment:

(a) The BRS contractor or BRS provider must use a therapeutic foster care model for this BRS type of care and provide skills-training in a day treatment setting;

(b) The BRS client placed in this BRS type of care requires enhanced structure during the day time hours. This level of care provides the structure of day treatment for necessary skill development and a less restrictive home setting with an approved provider parent;

(c) The BRS contractor or BRS provider providing this BRS type of care must ensure that a minimum of eleven hours of services are available per week to each BRS client as follows:

(A) Two hours of either individual counseling or individual skills-training, one of which is provided by social service staff; and

(B) Nine hours of individual or group counseling, crisis counseling, skills- training, or parent training;

(4) BRS Basic Residential, BRS Rehabilitation Services:

(a) The BRS contractor or BRS provider must use a residential care model for these BRS types of care. The BRS contractor or BRS provider must provide 24 hour supervision of the BRS client by ensuring that at least one direct care staff is on duty and awake whenever a BRS client is present in its program;

(b) The BRS client placed in these BRS types of care requires the structure, behavior management, and support services of a residential care model for necessary skill development;

(c) The BRS contractor or BRS provider providing these BRS types of care must ensure that a minimum of eleven hours of services are available per week to each BRS client as follows:

(A) Two hours of either individual counseling or individual skills-training, one of which is provided by social service staff; and

(B) Nine hours of any combination of individual or group counseling, crisis counseling, skills-training, or parent training.

(5) Intensive Rehabilitation Services, BRS Residential, BRS Enhanced, Short-Term Stabilization Program:

(a) The BRS contractor or BRS provider must use a residential care model for these BRS types of care. The BRS contractor or BRS provider must provide 24-hour supervision of the BRS client by ensuring that at least one direct care staff is on duty and awake whenever a BRS client is present in its program;

(b) The BRS client placed in these BRS types of care requires more intensive structure, behavior management and support services than a BRS client in the BRS types of care described in section (4) of this rule;

(c) The BRS contractor or BRS provider providing one of these BRS types of care must ensure that a minimum of 11 hours of services are available per week to each BRS client as follows:

(A) Two hours of either individual counseling or individual skills-training, one of which is provided by social service staff; and

(B) Nine hours of any combination of individual or group counseling, crisis counseling, skills-training, or parent training.

(6) Enhanced Therapeutic Foster Care:

(a) The BRS contractor or BRS provider must use a therapeutic foster care model for this BRS type of care;

(b) The BRS client placed in this BRS type of care can be maintained in a home of an approved provider parent with structure, behavior management and enhanced supports. The BRS client placed in this BRS type of care has difficulty in a group setting and requires a placement utilizing a therapeutic foster care model;

(c) The BRS contractor or BRS provider providing this BRS type of care must ensure that a minimum of 13 hours of services are available per week to each BRS client as follows:

(A) Two hours of either individual counseling or individual skills-training, one of which is provided by social service staff; and

(B) Eleven hours of any combination of individual or group counseling, crisis counseling, skills-training, or parent training.

Stat. Auth.: ORS 413.042 & 414.065

Stats. Implemented: ORS 414.065

Hist.: DMAP 63-2013, f. 11-14-13, cert. ef. 1-1-14

410-170-0100

Placement Related Activities for the Authority’s BRS Contractors and BRS Providers

(1) In cases where the Authority is the agency, the BRS contractor or BRS provider must provide the following placement related activities, and all facilities, personnel, materials, equipment, supplies and services, and transportation necessary to provide those activities including but not limited to:

(a) Transportation: The BRS contractor or BRS provider is responsible for the transportation of the BRS client to: attend school, to the extent not provided by the school district; medical, dental, and therapeutic appointments, to the extent not provided through the Oregon Health Plan; recreational and community activities; places of employment; and shopping for incidental items;

(b) Educational and vocational activities: The BRS contractor or BRS provider must have a system in place to meet the educational and vocational needs of the BRS client in its program either on-site or at an off-site location or a combination of the two;

(c) Recreational, social, and cultural activities:

(A) The BRS contractor or BRS provider shall provide recreation time for the BRS client on a daily basis, and offer activities that are varied in type to allow BRS clients to obtain new experiences. The BRS contractor or BRS provider shall document recreation as having been provided, by recording the type of activity the BRS client participated in, and the date it occurred;

(B) The BRS contractor or BRS provider shall provide each BRS client 2 to 3 opportunities per week to participate in recreational activities in the community, unless the BRS client is clearly unable to participate in offsite activities due to safety issues. If a BRS client is restricted from participation in community recreation, the BRS contractor or BRS provider shall document the reason in the BRS client’s case file, and the reason must be reviewed regularly to ensure that the BRS client is not unnecessarily restricted from offsite activities. The BRS contractor or BRS provider shall offer any BRS client who is restricted from community activities alternative opportunities for recreation on-site;

(C) The BRS contractor or BRS provider shall provide access to or make available social and cultural activities for the BRS clients as part of the therapeutic milieu of the program. These activities are to promote the BRS client’s normal development and help broaden the BRS client’s understanding and appreciation of the community, arts, environment and other cultural groups;

(D) The BRS contractor or BRS provider may not permit BRS clients to participate in recreational activities that present a higher level of risk to BRS clients without pre-approval by the caseworker. This applies to activities that require a moderate to high level of technical expertise to perform safely, present environmental hazards, or where special certification or training is recommended or required such as: whitewater rafting, rock climbing, ropes courses, activities on or in any body of water where a certified lifeguard is not present and on duty, camping, backpacking, mountain climbing, using motorized yard equipment, and horseback riding;

(d) Academic Assistance: The BRS contractor or BRS provider shall provide adequate opportunities for the BRS clients to complete homework assignments with assistance from staff if needed.

