Or. Admin. Code § 410-170-0040 - Prior Authorization for the BRS Program; Hearing Rights

(1) The BRS program requires prior authorization from the agency in accordance with the Authority's rules, the general BRS program rules, and applicable agency-specific BRS program rules. A referral by an LPHA or agency to the Authority for prior authorization of the BRS program is not a prior authorization.

(2) Prior Authorization Criteria for the BRS program:

(a) The Authority shall provide prior authorization for the BRS program to an individual who:

(A) Is enrolled in the Oregon Health Plan (OHP), is eligible for Oregon's Medicaid or CHIP program, and is eligible for Early and Periodic Screening, Diagnosis and Treatment (EPSDT) Services, according to the procedures established by the Authority;

(B) Has a determination by a designated LPHA that the BRS program is medically appropriate to meet the individual's medical needs;

(C) Is not receiving residential mental health or residential developmental disability services from another governmental unit or entity;

(D) Is a child; and

(E) Does not have a current prior authorization for the BRS program for the requested time period from OYA or the Department.

(b) OYA or the Department may provide prior authorization for the BRS program for an individual that meets the requirements in its agency-specific BRS program rules.

(3) To meet the requirement in section (2)(a)(B) of this rule, the designated LPHA shall determine that the BRS program is medically appropriate because the individual:

(a) Has a primary mental, emotional, or behavioral disorder or developmental disability that prevents the individual from functioning at a developmentally appropriate level in the individual's home, school, or community;

(b) Demonstrates severe emotional, social, and behavioral problems, including but not limited to: Drug and alcohol abuse; anti-social behaviors requiring close supervision, intervention, and structure; sexual behavioral problems; or behavioral disturbances;

(c) Requires out-of-home behavioral rehabilitation treatment to restore or develop the individual's appropriate functioning at a developmentally appropriate level in the individual's home, school, or community;

(d) Is able to benefit from the BRS program at a developmentally-appropriate level;

(e) Does not have active suicidal, homicidal, or serious aggressive behaviors; and

(f) Does not have active psychosis or psychiatric instability.

(4) The Authority may also request that the designated LPHA determine the BRS type of care that is medically appropriate for the individual. The designated LPHA shall make that determination based on the following factors, including but not limited to the:

(a) Severity of the individual's psychosocial, emotional, and behavior disorders;

(b) Intensity and type of services that would be appropriate to treat the individual;

(c) Type of setting or treatment model that would be most beneficial to the individual;

(d) Least restrictive and intensive setting based on the individual's treatment history, degree of impairment, current symptoms, and the extent of family, including fictive kin, and other supports; and

(e) Behavior management needs of the individual.

(5) The agency is not required to provide prior authorization or to make payment for services or placement-related activities under the following circumstances:

(a) The individual was not eligible for the BRS program at the time services or placement-related activities were provided;

(b) The documentation is not adequate to determine the type, medical appropriateness, or frequency and duration of services;

(c) The services or placement-related activities billed or provided are not consistent with the information submitted when the prior authorization was requested;

(d) The services or placement-related activities billed are not consistent with those provided;

(e) The services or placement-related activities were not provided within the timeframe specified on the notice of prior authorization;

(f) The BRS program is not covered under the individual's medical assistance package;

(g) The services or placement-related activities were not authorized or provided in compliance with the BRS program general rules, agency-specific BRS program rules, or applicable Oregon Health Authority General Rules (OAR Chapter 410, Division 120);

(h) The individual does not meet the prior authorization requirements as stated above;

(i) The BRS contractor or BRS provider was not eligible to receive reimbursement through the BRS program at the time the services or placement-related activities were provided; or

(j) The individual's needs are better met through another system of care; the individual is eligible for services under that system of care; the individual is given notice of that eligibility; and the services necessary to support a successful transition to the alternate system of care are provided.

(6) Retroactive eligibility and authorization:

(a) In those instances when the BRS client is made retroactively eligible for the BRS program, the agency may grant prior authorization if:

(A) The BRS contractor or BRS provider received preliminary approval from the agency prior to admitting the BRS client into its program while the prior authorization process was pending; and

(B) The BRS client met all prior authorization criteria and eligibility requirements on the date that the services and placement-related activities were provided; and

(C) The BRS provider delivered the services and placement-related activities in accordance with all applicable BRS program general rules and agency-specific BRS program rules; and

(D) Prior authorization was retroactively approved by the agency within five business days from the date that the BRS client was admitted into the BRS provider's program.

(b) Prior authorization after five business days from the date the BRS client was admitted into the BRS contractor's or BRS provider's program requires documentation that prior authorization could not have been obtained within those five business days.

(7) Prior authorization is valid for the time-period specified on the agency's prior authorization notice but is not to exceed 12 months from the date on the notice, unless the BRS client is no longer eligible for a medical assistance program that covers the BRS program, in which case the authorization shall terminate on the date coverage ends.

(8) The BRS contractor and BRS provider is responsible for ensuring that there is a prior authorization from the agency for the BRS client in advance of providing the services or placement-related activities for the applicable time period unless section (6) of this rule applies.

(9) If an individual is denied prior authorization for the BRS program under section (2)(a) of this rule, OAR 413-095-0040(1)(a) or OAR 416-335-0040(1)(a), the individual is entitled to notice and contested hearing rights under OAR 410-120-1860 and 410-120-1865. The contested case hearing shall be held by the Authority.

Notes

Or. Admin. Code § 410-170-0040

DMAP 63-2013, f. 11-14-13, cert. ef. 1-1-14; DMAP 118-2018, amend filed 12/26/2018, effective 1/1/2019; DMAP 30-2020, temporary amend filed 06/26/2020, effective 07/01/2020 through 12/27/2020; DMAP 60-2020, amend filed 12/10/2020, effective 12/27/2020

Statutory/Other Authority: ORS 413.042 & 414.065

Statutes/Other Implemented: ORS 414.065