Or. Admin. Code § 309-033-0265 - The Authority's Denial of Payment for Services to Persons in Custody or on Diversion
(1) The Authority
denial. The Authority shall deny part or all payment for services for a person
in custody or on a diversion only when the Authority determines that there is
insufficient evidence to reasonably support the belief that the person in
custody demonstrated:
(a) Living with a mental
disorder; and
(b) Dangerousness to
self or others as evidenced by thoughts, plans, means, actions, history of
dangerousness or other indicators of imminent dangerousness which Division
believes are within accepted community standards of professional
knowledge.
(2) The
Authority consultation with Licensed Independent Practitioner (LIP). When
making a determination under this rule which is primarily based on accepted
community standards of professional knowledge, the Authority shall consult with
a LIP.
(3) Information payer must
submit. When making a request for denial of payment, the payer responsible for
the services provided to the person in custody or on diversion under ORS
426.241 shall submit the
following to the Authority:
(a) A statement
requesting the Authority review the appropriateness of the hold or diversion
for the purpose of approving denial of part or all payment for services
rendered;
(b) An explanation of why
the payer believes the services provided to the person in custody or on
diversion do not meet criteria described in ORS
426.232,
426.233 or
426.237;
(c) Any documentation which supports the
payer's belief that the services provided to the person in custody or on
diversion were inappropriate.
(4) Clinical records to be submitted. At the
request of the Authority, as provided by ORS
426.241(5)(b),
the following shall submit clinical records and other documents requested
relating to the services in question to the Division:
(a) A hospital or a nonhospital facility
approved under OAR 309-033-0530;
(b) A LIP or person providing services to the
person in custody or on diversion.
Notes
Statutory/Other Authority: 413.042, 426.005, 426.060, 426.110(2), 426.232, 426.236
Statutes/Other Implemented: 426.241
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