Or. Admin. R. 411-070-0028 - Bariatric Authorization and Payment
(1) PRIOR AUTHORIZATION. APD may authorize
payment for the bariatric rate when a Medicaid individual's needs meet the
criteria listed in OAR 411-070-0087. A nursing facility must obtain prior
authorization from the Department prior to admitting or submitting payment for
a bariatric individual using a form designated by the Department.
(2) APD shall issue a decision regarding
prior authorization within seven business days of receipt of the form described
in section (1) of this rule. APD may extend this timeframe for up to ten
additional business days pursuant to written notice to the nursing facility if
APD requires further information from the nursing facility in order to make a
prior authorization determination. If APD does not issue a decision within the
timeframes described in this paragraph, prior authorization shall be deemed to
be granted on the day the required timeframe expires.
(3) Prior authorization provided pursuant to
this rule shall be effective as of the date APD issues the decision or prior
authorization is deemed to be granted pursuant to section (2) of this rule or,
if the nursing facility submits the form described in section (1) of this rule
after admitting the resident, on the date of admission if that date occurs no
more than seven calendar days prior to submission of the form.
(4) PAYMENT. For a Medicaid individual who
meets the criteria in OAR 411-070-0087, the bariatric rate will be effective
from the date a prior authorization from the Department is in effect to the
last date the individual meets the criteria.
(5) DOCUMENTATION. The licensed nursing staff
of the facility must maintain a weekly nursing note of sufficient documentation
pertinent to the bariatric individual in the clinical record to justify the
bariatric payment determination in accordance with OAR 411-070-0087. This
documentation must be available to APD upon request.
(6) Bariatric per diem rates shall cover all
services in the bundled rate (OAR 411-070-0085) as well as all services,
equipment, supplies and costs related to bariatric services.
(7) BARIATRIC RATE PROHIBITED. APD may not
provide bariatric payments for a facility with a waiver that allows a reduction
of eight or more hours per week from required licensed nurse staffing
hours.
(8) OVERPAYMENT FOR
BARIATRIC MEDICAID PAYMENTS. The Department may collect monies that were
overpaid to a facility for any period the Department determines the
individual's condition or service needs did not meet the criteria for an
eligible individual or determines the facility did not maintain the required
documentation per (5) of this rule. The Department shall issue an order to the
facility that includes the determination described in this paragraph and the
facts supporting the determination as well as the amount of overpayment the
Department seeks to recoup.
(9)
ADMINISTRATIVE REVIEW.
(a) If a provider
disagrees with the order of the Department regarding authorization pursuant to
section (1) of this rule or overpayment pursuant to section (8) of this rule,
the provider may either request from APD an informal administrative review of
the decision or appeal the order as described in this paragraph.
(b) If the provider requests an informal
administrative review, the provider must submit its request for review in
writing within 30 days of receipt of the notice.
(A) The provider must submit documentation,
as requested by APD and as the provider may choose to further submit to
substantiate its position.
(B) APD
shall notify the provider in writing of its informal decision within 45 days of
APD's receipt of the provider's request for review.
(C) APD's informal decision shall be an order
in other than a contested case and subject to review pursuant to ORS chapter
183.
(c) A provider who
disagrees with the order issued pursuant to section (9) of this rule may appeal
the order pursuant to a contested case proceeding. The provider must submit an
appeal in writing within 60 days of receipt of the order.
Notes
Statutory/Other Authority: ORS 410.070
Statutes/Other Implemented: ORS 410.070
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