Or. Admin. Code § 410-120-2015 - [Effective until 6/29/2025] HRSN Eligibility Screening
(1) After receipt
of an HRSN Request, an MCE and, as applicable, the Authority, shall offer to
screen the Member for whom the HRSN Request was made. If the Member consents to
the screening, the MCE or, as applicable, the Authority shall conduct an HRSN
Eligibility Screening in accordance with OAR
410-120-0000 and this rule to
determine whether to authorize the HRSN Service requested.
(2) If the HRSN Connector does not include
all the information in the HRSN Request that is necessary for determining
whether the Member is eligible to receive an HRSN Service, the MCE or, as
applicable, the Authority, shall obtain all the information necessary in order
to conduct the HRSN Eligibility screening, including identifying the specific
service the individual needs.
(a) If an MCE
determines the individual is enrolled in OHP but is enrolled in a different MCE
or is enrolled in FFS, the MCE shall forward the HRSN Request to, as
applicable, the MCE in which the Member is enrolled or the Authority;
(b) If the Authority determines the
individual is enrolled in OHP but is enrolled in an MCE, the Authority shall
forward the HRSN Request to the MCE in which the Member is enrolled.
(3) Except as set forth in section
4 of this rule, Members who provide an MCE or the Authority with a
Self-Attestation, the MCE, or as applicable, the Authority, shall rely on the
Self-Attestation to complete the HRSN Eligibility Screening. If the
Self-Attestation does not include all the information necessary to complete the
HRSN Eligibility Screening, the MCE, or as applicable, the Authority, shall use
good faith efforts to obtain and verify all information necessary to complete
the HRSN Eligibility Screening.
(4)
Self-Attestation of the HRSN Clinical Risk Factor is not sufficient to justify
the medical appropriateness and medical necessity of Medically Tailored
Meals.
(5) All MCEs and the
Authority shall document the results of each HRSN Eligibility Screening, which
must include at minimum, all of the following:
(a) Confirmation the individual is enrolled
in OHP Plus, including the Member's OHP number;
(b) The HRSN Service requested, and whether
the source of the HRSN Request was, (i) Member self-referral/attestation, (ii)
Member Representative, (iii) HRSN Connector (other than an HRSN Service
Provider), (iii) HRSN Service Provider, or (iv) direct outreach from an MCE or
the Authority;
(c) The HRSN Covered
Population to which the Member belongs;
(d) The Member's HRSN Clinical Risk Factor(s)
applicable to the requested HRSN Service as set forth in the Tables 1 and 2
included in OAR 410-120-2005;
(e) The Member's HRSN Social Risk Factors, as
applicable to the requested HRSN Service as set forth in the Tables included in
OAR 410-120-2005;
(f) The Member's HRSN Services authorized (or
denied);
(g) All other eligibility
criteria that may be applicable to the requested HRSN Service as set forth in
the Tables included in OAR
410-120-2005;
(h) All required documentation that may be
applicable to the requested HRSN Service as set forth in the Tables included in
OAR 410-120-2005;
(i) Confirmation or a determination that the
Member is not receiving the same service as the requested HRSN Services from a
local, state, or federally funded program, based on existing documentation or
Member attestation.
(A) If the determination
is made based on Member Self-Attestation without existing, supporting
documentation, the determination must be reasonable in light of the existing
documentation and circumstances.
(B) If the Member is receiving a similar
service as the HRSN Service requested, the HRSN Service may be provided to an
HRSN Authorized Member to fill gaps or otherwise supplement current program,
but in no event shall a Member be authorized to receive duplicate existing
services.
(6)
MCEs and the Authority must document all efforts to collect information to
determine HRSN Service Eligibility. If the information included in a Member's
Self-Attestation cannot, using good faith efforts, be verified within a
reasonable period of time the MCE, or, as applicable, the Authority, must
authorize the identified HRSN Services need(s) if the MCE or, as applicable,
the Authority, has a reasonable basis for concluding the Self-Attestation is
truthful.
(7) HRSN Eligibility
Screenings must be completed within sufficient time to meet the deadline for
authorizing or denying the HRSN Service within fourteen (14) days of receipt of
the complete HRSN Request, in accordance with OAR
410-141-3835.
(8) If the potentially eligible individual is
not enrolled in OHP or is enrolled in OHP but is not enrolled in OHP Plus, the
MCE or the Authority shall connect individuals to resources to determine OHP
Eligibility as requested or consented to by the Member.
