AUTHORIZATION. The Department may reimburse a nursing facility for services
provided to a Department resident only if prior authorized after the Department
has participated in development of the placement plan and is satisfied that the
placement is justified and most suitable for the person according to the
Department care plan. The Department may not reimburse a nursing facility for
services rendered prior to the date of referral to the Department. A nursing
facility must verify that the local SPD/Type B AAA where the facility is
located is involved in the placement.
(2) The facility must confirm an individual's
financial eligibility for Medicaid payment of any nursing facility service with
the local office. Medicaid eligibility is based on the requirements outlined in
OAR chapter 461. The facility is responsible for collecting resident liability
from the resident or their responsible party.
(3) PAYMENT TO PROVIDER. Provider payments
will be made following the month of service. For billing, the Department will
mail Form SDS 483, Invoice and Payment Authorization, to each
(4) RESIDENT'S INCOME. A
resident's income, exclusive of the authorized allowance for personal
incidental needs and other prior authorized special needs, will be offset as a
credit against the established Department rate paid to that facility.
REDUCED PAYMENT FOR ABUSE.
If abuse of a resident, according to the
provisions of ORS 441.630
, is substantiated by the
Department, the Department may reduce the payment for the resident(s) for the
month the abuse occurred, and until such time as the Department determines the
conditions leading to the abuse have been corrected.
(A) The facility will receive payment for
services provided for the resident as determined by the Department. This
determination will be based on the absence of appropriate services that
resulted in the substantiated abuse of a resident.
(B) The reduced payment may not be considered
a reduction in benefits for the resident.
The Department will notify the facility
by certified mail at least 15 days prior to taking action to reduce payment.
(A) The notice will include the basis of the
Department decision, the effective date of the reduced payment, the amount of
the reduced payment, and will advise the facility of their right to request
review by the Assistant Director if such request is made in writing within 30
days of the receipt of the notice.
(B) If a request for review is made, the
Assistant Director will include the basis of the Department decision, the
effective date of the reduced review and all material relating to the
allegation of resident abuse and to the reduction in payment. The Assistant
Director will include the basis of the Department decision, the effective date
of the reduced determination, based upon review of the material, whether or not
to sustain the decision to reduce payments to the facility and will notify the
facility of the decision within 20 days of receiving the request for
(C) If the Assistant
Director determines not to sustain the decision to reduce payments, the
reduction will be lifted immediately. Otherwise, the reduction in payment will
remain in effect until the Department determines the conditions leading to the
abuse have been corrected.
the decision to reduce payment is sustained, the payment reduction will not be
recovered in the year end settlement.
Or. Admin. R.
PWC 847(Temp), f. & ef.
7-1-77; PWC 859, f. 10-31-77, ef. 11-1-77; Renumbered from 461-017-0070 by Ch.
184, OL 1981 & AFS 69-1981, f. 9-30-81, ef. 10-1-81; SSD 20-1990, f. &
cert. ef. 10-4-90; SPD 9-2006, f. 1-26-06, cert. ef. 2-1-06; SPD 2-2008, f.
2-29-08, cert. ef. 3-1-08
Forms referenced are available from the
Stat. Auth.: ORS
Stats. Implemented: ORS