Or. Admin. Code § 410-120-2020

Current through Register Vol. 63, No. 12, December 1, 2024

Section 410-120-2020 - Authorization of HRSN Services; Referral to HRSN Service Provider.

(1) If, after completing the HRSN Eligibility Screening in accordance with OAR 410-120-2015, an MCE or, as applicable, the Authority, determines the Member meets all of the applicable HRSN Eligibility criteria, the MCE or the Authority shall authorize the identified HRSN Services and provide notice as expeditiously as the circumstances require, which must not exceed fourteen (14) days following the receipt of the HRSN Request in accordance with OAR 410-141-3835.

(2) If, after completing the HRSN Eligibility Screening in accordance with OAR 410-120-2015, the MCE or, as applicable, the Authority, determines the Member does not meet all of the applicable HRSN Eligibility, Contractor shall deny the delivery of HRSN Services as expeditiously as possible, which must not exceed fourteen (14) days following the receipt of the HRSN Request, in accordance with OAR 410-141-3835. Contractor shall document the reason for the denial.

(3) The Authorization must identify service duration, as is Clinically Appropriate. The duration of an Authorized HRSN Service shall not exceed the allowable service duration detailed in the Tables in OAR 410-120-2005. The duration may be less if required per the applicable Tables in OAR 410-120-2005, as well as the amount and scope in accordance with 42 CFR 438.210.

(4) MCEs and the Authority must use reasonable efforts to ensure that HRSN Eligible Members who are receiving a similar service from a state, local, or federally funded organization or agency are only Authorized for any similar HRSN Services in accordance with OAR 410-120-2015(4)(g).

(5) MCEs and the Authority must require clinical staff to review HRSN Service denials or reductions in scope, amounts, or duration requested only when the following clinically-based eligibility circumstances exist:

(a) HRSN Climate-Related Supports: A decision by an MCE or the Authority to deny a Member's request for a climate-related device based on a determination that the Member does not meet the HRSN Climate Device Social Risk Factor must include review by clinical staff to ensure the climate-related device was not Clinically Appropriate as a component of health services treatment or prevention as set forth in Table 1 included in OAR 410-120-2005.

(b) HRSN Housing-Related Supports: A decision by an MCE or the Authority to deny a Member's request for a home modification or remediation service or reduce the scope, amount or duration of the home modification or remediation service due to a determination that the Member does not meet the HRSN Housing-Related Social Risk Factor of requiring a home modification or remediation service to treat, improve, stabilize, or prevent their HRSN Clinical Risk Factor, must include a review by clinical staff to ensure the denial or limitation was not Clinically Appropriate as set forth in OAR 410-120-0000.

(c) All HRSN Services: Any decision by an MCE or the Authority to deny or reduce a Member's request for an HRSN Service based on a determination that the Member did not have the HRSN Clinical Risk Factor applicable to the HRSN Service for which they were screened, must include review by clinical staff to ensure such determination was made in accordance with applicable clinical standards.

(d) Clinicians who review decisions to deny or reduce the scope, amount or duration of an HRSN Service must have appropriate expertise in addressing the Member's HRSN needs.

(6) All MCEs and the Authority must document the approval, or denial, or reduction of HRSN Services.

(7) HRSN Services must be authorized before the expiration of HRSN Covered Populations eligible timeframes:

(a) For Adults and Youths Discharged from an HRSN Eligible Behavioral Health Facility and Adults and Youth Released from Incarceration, services must be authorized prior to the 366th day post-discharge.

(b) For Individuals Transitioning to Dual Status, services must be authorized within 90 days prior to the date Medicare coverage takes effect or prior to the 271st day after Medicare coverage takes effect.

(8) In accordance with 42 CFR 438.210, all MCEs must (i) offer their Members the same HRSN Services, in type, amount, duration and scope that the Authority offers to Fee-for-Service Members; and (ii) Screen and Authorize of HRSN Services for their Members in a manner that is no less restrictive than the Authority Screens and Authorizes HRSN Services for Fee-for-Service Members.

(9) All MCEs or, as applicable, the Authority, must notify HRSN Connectors of an individual's HRSN Service authorization or denial if the HRSN Connector submitted the HRSN Request for the individual and such HRSN Connector (i) may be or may have been the HRSN Service Provider, or (ii) provided HRSN O&E Services to the individual who was authorized or denied the HRSN Service.

(10) Members may be rescreened for HRSN Services authorization after their then-current authorization expires or if their circumstance or need changes.

(11) HRSN Authorized Members must be referred to an HRSN Service Provider that provides the HRSN Service that has been Authorized. The referral must be made through a Closed Loop Referral unless the MCE or Authority is providing the HRSN Service in accordance with OAR 410-120-2000 (7)(a).

(a) The MCE or the Authority must inform the HRSN-Authorized Member they have the right to opt out of technology, like CIE, for Closed Loop Referrals and still receive HRSN Services; and

(b) Before an HRSN-Authorized Member is referred to the applicable HRSN Service Provider, the MCE, or as applicable, the Authority, must obtain prior written authorization from the HRSN Authorized Member to share the information necessary to make the referral. The prior written authorization must comply with all applicable state and federal laws, which may include without limitation, HIPAA regulations such as 45 CFR 164.508.

(c) The provision of HRSN Services must not require an HRSN-Authorized Member to authorize the sharing of their personal information with the HRSN Service Provider.

(d) If the HRSN Authorized Member declines to authorize in writing the sharing of their personal information with an HRSN Service Provider, then the MCE or the Authority must provide the HRSN Authorized Member with a written referral that they may deliver to the HRSN Service Provider to which they have been referred.

(12) When referring HRSN-Authorized Members to HRSN Service Providers, MCEs and the Authority must:

(a) To the extent capacity permits, support the HRSN-Authorized Member's choice of HRSN Service Provider;

(b) Identify and refer the HRSN Authorized Member to different HRSN Service Providers if the original provider is not able to provide the HRSN Service in a timely manner, and available in accordance with Care Coordination requirements outlined in OARs 410-141-3860, 410-141-3865, and 410-141-3870.

Or. Admin. Code § 410-120-2020

DMAP 130-2024, adopt filed 10/24/2024, effective 11/1/2024

Statutory/Other Authority: ORS 413.042

Statutes/Other Implemented: 414.572, 414.605, 414.665, 414.719 & 414.632