Or. Admin. Code § 410-170-0110 - Billing and Payment for Services and Placement-Related Activities
Effective July 1, 2023:
(1) The BRS contractor is compensated for a
billable care day (service and placement-related activities rates) on a
fee-for-service basis, except as otherwise provided for in these rules. The
Authority does not make payments for any calendar day that does not meet the
definition of a billable care day under this rule.
(2) Billable care day rates are provided in
the "BRS Rates Table," dated July 1, 2023, which is adopted as Exhibit 1 and
incorporated by reference into this rule. The BRS Rates Table is available at
http://www.oregon.gov/oha/HSD/OHP/Pages/Policy-BRS.aspx.
A printed copy may be obtained from the agency. BRS contractors not meeting the
QRTP requirements will be paid at the non-QRTP rate.
(3) Billable Care Day:
(a) For purposes of computing a billable care
day, the BRS client must be in the direct care of the BRS contractor or BRS
provider at 11:59 p.m. of that day, be on runaway status as defined in this
rule or be on an authorized home or transitional visit in accordance with
section (4) of this rule;
(b) A
billable care day does not include any day where the BRS client is in
detention, an inpatient in a hospital, or has not yet entered or is discharged
from the BRS contractor's or BRS provider's program;
(c) A billable care day does not include any
day in which a BRS client is on runaway status and the BRS contractor or BRS
provider was responsible for less than an accumulated period of 8 hours for the
primary care, support, safety, and well-being of the BRS client.
(4) Home and Transitional Visits:
(a) The BRS contractor and BRS provider shall
include only a maximum of eight (8) calendar days of a combination of home and
transitional visits in a month, as billable care days;
(b) In order to qualify as an authorized home
or transitional visit day, the BRS contractor and BRS provider must:
(A) Ensure that the home or transitional
visit is tied to the BRS client's service plan;
(B) Work with the BRS client and the BRS
client's family, including fictive kin, or aftercare resource on goals for the
home or transitional visit and receive regular reports from the family or
aftercare resource on the BRS client's progress while on the visit;
(C) Have staff available to answer calls from
the BRS client and BRS client's family, including fictive kin, or aftercare
resource and to provide services to the BRS client during the time planned for
the home or transitional visit if the need arises;
(D) Document communications with the BRS
client's family, including fictive kin, or aftercare resource; and
(E) Document the BRS client's progress on
goals set for the home or transitional visits.
(5) Invoice form:
(a) The BRS contractor shall submit a monthly
billing form to the agency in a format acceptable to the agency on or after the
first day of the month following the month in which it provided services and
placement-related activities to the BRS client. The billing form must specify
the number of billable care days provided to each BRS client in that
month;
(b) The BRS contractor shall
provide upon request, in a format that meets the agency's approval, written
documentation of each BRS client's location for each day claimed as a billable
care day;
(c) The BRS contractor
shall submit only claims for billable care days consistent with the agency's
prior authorization.
(6)
Payment for a Billable Care Day:
(a) The
agency shall pay the service and placement related activities rates to the BRS
contractor for each billable care day in accordance with the BRS Rates Table
described in section (2) of this rule;
(b) Notwithstanding section (6)(a) of this
rule, the Authority shall pay only the service rate for each billable care day
to a public child-caring agency who by rule or contract provides the local
match share for Medicaid claims under OAR
410-120-0035 and 42 CFR 433
Subpart B. The Authority may not pay the placement related activities rate for
each billable care day to these types of public child-caring
agencies;
(c) To the extent the
payment for services is funded by Medicaid and CHIP funds:
(A) The BRS contractor and the BRS provider
are subject to Medicaid billing and payment requirements in these rules and the
Authority's general rules (OAR Chapter 410, Division 120);
(B) Payment using Medicaid and CHIP funds may
be made only to the originating BRS contractor and not to the aftercare
resource.
(d) To be
eligible as a QRTP and receive the QRTP rate, the BRS contractor and the BRS
provider are required to:
(A) Meet the QRTP
definition in OAR 410-170-0020; and
(B) Submit accreditation documentation in
writing annually to the contract administrator; and
(C) Maintain compliance as described in OAR
410-170-0030(11)(L).
(7) Third Party
Resources:
(a) The Authority's BRS
contractors must make reasonable efforts to obtain payment first from other
resources consistent with OAR
410-120-1280;
(b) The Department's and OYA's BRS
contractors are not required to review or pursue third party resources. The
Department and OYA must make reasonable efforts to obtain payment first from
other resources consistent with OAR
410-120-1280 for
Medicaid-eligible BRS clients.
(8) Public child-caring agencies who are
responsible by rule or contract for the local match share portion of eligible
Medicaid claims must comply with OAR
410-120-0035 and 42 CFR 433
Subpart B.
(9) In cases where the
BRS contractor is not also the BRS provider, the BRS contractor is responsible
for compensating the BRS provider for billable care days pursuant to the
agency-approved subcontract between the BRS contractor and the BRS
provider.
(10) The Authority may
not be financially responsible for the payment of any claim that the Centers
for Medicare and Medicaid Services (CMS) disallows under the Medicaid or CHIP
program. If the Authority previously paid the agency or BRS contractor for any
claim that CMS disallows, the payment shall be recouped pursuant to OAR
410-120-1397. The Authority
shall recoup or recover any other overpayments as described in OAR
410-120-1397 and
943-120-0350 and
943-120-1505.
Notes
To view attachments referenced in rule text, click here to view rule.
Statutory/Other Authority: ORS 413.042 & ORS 414.065
Statutes/Other Implemented: ORS 414.065
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