Notes
Statutory/Other Authority: ORS 413.042
Statutes/Other Implemented: 414.572, 414.605, 414.665, 414.719 & 414.632
State regulations are updated quarterly; we currently have two versions available. Below is a comparison between our most recent version and the prior quarterly release. More comparison features will be added as we have more versions to compare.
(1) After receipt of an HRSN Request , an MCE and, as applicable, the Authority, shall offer to screen the Member for whom the HRSN Request was made. If the Member consents to the screening, the MCE or, as applicable, the Authority shall conduct an HRSN Eligibility Screening in accordance with OAR 410-120-0000 and this rule to determine whether to authorize the HRSN Service requested.
(2) If the HRSN Connector does not include all the information in the HRSN Request that is necessary for determining whether the Member is eligible to receive an HRSN Service, the MCE or, as applicable, the Authority, shall obtain all the information necessary in order to conduct the HRSN Eligibility screening , including identifying the specific service the individual needs.
(a) If an MCE determines the individual is enrolled in OHP but is enrolled in a different MCE or is enrolled in FFS, the MCE shall forward the HRSN Request to, as applicable, the MCE in which the Member is enrolled or the Authority;
(b) If the Authority determines the individual is enrolled in OHP but is enrolled in an MCE, the Authority shall forward the HRSN Request to the MCE in which the Member is enrolled.
(3) Except as set forth in section 4 of this rule, Members who provide an MCE or the Authority with a Self-Attestation, the MCE, or as applicable, the Authority, shall rely on the Self-Attestation to complete the HRSN Eligibility Screening . If the Self-Attestation does not include all the information necessary to complete the HRSN Eligibility Screening , the MCE, or as applicable, the Authority, shall use good faith efforts to obtain and verify all information necessary to complete the HRSN Eligibility Screening .
(4) Self-Attestation of the HRSN Clinical Risk Factor is not sufficient to justify the medical appropriateness and medical necessity of Medically Tailored Meals.
(5) All MCEs and the Authority shall document the results of each HRSN Eligibility Screening , which must include at minimum, all of the following:
(a) Confirmation the individual is enrolled in OHP Plus, including the Member 's OHP number;
(b) The HRSN Service requested, and whether the source of the HRSN Request was, (i) Member self-referral /attestation, (ii) Member Representative , (iii) HRSN Connector (other than an HRSN Service Provider ), (iii) HRSN Service Provider , or (iv) direct outreach from an MCE or the Authority;
(c) The HRSN Covered Population to which the Member belongs;
(d) The Member 's HRSN Clinical Risk Factor (s) applicable to the requested HRSN Service as set forth in the Tables 1 and 2 included in OAR 410-120-2005;
(e) The Member 's HRSN Social Risk Factors, as applicable to the requested HRSN Service as set forth in the Tables included in OAR 410-120-2005;
(f) The Member 's HRSN Services authorized (or denied);
(g) All other eligibility criteria that may be applicable to the requested HRSN Service as set forth in the Tables included in OAR 410-120-2005;
(h) All required documentation that may be applicable to the requested HRSN Service as set forth in the Tables included in OAR 410-120-2005;
(i) Confirmation or a determination that the Member is not receiving the same service as the requested HRSN Services from a local, state, or federally funded program, based on existing documentation or Member attestation.
(A) If the determination is made based on Member Self-Attestation without existing, supporting documentation, the determination must be reasonable in light of the existing documentation and circumstances.
(B) If the Member is receiving a similar service as the HRSN Service requested, the HRSN Service may be provided to an HRSN Authorized Member to fill gaps or otherwise supplement current program, but in no event shall a Member be authorized to receive duplicate existing services.
(6) MCEs and the Authority must document all efforts to collect information to determine HRSN Service Eligibility. If the information included in a Member 's Self-Attestation cannot, using good faith efforts, be verified within a reasonable period of time the MCE, or, as applicable, the Authority, must authorize the identified HRSN Services need(s) if the MCE or, as applicable, the Authority, has a reasonable basis for concluding the Self-Attestation is truthful.
(7) HRSN Eligibility Screenings must be completed within sufficient time to meet the deadline for authorizing or denying the HRSN Service within fourteen (14) days of receipt of the complete HRSN Request , in accordance with OAR 410-141-3835.
(8) If the potentially eligible individual is not enrolled in OHP or is enrolled in OHP but is not enrolled in OHP Plus, the MCE or the Authority shall connect individuals to resources to determine OHP Eligibility as requested or consented to by the Member .
Notes
Statutory/Other Authority: ORS 413.042
Statutes/Other Implemented: 414.572, 414.605, 414.665, 414.719 & 414.632