(2) Non BRS-Related Medical Care:

(a) If there is no record that the BRS client has received a physical examination within the six months immediately prior to the BRS client’s placement with its program, the BRS contractor or BRS provider shall ensure or make every effort to ensure that the BRS client receives a general medical check, consistent with health insurance allowances, within 30 days of placement. The BRS contractor or BRS provider shall keep documentation of this procedure in the BRS client’s file and send a copy to the BRS client’s caseworker;

(b) The BRS contractor or BRS provider shall ensure that each BRS client’s mental health, physical health, (including alcohol and drug treatment services), dental and vision needs are arranged for. This does not include paying the cost of services or medications which are covered by the Oregon Health Plan (OHP) or by the BRS client’s third party private insurance coverage. For services or medications not covered by OHP or third party private insurance, the BRS contractor or BRS provider must notify and work with the caseworker to resolve payment issues;

(c) The BRS contractor or BRS provider shall administer and monitor medications consistent with all applicable licensing rules and the program’s own medication management policy;

(d) The BRS contractor or BRS provider shall facilitate the BRS client’s access to other providers whenever identified needs cannot be met within the scope of services offered by the program. If health care services are needed but the program is unable to access the needed services for the BRS client, the BRS contractor or BRS provider shall immediately notify the caseworker about this in writing and document its unsuccessful efforts to access healthcare for the BRS client in the BRS client’s case file.

(3) The Authority’s BRS contractor, if not also the BRS provider, is responsible for ensuring its BRS provider provides the placement related activities to the BRS client as described in this rule.

Stat. Auth.: ORS 413.042, 414.065

Stats. Implemented: ORS 414.065

410-170-0110

Billing and Payment for Services and Placement Related Activities

(1) The BRS contractor is compensated for a billable care day (service and placement related activities rates) on a fee-for-service basis, except as otherwise provided for in these rules. The Authority does not make payments for any calendar day that does not meet the definition of a billable care day under this rule.

(2) Billable care day rates are provided in the “BRS Rates Table”, dated January 1, 2014, which is adopted as Exhibit 1 and incorporated by reference into this rule. The BRS Rates Table is available at www.dhs.state.or.us/policy/healthplan/guides/brs/main.html. A printed copy may be obtained from the agency.

(3) Billable Care Day:

(a) For purposes of computing a billable care day, the BRS client must be in the direct care of the BRS provider at 11:59 p.m. of that day or be on an authorized home visit in accordance with section (4) of this rule;

(b) A billable care day does not include any day where the BRS client is on runaway status, in detention, an inpatient in a hospital, or has not yet entered or has been discharged from the BRS contractor’s or BRS provider’s program.

(4) Home Visits:

(a) The BRS contractor shall only include a maximum of 8 calendar days of home visits in a month as billable care days;

(b) In order to qualify as an authorized home visit day, the BRS contractor must:

(A) Ensure that the home visit is tied to the BRS client’s ISP or MSP;

(B) Work with the BRS client and the BRS client’s family or substitute family on goals for the home visit and receive regular reports from the family on the BRS client’s progress while on the home visit;

(C) Have staff available to answer calls from the BRS client and BRS client’s family or substitute family, and to provide services to the BRS client during the time planned for the home visit if the need arises;

(D) Document communications with the BRS client’s family or substitute family; and

(E) Document the BRS client’s progress on goals set for the home visits.

(5) Invoice form:

(a) The BRS contractor must submit a monthly billing form to the agency in a format acceptable to the agency, on or after the first day of the month following the month in which it provided services and placement related activities to the BRS client. The billing form must specify the number of billable care days provided to each BRS client in that month;

(b) The BRS contractor must provide upon request, in a format that meets the agency’s approval, written documentation of each BRS client’s location for each day claimed as a billable care day;

(c) The BRS contractor may only submit a claim for a billable care day consistent with the agency’s prior authorization.

(6) Payment for a Billable Care Day:

(a) The agency shall pay the service and placement related activities rates to the BRS contractor for each billable care day in accordance with the BRS Rates Table described in section (2) of this rule;

(b) Notwithstanding section (6)(a) of this rule, the Authority shall only pay the service rate for each billable care day to a public child-caring agency, who by rule or contract provides the local match share for Medicaid claims under OAR 410-120-0035 and 42 CFR 433 Subpart B. The Authority shall not pay the placement related activities rate for each billable care day to these types of public child-caring agencies;

(c) To the extent the payment for services is funded by Medicaid and CHIP funds, the BRS contractor and the BRS provider are subject to Medicaid billing and payment requirements in these rules and the Authority’s general rules (OAR 410-120-0000 to 410-120-1980).

