Or. Admin. Code § 411-380-0090 - Provider Billing and Payment
(1)
AUTHORIZATION OF HOURS. Authorization for direct nursing service hours are:
(a) Based on acuity levels from the Direct
Nursing Services Criteria and documented on an individual's Direct Nursing
Service Criteria Memo.
(b)
Authorized in the ISP by the case management entity.
(2) PRIOR AUTHORIZATION.
(a) Providers must request electronic
authorization for direct nursing service hours through MMIS and have hours
prior authorized by the Department.
(b) The Department may withdraw, modify, or
deny prior authorizations in the event of any of the following:
(A) Change in the status of the individual,
such as eligibility for direct nursing services, hospitalization, improvement
in health status, or death.
(B)
Decision of the individual, their family, or the legal representative, to
change providers.
(C) Failure to
comply with the delivery of direct nursing services and
documentation.
(D) Failure to
perform other expected duties.
(3) CLAIMS.
(a) A provider must comply with the rules for
timely submission of claims as written in OAR
410-120-1300 and authorization
of payment in OAR 410-120-1320. A provider must
submit a claim for payment to the case management entity within 12 months of
the date of service.
(b) A provider
must follow all Department required documentation procedures for timesheets,
invoices, and signatures and submit true and accurate information.
(c) Medicaid funds are the payer of last
resort. A provider must bill all third party resources until all resources are
exhausted.
(d) A provider may not
submit any of the following to the Department or case management entity:
(A) A false billing form for
payment.
(B) A billing form for
payment that has been, or is expected to be, paid by another source.
(C) Any billing form for services that have
not been provided.
(e)
The billing form used to submit a claim must include the prior authorization
number.
(f) A provider must sign
the billing form acknowledging agreement with the terms and conditions of the
claim and attesting that the hours were delivered as billed.
(g) The case management entity must review
the claim and match the number of hours claimed by the provider against the
number of hours prior authorized. The case management entity must review,
approve, and forward the claim to the Department in a timely manner.
(h) Claims for direct nursing services may be
paid for nursing ratio other than 1:1 as long as each individual's case does
not overlap with another individual's case. Only time spent with each
individual may be billed. Claims must be billed in 15 minute units.
(4) PAYMENT.
(a) Payment for direct nursing services is
made in accordance with the following:
(A)
These rules.
(B) OAR
410-120-1300 for timely
submission of claims.
(C) OAR
410-120-1320 for authorization
of payment.
(D) OAR
410-120-1340 for
payment.
(E) OAR
410-120-1380 for compliance with
federal and state statutes.
(G) OAR
407-120-1505 for provider and
contractor audits, appeals, and post payment recoveries.
(b) Funds may not be used to support, in
whole or in part, a provider in any capacity who has been convicted of any of
the disqualifying crimes listed in ORS
443.004.
(c) Payment for direct nursing services are
fee-for-service with payment made subsequent to the delivery of the
services.
(d) The Department does
not pay for services that are not authorized in the ISP.
(e) Providers must be present with an
individual in the delivery of direct nursing services in order to claim
payments.
(f) Holidays are paid at
the same rate as non-holidays.
(g)
Overtime hours are not authorized.
(h) Payment by the Department for direct
nursing services is considered payment in full for the services rendered under
Medicaid. A provider may not demand or receive additional payment for direct
nursing services from an individual, their family member, foster care provider,
agency provider, or any other source, under any circumstances.
(i) Payment may be denied based on the
provisions of these rules and OAR
410-120-1320.
(5) OVERPAYMENT. An overpayment
occurs when a provider submits a claim or encounter, or received payment the
provider is not properly entitled to. The determination of overpayment is based
on OAR 410-120-1397(5)(a)-(h).
The Department and OHA recoup all overpayments under OAR
410-120-1397.
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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