Or. Admin. R. 411-370-0010 - Definitions and Acronyms
In addition to the following definitions, OAR 411-317-0000 includes general definitions for words and terms frequently used in OAR chapter 411, division 370. If a word or term is defined differently in OAR 411-317-0000, the definition in this rule applies.
(1) "Administrator"
means the Director of the Oregon Department of Human Services, Office of
Developmental Disabilities Services, or their designee.
(2) "Appropriate Service" means services that
are required by a recipient's approved individual service or support plan that
are:
(a) Consistent with the recipient's
identified needs, goals, and desired outcomes.
(b) Appropriate with regard to standards of
generally recognized practice, evidence based practice, and professional
standards of service as effective.
(c) Not solely for the convenience of a
provider of the service.
(d) The
most cost effective of the alternative services that may be effectively
provided to a recipient.
(e)
Coordinated with the recipient's local case management entity.
(3) "Authorization" means either
service or payment authorization for specified covered services given prior to
services being rendered by Department staff, or the Department's designee
including Community Developmental Disabilities Programs and
Brokerages.
(4) "Billing Provider"
means a person, agent, business, corporation, or other entity who, in
connection with submission of claims to the Department, receives or directs
payment from the Department on behalf of a performing provider and has been
delegated the authority to obligate or act on behalf of the performing
provider.
(5) "Claim" means a bill
for services, a line item of a service, or all services for one recipient
within a specified billing period. Claims include a bill submission, an
invoice, or an encounter associated with requesting payment whether submitted
on paper or electronically. Claim also includes any other methodology for
requesting payment or as verification of an expenditure of an advanced payment
that may be established in contract, provider enrollment agreement, or
program-specific rules.
(6)
"Community Services Programs" are developmental disabilities services provided
for recipients under the following program names, service element numbers, or
descriptions:
(a) Nursing facility
specialized services (DD 45) as described in OAR chapter 411, division
070.
(b) Residential programs (DD
50) as described in OAR chapter 411, division 325.
(c) Supported living programs (DD 51) as
described in OAR chapter 411, division 328.
(d) Transportation services (DD 53) as
described in the applicable service element standards and procedures and
community transportation services as described in OAR chapter 411, division
435.
(e) Employment services as
described in OAR chapter 411, division 345.
(f) Community living supports as described in
OAR chapter 411, division 450.
(g)
Rent subsidies (DD 56) as described in the applicable service element standards
and procedures.
(h) Developmental
disabilities special projects (DD 57) as described in the applicable service
element standards and procedures.
(i) Children's residential programs (DD 142)
as described in OAR chapter 411, division 325.
(j) Host home programs as described in OAR
chapter 411, division 348.
(k) Room
and board (DD 156) as described in the applicable service element standards and
procedures.
(l) Professional
behavior services as described in OAR chapter 411, division 304.
(m) Direct nursing services as described in
OAR chapter 411, division 380. The implementation and provision of direct
nursing services for 24-hour residential programs and settings shall occur upon
official approval from the Centers for Medicare and Medicaid
Services.
(n) Adult foster care
programs (DD158) as described in OAR chapter 411, division 360.
(o) Foster homes for children (DD258) as
described in OAR chapter 411, division 346.
(7) "Covered Services" mean appropriate
services that are funded by the legislature and applicable Department rules
describing the community services programs provided to eligible recipients
under service element standards and procedures, program-specific requirements,
provider enrollment agreements, or contracts by providers required to enroll
with the Department under these rules.
(8) "Date of Service" means the date the
recipient receives community services program services, unless otherwise
specified in the appropriate program-specific rules.
(9) "Department" means the Oregon Department
of Human Services. For the purpose of these rules, Department also includes the
responsibility for the day-to-day operation and administration of 1915(c) Home
and Community-Based Services waivers and the 1915(k) Community First Choice
state plan as the operating agency designated by OHA.
(10) "Express Payment and Reporting System
(eXPRS)" means the Department's information system for managing the
disbursement and tracking of Department funding for certain developmental
disabilities services.
(11) "False
Claim" means a claim or encounter a provider knowingly submits or causes to be
submitted that contains inaccurate or misleading information, and that
information would result, or has resulted, in an overpayment or other improper
payment.
(12) "Fraud" means an
intentional deception or misrepresentation made by a recipient or provider with
the knowledge the deception may result in some unauthorized benefit to himself
or herself, or some other recipient or provider. Fraud includes any act that
constitutes fraud or false claim under applicable federal or state
law.
(13) "Medicaid" means a
federal and state funded program established by Title XIX of the Social
Security Act, as amended, and administered in Oregon by the
Department.
(14) "Medicaid Fraud
Control Unit (MFCU)" means the unit of the Oregon Department of Justice that
investigates and prosecutes billing fraud committed by Medicaid providers. MFCU
also may investigate and prosecute physical, sexual, or financial abuse and
neglect of residents who reside in Medicaid-funded facilities.
(15) "Medicaid Management Information System
(MMIS)" means the automated claims processing and information retrieval system
for handling all Medicaid transactions. The objectives of MMIS include
verifying provider enrollment and client eligibility, managing health care
provider claims and benefit package maintenance, and addressing a variety of
Medicaid business needs.
(16)
"Medicare" means the federal health insurance program for the aged and disabled
administered by the Centers for Medicare and Medicaid Services under Title
XVIII of the Social Security Act.
(17) "OHA" means Oregon Health Authority. OHA
is the Single State Medicaid Agency for Oregon and retains ultimate authority
and responsibility for the administration of the Medicaid State Plan.
(18) "Provider" or "Performing Provider"
means an individual, agency, corporate entity, or other organization that
provides community services program services and is enrolled with the
Department in accordance with these rules to seek payment from the
Department.
(19) "Quality
Improvement" means the effort to improve the level of performance of key
processes, practices, or outcomes in service provision. A quality improvement
program measures the level of current performance of the processes and
practices, finds ways to improve the performance or outcomes, and implements
new and better methods for the processes or practices. Quality improvement
includes the goals of quality assurance, quality control, quality planning, and
quality management.
(20)
"Recipient" means an individual found eligible by the Community Developmental
Disabilities Program and the Department under OAR chapter 411, division 320 to
receive community services program services.
(21) "Service Element Standards and
Procedures" means the standard for a particular service element number that
further describes the applicable service and details the purpose, performance
requirements, special reporting requirements, and applicable rules to adhere to
when providing that particular service element.
(22) "SFMA" means the "Oregon Statewide
Financial Management Services".
(23) "Suspension" means a sanction
prohibiting a provider's participation in the Department's community services
programs by deactivation of the assigned provider number for a specified period
of time or until the occurrence of a specified event.
(24) "These Rules" mean the rules in OAR
chapter 411, division 370.
(25)
"Third Party Resource (TPR)" means a service or financial resource that, by
law, is available and applicable to pay for covered services for community
services programs.
(26) "United
States Department of Health & Human Services (USDHHS)" means the Cabinet
department of the United States government with the goal of protecting the
health of all Americans and providing essential human services.
Notes
Statutory/Other Authority: ORS 409.050, 411.060 & 430.662
Statutes/Other Implemented: ORS 409.010, 427.007, 430.215, 430.610, 430.620, 430.662 & 430.664
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