Or. Admin. Code § 410-125-0230 - Qualified Directed Payments
Qualified Directed Payments (QDP) are payments made by the Oregon Health Authority (Authority) to Coordinated Care Organizations (CCOs) from three Quality and Access pools for distinct provider classes as follows:
(i) Rural Type A and Type B
hospitals,
(ii) Public Academic
Health Centers and
(iii) DRG
hospitals. Each provider class is defined in §438.6(c) Preprint forms
approved by the U.S. Department of health and Human Services Centers for
Medicare and Medicaid Services. QDPs are tied to inpatient and outpatient
encounters with Medicaid and Children's Health Insurance Program (CHIP) members
enrolled in Coordinated Care Organizations. However, the Authority does not
make Qualified Directed Payments for encounters with members who received
Citizenship Waived Medical (CWM) or CWM Plus Benefit Packages.
(1) Type A and Type B hospitals:
(a) The Authority shall make a qualified
directed payment only if the Type A or Type B hospital meets criteria
established by the Authority for the Type A or Type B hospital Quality and
Access program in accordance with applicable federal requirements, which may be
updated as needed.
(b) The
Authority shall make a qualified directed payment for each inpatient and
outpatient encounter; one encounter per member, per day, per
facility;
(c) QDP amounts shall be
at two separate rates; one for inpatient encounters and one for outpatient
encounters;
(d) Payment rates shall
be set by the Authority and may be adjusted based on actual utilization and
available Quality and Access Funds;
(e) The Authority shall create a monthly
report to assist CCOs in distributing funds to the appropriate hospital. The
report shall be distributed to each CCO and each Type A and Type B
hospital;
(f) Within five (5)
business days after receipt of the monthly report, the CCO shall submit an
electronic payment to an account established by the hospital for the amount
indicated on the report;
(g)
Adjustments shall be processed weekly through the Medicaid payment system and
included in the monthly report.
(2) Public Academic Health Centers:
(a) The Authority shall make a qualified
directed payment only if the public academic medical center meets criteria
established by the Authority for the Public Academic Medical Center Quality and
Access program in accordance with applicable federal requirements, which may be
updated as needed.
(b) The
Authority shall make a qualified directed payment for each inpatient and
outpatient encounter; one encounter per member, per day, per
facility;
(c) QDP amounts shall be
at two separate rates. One for inpatient encounters and one for outpatient
encounters;
(d) Payment rates shall
be set by the Authority and may be adjusted based on actual utilization and
available Quality and Access Funds;
(e) The Authority shall combine the weekly
encounters into a monthly report to assist CCOs in distributing the funds to
the appropriate hospital. The report shall be distributed to each CCO and
public academic health center;
(f)
Within five (5) business days after receipt of the monthly report, the CCO
shall submit an electronic payment to an account established by each public
health center for the amount indicated on the report;
(g) Adjustments shall be processed weekly
through the Medicaid payment system and included in the monthly
report.
(3) Diagnosis
Related Grouper (DRG) Hospitals:
(a) The
Authority shall make a qualified directed payment only if the DRG Hospital
meets criteria established by the Authority for the DRG Hospital Quality and
Access Pool program in accordance with applicable federal requirements, which
may be updated as needed.
(b) The
Authority shall make a qualified directed payment for each inpatient and
outpatient encounter; one encounter per member, per day, per
facility;
(c) QDP amounts shall be
at two separate rates. One for inpatient encounters and one for outpatient
encounters;
(d) Payment rates shall
be set by the Authority and may be adjusted based on actual utilization and
available Quality and Access Funds;
(e) The Authority shall create a monthly
report to assist CCOs in distributing funds to the appropriate hospital. The
report shall be distributed to each CCO and each DRG hospital;
(f) Within five (5) business days after
receipt of the monthly report, the CCO shall submit an electronic payment to an
account established by the hospital for the amount indicated on the
report;
(g) Adjustments shall be
processed weekly through the Medicaid payment system and included in the
monthly report.
(4) If
an error is identified in the monthly report, the CCO shall make the payment
based on the original amount provided in the report. The Authority shall
identify separately the correction in the following month's report and adjust
the total payment amount to account for the error.
Notes
Statutory/Other Authority: ORS 413.042 & ORS 414.869
Statutes/Other Implemented: ORS 414.869
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