justicedao/ipfs_state_laws huggingface dataset:
410-152-0020 Documentation Requirements. (1) The Plan of Care shall include the individuals need for: safety planning, interest in employment, housing, education, mental health and substance abuse treatment services, gang affiliation, legal needs and history of injury within the last six (6) months. (2) Services rendered must be documented and signed, electronically or wet, by the certified Violence Prevention Professional rendering the service on each date of service. (3) The provider shall maintain a record of each service provided to each eligible individual for each date of service including, but not limited to: (a) Name and Medicaid identification number of individual receiving the service; (b) Name and credentials of the certified Community Violence Prevention professional; (c) Date the service was provided; ( d) Description of each service provided to the individual to address the psychosocial and safety needs of the client to include coordination of all services and interventions as developed in the individuals plan of care. (e) Description of outcomes, including the individual’s responsiveness to services and any change in the frequency of: emergency room visits, retaliatory violence, arrest and acute stress and post-traumatic stress disorder. (f) Document referrals to other identified services and supports, including referrals to entities completing eligibility assessments. (4) The billing provider shall maintain adequate records for all Community Violence Prevention services rendered that fully supports the charges billed. Provider is responsible for the completeness, accuracy and secure storage of financial and clinical records and all other documentation of the specific care, service. Statutory/Other Authority: Oregon Medicaid State Plan Amendment, 42 C.F.R 440.130 (c), House Bill 4045 & 2022 Legislative Session Statutes/Other Implemented: ORS 413.032, 413.042 & 414.065 History: DMAP 89-2024, adopt filed 05/01/2024, effective 05/01/2024
410-152-0025 Eligibility Requirements. (1) To be eligible to receive Community Violence Prevention services performed by a certified Violence Prevention Professional the individual shall: (a) be enrolled in the Oregon Health Plan; (b) have a history of injury sustained because of an act of community violence; (c) received a recommendation for services by a physician or other qualified licensed practitioner of the healing arts within the practitioner’s scope of practice under the state law; and (2) Individuals receiving Community Violence Prevention services shall have a plan of care in place that meets requirements described in section OAR 410-152-0030. (a) The plan of care must be directed by the individual receiving Community Violence Prevention services; and (b) The plan of care must be signed by the recipient of Community Violence Prevention services or a legal representative and the certified Violence Prevention Professional. (c) The individual shall be re-assessed, and the plan of care shall be reviewed and updated by the certified Community Violence Prevention Professional every three months. Statutory/Other Authority: Oregon Medicaid State Plan Amendment, 42 C.F.R 440.130 (c), House Bill 4045 & 2022 Legislative Session Statutes/Other Implemented: ORS 413.032, 413.042 & 414.065 History: DMAP 89-2024, adopt filed 05/01/2024, effective 05/01/2024
410-153-0000 Purpose and Scope These rules define the requirements for Certified Community Behavioral Health Clinic (CCBHC) reimbursement through a bundled daily rate, cost reporting, rebasing, change in scope, and oversight for services provided to Oregon Health Plan members by CCBHCs certified by Oregon Health Authority under Oregon Administrative Rules chapter 309, division 009. Statutory/Other Authority: ​ORS 413.042 & ORS 414.065​ Statutes/Other Implemented: ORS 414.065​ History: DMAP 73-2025, adopt filed 09/26/2025, effective 10/01/2025
410-153-0010 Provider Requirements (1) To qualify for payment under these rules, a provider must: (a) Be certified by Oregon Health Authority (Authority) as a Certified Community Behavioral Health Clinic (CCBHC), Oregon Administrative Rule (OAR) chapter 309, division 009; (b) Maintain an active Medicaid provider enrollment as required under OAR 410-120-1260; (c) Meet all applicable state and federal Medicaid requirements for services, billing and payment, including but not limited to OAR chapter 410, division 120 and OAR chapter 410, division 141; Payment shall be made to a CCBHC only for services that are adequately documented; and (d) Meet all the requirements of these rules, OAR chapter 410, division 153. (2) CCBHCs must ensure that services are available to any individual eligible for services under their certification, regardless of ability to pay, consistent with OAR chapter 309, division 009. Statutory/Other Authority: ​ORS 413.042 & 414.065 Statutes/Other Implemented: ORS 414.065 History: DMAP 73-2025, adopt filed 09/26/2025, effective 10/01/2025
