Or. Admin. Code § 411-348-0490

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

Section 411-348-0490 - 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; or

(d) Is outside of the United States.

(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.

Or. Admin. Code § 411-348-0490

APD 36-2019, adopt filed 10/29/2019, effective 11/1/2019

Statutory/Other Authority: ORS 409.050, 427.104, 441.715, 443.450 & 443.455

Statutes/Other Implemented: ORS 427.104, 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