Or. Admin. R. 410-141-3960

Current through Register Vol. 63, No. 6, June 1, 2024

Section 410-141-3960 - Transportation: Member Reimbursed Mileage, Meals, and Lodging

(1) A Coordinated Care Organization (CCO) may prior authorize a member's mileage, meals, and lodging to covered medical service in order for the member to qualify for reimbursement.

(2) A CCO may disallow a client reimbursement request received more than 45 days after the travel.

(3) A CCO shall reimburse a member for mileage, meals, and lodging at rates not less than the Authority's allowable rates. The Oregon Health Plan (OHP) fee schedule is available on the Oregon Health Authorities (Authority's) website.

(4) The member must return any documentation a CCO requires before receiving reimbursement.

(5) A member must be reimbursed within fourteen (14) days after verifying the member's attendance of the appointment after the CCO receiving the reimbursement request.

(a) A CCO may hold reimbursements under the amount of $10 until the member's reimbursement reaches $10; or

(b) A CCO must issue the member a Notice of Adverse Benefit Determination, in accordance with requirements in OAR 410-141-3885, within fourteen (14) days if the member reimbursement is denied for any reason. If the member reimbursement request is incomplete the CCO shall take an additional fourteen (14) days to assist the member in completing the submission.

(6) A CCO shall reimburse members for meals when a member travels:

(a) Out of their local area as outlined in OAR 410-141-3515;

(b) For a minimum of four (4) hours round-trip; or

(c) The travel must span the following meal times:

(A) For a breakfast allowance, the travel must begin before 6:00 a.m.;

(B) For a lunch allowance, the travel must span the entire period from 11:30 a.m. through 1:30 p.m.; and

(C) For a dinner allowance, the travel must end after 6:30 p.m.

(7) A CCO's brokerage or other transportation subcontractor shall reimburse members for lodging when:

(a) A member would otherwise be required to begin travel before 5:00 a.m. in order to reach a scheduled appointment; or

(b) Travel from a scheduled appointment would end after 9:00 p.m.; or

(c) The member's health care provider documents a medical need.

(8) A CCO may reimburse members for lodging under additional circumstances at the CCO's discretion.

(9) A CCO shall reimburse for meals or lodging for one attendant, which may be a parent, to accompany the member if medically necessary, if:

(a) The member is a minor child and unable to travel without an attendant;

(b) The member's attending physician provides a signed statement indicating the reason an attendant must travel with the member;

(c) The member is mentally or physically unable to reach their medical appointment without assistance; or

(d) The member is or would be unable to return home without assistance after the treatment or service.

(10) A CCO may reimburse members for meals or lodging for additional attendants or under additional circumstances at the CCO's discretion.

(11) A CCO may recover overpayments made to a member. Overpayments occur when a CCO's brokerage or other transportation subcontractor paid the member:

(a) For mileage, meals, and lodging, and another resource also paid:

(A) The member; or

(B) The ride, meal, or lodging provider directly.

(b) Directly to travel to medical appointments, and the member did not use the money for that purpose, did not attend the appointment, or shared the ride with another member whom the brokerage also paid directly;

(c) For common carrier or public transportation tickets or passes, and the member sold or otherwise transferred the tickets or passes to another individual.

(12) If an individual or entity other than the member or the minor member's parent or guardian provides the ride, a CCO's brokerage or other transportation subcontractor may reimburse the individual or entity that provided the ride.

Or. Admin. R. 410-141-3960

DMAP 57-2019, adopt filed 12/17/2019, effective 1/1/2020; DMAP 60-2022, amend filed 06/24/2022, effective 7/1/2022; DMAP 89-2022, amend filed 12/16/2022, effective 1/1/2023; DMAP 95-2023, amend filed 12/22/2023, effective 1/1/2024

Statutory/Other Authority: ORS 413.042

Statutes/Other Implemented: ORS 413.042