410-153-0020 Required Services (1) Certified Community Behavioral Health Clinics (CCBHC) must follow the Oregon Administrative Rules (OAR) chapter 410, division 120 and division 141 coverage rules applicable to each service in section (2) below. (2) CCBHCs are reimbursed by the Authority through the bundled daily rate for qualifying CCBHC services including: (a) 24-hour crisis behavioral health services, including mobile crisis outreach; (b) Screening, assessment, and diagnosis; (c) Person-centered and family-centered treatment planning; (d) Outpatient mental health and substance use disorder services; (e) Primary care screening and monitoring; (f) Targeted case management; (g) Psychiatric rehabilitation services; (h) Peer and family support services; (i) Intensive, community-based mental health care for members of the armed forces and veterans. (3) Services provided by a Designated Collaborating Organization must comply with standards outlined in OAR chapter 309, division 019 and other applicable Medicaid coverage guidelines in OAR chapter 410, division 120 and division 141. (4) CCBHCs must provide all required services directly or through written formal Designated Collaborating Organization agreements. (5) CCBHCs must develop and maintain adequate financial and clinical records and other documentation that supports the specific care, items, or services for which payment has been requested. Statutory/Other Authority: ​ORS 413.042 & 414.065 Statutes/Other Implemented: ​ORS 414.065 History: DMAP 73-2025, adopt filed 09/26/2025, effective 10/01/2025
410-153-0025 Designated Collaborating Organization (1) Designated Collaborating Organization are entities that are not under the direct supervision of a CCBHC but engage in a contractual agreement with a Certified Community Behavioral Health Clinic (CCBHC) to provide CCBHC services. (2) Designated Collaborating Organizations must be appropriately licensed and certified by Oregon Health Authority (Authority) to provide services they are contracted to provide. (3) Services provided by the Designated Collaborating Organization must meet the same standards as the CCBHC as outlined in Oregon Administrative Rules (OAR) chapter 309, division 009 for the services they are providing. (4) Designated Collaborating Organization arrangements must be evidenced by a legally binding document. (5) The CCBHC must pay for the services provided by the Designated Collaborating Organization at daily bundle rate with exception to state-sanctioned mobile crisis services. As such: (a) Costs associated with the provision of the services for the Designated Collaborating Organization must be reported in the cost report. (b) CCBHC daily encounters from the Designated Collaborating Organization must be reported in the cost report. (c) The CCBHC and Designated Collaborating Organization must have policies and procedures outlining how the Designated Collaborating Organization will avoid duplication of payment. (6) Designated Collaborating Organization are required to provide CCBHCs with the data needed to calculate CCBHC daily encounters, cost of services, and any related data reporting and quality metrics. (7) Designated Collaborating Organizations are required to provide services on behalf of the CCBHC in accordance with CCBHC rules and regulations and defined in OAR chapter 309, division 009. Statutory/Other Authority: ​ORS 413.042 & 414.065 Statutes/Other Implemented: ORS 414.065 History: DMAP 73-2025, adopt filed 09/26/2025, effective 10/01/2025
410-153-0030 Eligibility for Payment (1) Certified Community Behavioral Health Clinics (CCBHC) must bill the clinic-specific bundled daily rate when at least one qualifying CCBHC service, as these services are described in Oregon Administrative Rules (OAR) 410-153-0020, is provided by the CCBHC or Designated Collaborating Organization to an Oregon Health Plan member (OHP). (2) Only one bundled daily rate is permitted to be paid per OHP member per calendar day, regardless of the number of services or provider contacts. (3) Services rendered by Designated Collaborating Organizations must be included within the CCBHC’s bundled daily rate and billed by the CCBHC, not separately by the Designated Collaborating Organization. (4) Only services provided at approved CCBHC facilities are eligible the bundled daily rate. (5) Telephone CCBHC daily encounters qualify as a valid CCBHC daily encounter for services provided in accordance with OAR 410-120-1990. (6) Claims must include ICD-10-CM and CPT/HCPC codes as required by OAR 410-120-1280. Statutory/Other Authority: ORS 413.042 & 414.065 Statutes/Other Implemented: ​ORS 414.065 History: DMAP 73-2025, adopt filed 09/26/2025, effective 10/01/2025
