Or. Admin. Code § 411-348-0490 - [Effective until 7/21/2025] Provider Eligibility for Medicaid Service Payment
(1) In addition to
meeting the licensing standards and conditions set forth in these rules, a
program provider must have an approved prior authorization through the
Department payment system for children receiving Medicaid-funded services
before the program provider is eligible to claim for delivering Medicaid-funded
services. The prior authorization includes dates of authorized services and the
funding amount allocated.
(2) A
program provider may only claim for a day of service when:
(a) A child sleeps in the Host Home or
alternative care setting overnight; or
(b) A child does not sleep in the Host Home
overnight, but intends to return to the Host Home, and the program provider was
responsible for an accumulated period of eight hours for the primary care,
support, safety, and well-being of the child, including any of the following:
(A) Providing intermittent physical support
or care.
(B) Providing stand-by
support with the ability to respond in person within the response times as
outlined in the child's ISP.
(C)
Being responsible to communicate reciprocally within the response times agreed
upon by the child's ISP team and documented in the child's ISP, based on the
child's identified support needs.
(3) A day of service does not apply when a
child:
(a) Has been admitted overnight to a
hospital.
(b) Has been admitted to
a nursing facility.
(c) Is held in
detention or jail.
(4) A
program provider may only claim for a day of service under section (2)(b) of
this rule when a child is away from the Host Home or alternative care setting,
accompanied by a program provider, in-residence caregiver, or staff, for up to
30 consecutive days or 45 calendar days in an ISP year.
(a) The program provider is not paid for the
31st and following consecutive days when a child is away from the Host
Home.
(b) A program provider is not
paid for the 46th and following non-consecutive days a child is not at the
licensed Host Home overnight.
(c)
Days not paid do not count in the 45-calendar day total.
Notes
Statutory/Other Authority: ORS 409.050, 427.104, 430.662, 441.715, 443.450 & 443.455
Statutes/Other Implemented: ORS 409.010, 427.007, 427.101, 427.104, 430.215, 430.610, 430.662, 441.705-441.720, 441.740, 441.745, 443.384, 443.392, 443.400-443.445, 443.450, 443.455, 443.880, 443.881 & 443.991
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