(7) Third Party Resources:

(a) The Authority’s BRS contractors must make reasonable efforts to obtain payment first from other resources consistent with OAR 410-120-1280(16);

(b) The Department’s and OYA’s BRS contractors are not required to review or pursue third party resources. The Department and OYA must make reasonable efforts to obtain payment first from other resources consistent with OAR 410-120-1280(16) for Medicaid-eligible BRS clients.

(8) Public child-caring agencies, who are responsible by rule or contract for the local match share portion of eligible Medicaid claims, must comply with OAR 410-120-0035 and 42 CFR 433 Subpart B.

(9) In cases where the BRS contractor is not also the BRS provider, the BRS contractor is responsible for compensating the BRS provider for billable care days pursuant to the agency-approved subcontract between the BRS contractor and the BRS provider.

(10) The Authority shall not be financially responsible for the payment of any claim that the Centers for Medicare and Medicaid Services (CMS) disallows under the Medicaid or CHIP program. If the Authority has previously paid the agency or BRS contractor for any claim which CMS disallows, the payment shall be recouped pursuant to OAR 410-120-1397. The Authority shall recoup or recover any other overpayments as described in OAR 410-120-1397 and OAR 943-120-0350 and 943-120-0360.

Stat. Auth.: ORS 413.042 & 414.065

Stats. Implemented: ORS 414.065

Hist.: DMAP 63-2013, f. 11-14-13, cert. ef. 1-1-14

410-170-0120

Compliance Reviews & Sanctions

(1) The BRS contractor must cooperate, and ensure its BRS providers cooperate, with program compliance reviews or audits conducted by any federal or state or local governmental agency or entity related to the BRS program.

(2) The Authority or agency, or both, must conduct compliance reviews periodically, including but not limited to review of documentation and onsite inspections.

(3) If the agency determines that the BRS contractor is not in compliance with its contract to provide BRS services or placement related activities, including but not limited to non-compliance with state or federal law or regulation, then the agency may:

(a) Provide technical assistance;

(b) Require the BRS contractor or BRS provider to develop and implement a corrective action plan;

(c) Pursue any or all remedies authorized under the contract;

(d) Pursue any other remedy authorized by state or federal law; or

(e) Pursue any combination of the above.

(4) If the agency determines that the BRS contractor or the BRS provider is not in compliance with state or federal law or regulation then, in addition to pursuing any contract remedy, the agency may:

(a) Provide technical assistance;

(b) Require the BRS contractor or BRS provider to develop and implement a corrective action plan;

(c) Refer the case to an appropriate licensing or other oversight federal or state or local governmental agency or entity;

(d) Pursue any other remedy authorized by state or federal law; or

(e) Pursue any combination of the above.

(5) In addition to the remedies provided in section (3) and (4) above, if the Authority determines that the BRS contractor or the BRS provider is not in compliance with state or federal law or regulation, then the Authority may:

(a) Impose sanctions pursuant to OAR 410-120-1400 and 410-120-1460;

(b) Recover an overpayment pursuant to OAR 410-120-1397; or

(c) Any combination of the above.

(6) Overpayment:

(a) The Authority Identified: When an overpayment is identified, the Authority must notify the BRS contractor or BRS provider in writing. The overpayment amount will be determined at the Authority’s discretion through direct examination of claims, through statistical sampling and extrapolation techniques or other means. Procedures for recovery of funds are as described in OAR 410-120-1397 or by applicable contract language;

(b) BRS contractor or Provider Identified: When a BRS contractor or BRS provider discovers that they requested and may have received reimbursement not in compliance with all applicable rules they must contact the Division’s Medicaid Policy Unit and Office of Payment Accuracy and Recovery (OPAR) promptly to report the possible inappropriate payment and discuss the manner by which the appropriateness will be determined as well as programmatic changes and other notifications to be made.

(7) The BRS contractor or the BRS provider may appeal an Authority’s notice of action for sanctions or overpayments under the appeal processes specified in the notice and applicable administrative rules for the Authority.

Stat. Auth.: ORS 413.042, 414.065

Stats. Implemented: ORS 414.065

Hist.: DMAP 63-2013, f. 11-14-13, cert. ef. 1-1-14

Notes
1.) This online version of the OREGON BULLETIN is provided for convenience of reference and enhanced access. The official, record copy of this publication is contained in the original Administrative Orders and Rulemaking Notices filed with the Secretary of State, Archives Division. Discrepancies, if any, are satisfied in favor of the original versions. Use the OAR Revision Cumulative Index found in the Oregon Bulletin to access a numerical list of rulemaking actions after November 15, 2012.

2.) Copyright 2013 Oregon Secretary of State: Terms and Conditions of Use

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