410-153-0035 Bundled Daily Rate Establishment (1) Oregon Health Authority (Authority) establishes an initial interim bundled daily rate for each Certified Community Behavioral Health Clinic (CCBHC) based on projected allowable costs and projected CCBHC daily encounters or based on payments to the nearest cost center with a similar caseload in the event that the Authority determines such methodology is more appropriate. (2) Allowable costs are based on: (a) Direct service costs, including salaries, benefits, contracted services, and supplies directly tied to delivering CCBHC services; (b) Allocated administrative and facility overhead costs, consistent with 2 CFR Part 200 and Centers for Medicaid and Medicare Services (CMS) cost principles. (3) The interim bundled daily rate is calculated by the Authority as: (a) Total projected allowable costs divided by total projected Medicaid and non-Medicaid CCBHC daily encounters; (b) Adjusted for Medicaid utilization projections if required by CMS guidance. (4) Each CCBHC’s interim rate must be effective on the date of initial certification and enrollment approval, or such other date as determined by the Authority. Statutory/Other Authority: ​ORS 413.042 & 414.065 Statutes/Other Implemented: ​ORS 414.065 History: DMAP 73-2025, adopt filed 09/26/2025, effective 10/01/2025
410-153-0040 Cost Reporting Requirements (1) Each Certified Community Behavioral Health Clinic (CCBHC) must submit a cost report on forms prescribed by Oregon Health Authority (Authority), identifying: (a) Total allowable direct and indirect costs; and (b) Total number of Medicaid and non-Medicaid CCBHC daily encounters. (2) The CCBHC must submit cost reports no later than 120 days after the close of the CCBHC's fiscal year on rebase years, unless an extension is granted in writing by the Authority. In addition, new CCBHCs must submit a cost report to the Authority after the first 12 months of operation to establish an updated rebased rate. (3) Cost reports submitted by the CCBHC must be based on accrual accounting methods unless a waiver is approved in writing by the Authority. (4) Failure to submit a completed and timely cost report may result in suspension of payment or other sanctions under Oregon Administrative Rules (OAR) 410-120-1395 through OAR 410-120-1460. (5) The Authority may request an updated cost report from a CCBHC when the CCBHC has an interruption in operations, whether this is due to suspension or termination of the CCBHC’s Oregon Health Plan enrollment or certification or other reasons. Statutory/Other Authority: ​ORS 413.042 & 414.065 Statutes/Other Implemented: ​ORS 414.065 History: DMAP 73-2025, adopt filed 09/26/2025, effective 10/01/2025
410-153-0045 Cost Reconciliation and Settlement (1) Oregon Health Authority (Authority) performs reconciliation following the establishment of a new bundled daily rate by comparing payments made under previous bundled daily rate to newly established bundled daily rate. (2) If the payments made to a Certified Community Behavioral Health Clinic (CCBHC) provider exceed the newly established bundled daily rate, the Authority must recoup the overpayment for period following the close of the cost reporting period and establishment of new rate. (3) If the payments made to a CCBHC provider are less than newly established bundled daily rate, the Authority may issue a settlement payment to the CCBHC for the period following the close of the cost reporting period and establishment of a new bundled daily rate. (4) All settlements are subject to audit and final determination by the Authority. The CCBHC may appeal the Authority’s determination, as outlined in Oregon Administrative Rules 410-153-0090. (5) Settlements are completed by the Authority within 18 months of the close of the cost report year, unless delayed by circumstances beyond the Authority’s control. (6) Payment or settlement by the Authority does not restrict or limit the Authority or any state or federal oversight entity’s right to review or audit a claim before or after the payment. Claim payment may be denied or subject to recovery if medical review, audit, or other post-payment review determines the service was not provided in accordance with applicable rules or does not meet the criteria for quality of care or medical appropriateness of the care or payment. Statutory/Other Authority: ​ORS 413.042 & 414.065 Statutes/Other Implemented: ​ORS 414.065 History: DMAP 73-2025, adopt filed 09/26/2025, effective 10/01/2025
