(a) Application and
Agreement. A provider must be an enrolled Medicaid provider in order to be
eligible to receive payment from the Department for claims in connection with
services provided by an IHCA.
The criteria for provider enrollment includes, but is not limited to:
(A) Meeting all program-specific
(B) Providing a copy
of the IHCA agency's current OHA Public Health issued comprehensive classified
(C) Obtaining a Medicaid
Business registration and assumed business name (DBA), if applicable, with the
Oregon Secretary of State's Corporations Division; and
(E) Completing a Medicaid Provider Enrollment
Staffing Requirements. According to OAR
, the agency owner or administrator shall ensure the agency has
qualified and trained employees sufficient in number to meet the needs of the
clients receiving services 365 days per year, including holidays.
On-site Monitoring and Assessment. The
IHCA shall provide to DHS or the AAA a quarterly summary report for each
Medicaid individual, which includes documentation of client needs and services
delivered. These records must be maintained by the IHCA to provide the records
necessary to fully disclose the extent of the services, care, and supplies
furnished to beneficiaries.
shall provide a copy of all information and documents as requested by DHS or
the AAA. This requested information may include, but is not limited to:
administration, and personnel records (OAR 333-536-0050
Individual surveys of services and
payments (OAR 333-536-0041
The requested information shall be submitted to DHS or the AAA within five
business days of the request. However, if the requesting DHS or AAA office
indicates the request involves individual safety, well-being, or a protective
service investigation, the information must be submitted within 24 hours of the
(b) The IHCA
shall cooperate with any DHS quality assurance visits regarding monitoring of
any provision of IHCA services.
(c) The IHCA shall participate in individual
conferences with DHS or AAA case managers, as requested.
(4) Insurance Requirements. Insurance
requirements are defined in the Provider Enrollment Agreement.
Payment and Financial Reporting.
(a) The case manager shall authorize
reimbursement for the service hours identified in the individual's Medicaid
Management Information System (MMIS) plan of care.
(b) The IHCA must use MMIS to submit claims
for reimbursement of Medicaid authorized services. All claims must be submitted
no later than 12 months from date of service.
The IHCA shall be reimbursed:
(A) Only for services delivered to an
(B) Only at the
approved hourly rate for ADL and IADL services.
(C) For up to three hours at the ADL care
rate, for the required, completed initial assessment.
(D) For community transportation mileage
related to an assessed ADL or IADL need (e.g. shopping). Reimbursement for
community transportation may not include mileage for an employee commuting to
and from the individual's home. The IHCA employee must maintain valid driver's
license, current vehicle registration and necessary auto insurance, if
transporting the Medicaid individual. Proof must be available upon the request
of the Department.
IHCA's shall be reimbursed per the rates established in the rate schedule for
home and community-based services in OAR 411-027-0170
Or. Admin. R.
12-2017, f. & cert. ef.
Stat. Auth.: ORS
Stats. Implemented: ORS