Or. Admin. Code § 411-380-0020 - Definitions and Acronyms
In addition to the following definitions, OAR 411-317-0000 includes general definitions for words and terms frequently used in OAR chapter 411, division 380. If a word or term is defined differently in OAR 411-317-0000, the definition in this rule applies.
(1) "Acuity Level"
means the amount of the medically related support needs of an individual as
measured by the Direct Nursing Services Criteria.
(2) "Authorization" means the approval of a
case management entity for the planning, provision, and payment of direct
nursing services.
(3) "Case
Management Entity" means the Community Developmental Disabilities Program or
Brokerage contracted to deliver the functions of case management.
(4) "Complex Health Management Support Needs"
mean those medical or nursing tasks, activities, or duties in response to a
health condition or series of conditions that impacts all aspects of the care
of an individual, requiring oversight by a nurse and physician.
(5) "Direct Nursing Services" mean the
services described in OAR
411-380-0050 determined
medically necessary to support an individual with complex health management
support needs in their home and community. Direct nursing services are provided
on a shift staffing basis.
(6)
"Direct Nursing Services Agency" means an agency certified under OAR chapter
411, division 323 and endorsed to deliver direct nursing services under these
rules.
(7) "Direct Nursing Services
Criteria" means the assessment to measure the acuity and support level of
nursing tasks to determine eligibility for direct nursing services.
(8) "Enrolled Medicaid Provider" means a
provider that meets and completes all the requirements in these rules, OAR
407-120-0300 through
407-120-0400, and OAR chapter
410, division 120, as applicable.
(9) "Home Health Agency" has the meaning
given that term in ORS
443.014.
(10) "HSD" means Health Systems Division,
Medical Assistance Programs under OHA.
(11) "Individual" means an adult, 21 years of
age or older, eligible for direct nursing services according to OAR
411-380-0030.
(12) "In-Home Care Agency" has the meaning
given that term in ORS
443.305.
(13) "ISP" means "Individual Support
Plan".
(14) "LPN" means a licensed
practical nurse who holds a current license from the Oregon State Board of
Nursing according to ORS chapter 678 and OAR chapter 851, division 045. An LPN
providing direct nursing services under these rules is either one of the
following:
(a) An independent contractor who
is an enrolled Medicaid provider.
(b) An employee of an in-home care agency,
home health agency, or direct nursing services agency.
(15) "MMIS" means "Medicaid Management
Information System". MMIS is the automated claims processing and information
retrieval system for handling all Medicaid transactions. The objectives of the
system include verifying provider enrollment and individual eligibility,
managing health care provider claims and benefit package maintenance, and
addressing a variety of Medicaid business needs.
(16) "Medicaid Provider Enrollment Agreement"
means an agreement between the Department and a provider for the provision of
covered services to covered individuals for payment.
(17) "National Provider Index Number" means a
federally directed provider number mandated for use on Health Insurance
Portability and Accountability Act (HIPAA) covered transactions by individuals,
provider organizations, and subparts of provider organizations that meet the
definition of health care provider (45 CFR
160.103) and who conduct HIPAA covered
transactions electronically.
(18)
"Nurse" means an "LPN" or "RN".
(19) "Nursing Intervention" means the actions
deliberately designed, selected, and performed by a nurse to implement the
Nursing Service Plan.
(20) "Nursing
Service Plan" means the written guidelines developed by an RN as described in
OAR 411-380-0050 that identifies the
specific needs of an individual and the intervention or regiment to assist the
individual to achieve optimal health potential. Developing the Nursing Service
Plan includes a comprehensive and focused nursing assessment of the health
status of the individual as part of the standards outlined in OAR
851-045-0060(3),
establishing individual and nursing goals, and determining nursing
interventions to meet care objectives.
(a)
The Nursing Service Plan is specific to an individual and identifies the
diagnoses and health needs of the individual and all direct nursing service
needs.
(b) The Nursing Service Plan
is separate from the ISP as well as any service plans developed by other health
professionals.
(21)
"OHA" means "Oregon Health Authority".
(22) "OSIPM" means "Oregon Supplemental
Income Program-Medical".
(23)
"Prior Authorization" means payment authorization for direct nursing services
given by the Department or case management entity prior to the delivery of the
service. A physician referral is not a prior authorization for
services.
(24) "Provider" means an
enrolled Medicaid provider who is qualified to deliver direct nursing services
according to OAR 411-380-0060 and is either one
of the following:
(a) A nurse.
(b) An in-home care agency, home health
agency, or direct nursing services agency.
(25) "RN" means a registered nurse who holds
a current license from the Oregon State Board of Nursing according to ORS
chapter 678 and OAR chapter 851, division 045. An RN providing direct nursing
services under these rules is either one of the following:
(a) An independent contractor who is an
enrolled Medicaid provider.
(b) An
employee of an in-home care agency, home health agency, or direct nursing
services agency that is an enrolled Medicaid provider.
(26) "These Rules" mean the rules in OAR
chapter 411, division 380.
(27)
"Third Party Resources" means a medical or financial resource that, under law,
is available and applicable to pay for medical services and items for an
individual.
Notes
Statutory/Other Authority: ORS 409.050, 413.085 & 427.104
Statutes/Other Implemented: ORS 409.010, 413.085, 427.007 & 427.104
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