410-153-0050 Scope of Service Changes (1) A Certified Community Behavioral Health Clinic (CCBHC) may submit a written request to the Oregon Health Authority (Authority) for an adjustment to its bundled daily rate if there is a documented scope of service change that results in at least a five (5) percent change in cost per encounter. (2) A CCBHC scope change request must include for each change for which the CCBHC is requesting an adjustment: (a) A detailed description of the change in services, staffing, or operations; (b) Supporting financial data showing the projected cost impact of each change; (c) Documentation of the implementation date of the change. (3) If approved by the Authority, the rate adjustment is effective on the first day of the calendar quarter following the date of the Authority’s approval. (4) A CCBHC may request a scope of service adjustment no more than once per calendar year, unless the Authority determines that multiple unrelated changes have occurred. (5) The Authority will begin its review of a CCBHC scope change request when all data and information required by section (2) above has been received by the Authority. The Authority may also request additional data or information from the CCBHC in the course of its review, as the Authority deems necessary. All such requests will be provided in writing to the CCBHC. (6) CCBHC scope changes may include but are not limited to: (a) Changes in the type, intensity, or duration of covered services required under the CCBHC; (b) Expansion or reduction of operational hours for services; (c) Changes in staffing models that affect service delivery capacity; (d) Changes in cost resulting from state or federal regulatory or statutory requirements. (7) CCBHC changes that do not generally qualify as a scope of service change include: (a) Routine fluctuations in encounter volume; (b) Changes in payer mix without associated scope changes; (c) Changes solely in administrative structure without service delivery impact. Statutory/Other Authority: ​ORS 413.042 & 414.065​ Statutes/Other Implemented: ​ORS 414.065 History: DMAP 73-2025, adopt filed 09/26/2025, effective 10/01/2025
410-153-0055 Rebasing Requirements (1) Oregon Health Authority (Authority) must rebase each Certified Community Behavioral Health Clinic’s (CCBHC) bundled daily rate no less frequently than once every two (2) years based on finalized cost reports and actual encounter data. (2) The Authority’s rebasing calculations considers the: (a) Total allowable costs for the rebasing year; (b) Total Medicaid and non-Medicaid encounters for the rebasing year; (c) Adjustments for approved scope of service changes during the rebasing period. (3) New CCBHCs must submit a cost report to the Authority after the first 12 months of operation to establish an updated rebased rate. (4) The Authority may stagger rebasing schedules to balance administrative workload, but no CCBHC shall go longer than two (2) years without a rebasing unless authorized by CMS. (5) The Authority may request an updated cost report from a CCBHC when the CCBHC has an interruption in operations, whether this is due to suspension or termination of the CCBHC’s Oregon Health Plan enrollment or certification or other reasons. Statutory/Other Authority: ​ORS 413.042 & 414.065 Statutes/Other Implemented: ​ORS 414.065 History: DMAP 73-2025, adopt filed 09/26/2025, effective 10/01/2025
410-153-0060 Annual Inflation Adjustment Using MEI The Authority will adjust for inflation annually, trending each clinic-specific from the mid-point of the previous calendar year to the midpoint of the following year using the Medicare Economic Index (MEI). Statutory/Other Authority: ​ORS 413.042 & 414.065 Statutes/Other Implemented: ORS 414.065 History: DMAP 73-2025, adopt filed 09/26/2025, effective 10/01/2025
410-153-0065 Coordinated Care Organization (CCO) Payments and Supplemental (Wraparound) Payments (1) Certified Community Behavioral Health Clinics (CCBHCs) must bill the applicable CCO for services provided to members enrolled in a CCO. CCOs are not required to pay CCBHCs at their bundled daily rate. (2) CCBHCs may receive supplemental Medicaid wraparound payments to ensure that total reimbursement for CCBHC daily encounters for CCO-enrolled members and dual-eligible members meets the bundled daily rate. (3) Oregon Health Authority (Authority) calculates the supplemental payments on a quarterly basis using the “CCBHC Wraparound Data Template” and “CCBHC Wraparound Guide” found on the CCBHC website. Calculations are based on: (a) Costs incurred during the settlement period; (b) Amounts received