Or. Admin. Code § 410-173-0015 - Service Authorization

(1) Authorization medical appropriateness and medical necessity for Residential Habilitation are satisfied by face-to-face eligibility or re-eligibility assessments of 1915(i) HCBS State Plan Option. These services include:

(a) Completion of a Division approved functional needs assessment tools; and

(b) Documentation of the accessed need for services by the Individual in the person-centered service plan; and

(c) Agreed to in writing by the Individual, legal representative or authorized representative, providers, Case Management Entity (CME) and IQA PCSP Coordinator.

(2) HCBS and supports for persons with chronic mental illness or an SPMI shall be deemed medically appropriate and necessary by a QMHP or other licensed provider within the scope of their practice, as outlined in OAR 410-120-0000 and OAR 410-172-0630 and for which required documentation has been submitted;

(3) Once deemed medically appropriate and necessary, HCBS identified in the PCSP are authorized for as long as deemed necessary by the QMHP, but no longer than twelve (12) months;

(4) The Division may authorize payment for the type of service that meets the Individual's assessed needs as determined by a Functional Needs Assessment and is adequately documented in the individuals PCSP. The Division or the IQA may request additional information from the provider to determine medical appropriateness and medical necessity;

(5) Required documentation for PSR services shall support the Individual's assessed need for the service request shall include:

(a) A cover sheet detailing relevant provider and recipient Medicaid numbers;

(b) Requested dates of service;

(c) HCPCS or CPT procedure codes requested;

(d) The amount of service or units requested;

(e) A behavioral health assessment and service plan meeting the requirements described in OAR 309-019-0135; and

(f) Any additional clinical information supporting medical justification for the services requested.

(6) The Division or the IQA may not authorize PSR services under the following circumstances:

(a) The request received by the Division or IQA was not complete;

(b) The provider did not hold the appropriate license, certificate, or credential at the time services were requested;

(c) The recipient was not eligible for Title XIX Medicaid at the time services were requested;

(d) The provider cannot produce appropriate documentation to support medical appropriateness;

(e) The services requested are not in compliance with OAR 410-120-1260 through 1860.

(7) Retroactive payments are not allowable. The service cannot be billed until it is documented and agreed upon by appropriate parties as describe by this rule;

(8) Payment for authorized services is valid for the time-period specified on the authorization notice but may not exceed twelve (12) months from the date of service;

(9) Authorizations expire when an Individual is found to be no longer eligible for 1915(i) HCBS;

(10) Athorized HCBS services shall be subject to random, periodic utilization review and retrospective review to ensure approved, paid services meet the definition of medical appropriateness and medical necessity as outlined in OAR 410-120-0000 and OAR 410-172-0630 are consistent with the Functional Needs Assessment.

Notes

Or. Admin. Code § 410-173-0015

DMAP 12-2019, temporary adopt filed 05/21/2019, effective 06/01/2019 through 11/27/2019; DMAP 46-2019, adopt filed 11/07/2019, effective 11/26/2019; DMAP 41-2023, minor correction filed 05/24/2023, effective 5/24/2023; DMAP 45-2023, minor correction filed 05/25/2023, effective 5/25/2023; DMAP 42-2024, amend filed 02/14/2024, effective 2/29/2024

Statutory/Other Authority: ORS 413.042, 414.025 & 430.640

Statutes/Other Implemented: ORS 413.042, 414.025, 430.640, ORS 414.065, 430.705 & 430.715