Or. Admin. Code § 410-172-0730 - Payment Limitations for Behavioral Health Services
(1) Services shall be subject to periodic
utilization review to determine medical appropriateness.
(2) If a review reveals that a recipient
received less than active treatment, payment may not be allowed under these
rules and prior authorization may be cancelled.
(3) The Division may make no payment for
services if the Division or designee has determined the service is not
medically appropriate.
(4)
Residential treatment services are provided to Medicaid Title XIX eligible
individuals in facilities with 16 or fewer beds. Payment is excluded for
individuals in "institutions of mental diseases" (IMD) who are over age 18 and
under age 65. IMDs are defined in
42 CFR
435.1010.
(5) For residential facilities, the Division
shall pay for the day of admission but may not pay for the day of transfer or
discharge.
(6) Medicaid may not
reimburse costs associated with room and board for recipients residing in
Authority licensed residential treatment programs.
Notes
Statutory/Other Authority: ORS 413.042 & 430.640
Statutes/Other Implemented: ORS 413.042, 414.025, 414.065, 430.640, 430.705 & 430.715
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