during the settlement period; (c) Costs less amounts received. (4) CCBHC must submit wraparound reports within 12 months of close of quarter being reported. Exceptions to the 12-month requirement that are permitted to be submitted to the Authority are as follows: (a) When Oregon Department of Human Services (ODHS), the Authority, or the member’s branch office makes an error that causes the provider not to be able to bill within 12 months of the date of service, the report is permitted to be filed up to six (6) months after the error is discovered. The Authority must confirm the error. (b) When a court or an Administrative Law Judge orders the Authority to make payment. (5) The Authority must issue supplemental payments within 90 days of receipt of complete and accurate quarterly reports. (6) CCBHCs must retain supporting documentation for all CCO encounters and payments for a minimum of 10 years for audit purposes. Statutory/Other Authority: ​ORS 413.042 & 414.065 Statutes/Other Implemented: ​ORS 414.065​ History: DMAP 73-2025, adopt filed 09/26/2025, effective 10/01/2025
410-153-0070 Fee-for-Service Payments Certified Community Behavioral Health Clinics (CCBHC) must bill the Oregon Health Authority directly for CCBHC daily encounters with fee-for-service Oregon Health Plan members using the clinic's bundled daily rate. Statutory/Other Authority: ​ORS 413.042 & 414.065 Statutes/Other Implemented: ​ORS 414.065 History: DMAP 73-2025, adopt filed 09/26/2025, effective 10/01/2025
410-153-0075 CCBHC Daily Encounter Definitions and Billing (1) A Certified Community Behavioral Health Clinic (CCBHC) submitting a claim or other request for payment to Oregon Health Authority (Authority) or a Coordinated Care Organization (CCO) must meet the requirements in Oregon Administrative Rules (OAR) 410-153-0010, OAR 410-120-1280 and OAR 410-120-1300. (2) Only one CCBHC daily encounter is permitted to be paid per Oregon Health Plan member per calendar day, regardless of the number of services rendered. (3) Covered services provided by a CCBHC or Designated Collaborating Organization via telehealth may qualify as encounters if the services meet federal and state telehealth standards and are documented appropriately. Services within the scope of CCBHC delivered via telehealth must be billed at the daily encounter rate and are not eligible to be billed separately. (4) Ancillary services (for example, laboratory tests, basic imaging) provided in connection with a same-day CCBHC service are included in the CCBHC daily encounter and not separately billable. (5) CCBHCs must list all applicable billing modifiers on the claim. (6) Before billing the Authority or a CCO, a CCBHC must make reasonable efforts to obtain payment first from other resources as required under OAR 410-120-0080. Statutory/Other Authority: ​ORS 413.042 & 414.065 Statutes/Other Implemented: ORS 414.065​ History: DMAP 73-2025, adopt filed 09/26/2025, effective 10/01/2025
410-153-0080 Program Integrity and Audit Compliance (1) Certified Community Behavioral Health Clinics (CCBHC) are subject to audits and other reviews by the Oregon Health Authority (Authority) under Oregon Administrative Rules (OAR) chapter 410, division 120. (2) The CCBHC must submit true, accurate, and complete claims. The Authority treats the submission of a claim or encounter, whether on paper or electronically, as certification by the CCBHC. (3) The CCBHC must maintain complete and accurate service and financial records supporting: (a) All encounters billed to Medicaid and Medicare; (b) Cost reports submitted to the Authority; (c) Supplemental Coordinated Care Organization (CCO) wraparound payment reports; (d) All services provided and payments received. (4) The Authority may at any time conduct audits, desk reviews, or on-site inspections of the CCBHC and any Designated Collaborating Organization, to verify CCBHC compliance with these rules, OAR chapter 410, division 120, and OAR chapter 410, division 141. (5) CCBHCs must cooperate fully with audits and investigations conducted by the Authority, Centers for Medicare and Medicaid Services, Medicaid Fraud Control Unit, or other authorized federal and state agencies as required under OAR 410-120-1395, OAR 410-120-1396, and OAR 410-120-1510. (6) If a CCBHC determines that a submitted claim, cost report, or wrap payment received from the Authority or a CCO is an overpayment, the CCBHC must refund the amount of the overpayment to the Authority or the CCO, as required under OAR 410-120-1280 or the CCBHC’s contract with the CCO. Statutory/Other Authority: ORS 413.042 & 414.065 Statutes/Other Implemented: ​ORS 414.065 History: DMAP 73-2025, adopt filed 09/26/2025, effective 10/01/2025