justicedao/ipfs_state_laws huggingface dataset:
309-015-0030 Billing Requirements (1) Bill submission time limits. Bills shall be submitted to the Division through the Division of Medical Assistance Programs, on forms designated by the Medicaid Intermediary, as soon as possible after the date service is rendered. Payment shall not be made for services which were provided more than 12 months prior to presentation of the claim unless the hospital shows that the delay was caused by factors outside its control. (2) Billing charge limits. Billings to the Division shall in no case exceed the customary charges to private patients for any like item or service charged by the hospital. (3) Customary charge criteria. In determining the customary charges to a private patient for use in billings or calculating interim or settlement rates, the following criteria will be applied: (a) The private patient billing rate must be for items and services comparable to the items and services included in the rate for Medicaid services; (b) When private patient rates are based on the number of beds in a room, the Medicaid intermediary considers the lowest room charge as the usual and customary charge for services; (c) When ancillary charges are made to private patients in addition to a basic charge, the Medicaid Intermediary considers the usual and customary charge to be the lowest basic room charge plus the average ancillary charge for those items included in the Medicaid rate. The average ancillary charge is determined by dividing the ancillary costs by the number of patient days; or (d) Where charges are based on the classification of the patient (i.e., Medicare, Medicaid and Private), the Medicaid Intermediary considers the usual and customary charge to be the rate for private patients exclusive of ancillary charges. (4) Payment restrictions. Payment will be made only for those days a patient is actually in residence at the hospital in active treatment or when a patient is on therapeutic leave. (5) Payment credit. Any payment received by the hospital prior to the submission of an invoice to the Division of Medical Assistance Programs shall be indicated as a credit on the invoice. (6) Post-payment receipt of funds. Any payments to the provider from any source subsequent to payment by the Division of Medical Assistance Programs shall be reported to that Division on an adjustment form specified by the Division of Medical Assistance Programs, giving full particulars. Failure to report such payments will be considered concealment of material facts and is grounds for recovery and/or sanction (see OAR 309-015-0052). Statutory/Other Authority: ORS 413.042 Statutes/Other Implemented: ORS 414.025 & 414.065 History: MHD 2-1994, f. & cert. ef. 2-24-94 MHD 12-1990, f. & cert. ef. 10-15-90 MHD 6-1989, f. & cert. ef. 11-17-89 MHD 7-1987, f. & ef. 12-30-87 MHD 21-1983, f. & ef. 12-5-83 MHD 17-1983(Temp), f. 9-30-83, ef. 10-1-83
309-015-0040 Accounting and Record Keeping (1) Records retention. The provider shall maintain, for a period of not less than three years following the date of submission of the annual Medicaid cost report to the Medicaid Intermediary, financial and statistical records of the period covered by such statement which are accurate and in sufficient detail to substantiate the cost data reported. If there are audit issues, the records shall be maintained for three years after the final audit settlement. The records shall be maintained in a condition that can be audited for compliance with generally accepted accounting principles and provisions of these rules. Failure to maintain records in such condition shall result in disallowance of costs. (2) Documentation of allowable costs. Expenses reported as allowable costs must be adequately documented in the financial records of the provider or they shall be disallowed. Statutory/Other Authority: ORS 413.042 Statutes/Other Implemented: ORS 414.025 & 414.065 History: MHD 6-1989, f. & cert. ef. 11-17-89 MHD 7-1987, f. & ef. 12-30-87 MHD 21-1983, f. & ef. 12-5-83 MHD 17-1983(Temp), f. 9-30-83, ef. 10-1-83
309-015-0050 Auditing (1) Desk review of annual Medicaid cost report. The Medicaid intermediary will analyze by desk review each annual Medicaid cost report after it has been properly completed and filed. (2) Scope of desk review. The scope of the desk review will verify, to the extent possible: (a) That the provider has properly included its allowable costs on the annual Medicaid cost report on the basis of generally accepted accounting principles and the provisions of these rules; (b) That the provider has properly applied the cost finding method specified by the Medicaid Intermediary to its allowable costs determined in subsection (a) of this section; and (c) Whether or not the analysis indicates that further auditing of the provider’s financial and statistical records is needed. (3) Allowable costs. The costs considered allowable may include part or all of the following (worksheet form numbers are correct as of the effective date of this rule): (a) The costs stated as final values on Worksheet B, HCFA-2552, Cost Allocation for General Services Costs; (b) Physician costs as determined by completing Worksheet A-8-2, HCFA-2552; (c) Return on equity as determined by completing the applicable portions of Worksheet F, HCFA-2552. (4) Ownership changes. Payments to providers shall not be increased, solely as a result of a change of ownership, in excess of the increase which would result from applying Section 1861(v)(1)(O) of the Social Security Act as applied to owners of record on or after July 18, 1984. (5) Field audit. All filed annual Medicaid cost reports are subject to a field audit. (6) Scope of field audit. The scope of the field audit will, at a minimum, be sufficiently comprehensive to verify that in all material respects: (a) Generally accepted accounting principles and the provisions of these rules have been adhered to; (b) Reported data is in agreement with supporting records; and (c) The report is reconcilable to the appropriate Medicare report, federal tax return, and payroll tax reports. Statutory/Other Authority: ORS 413.042 Statutes/Other Implemented: ORS 414.025 & 414.065 History: MHD 2-1994, f. & cert. ef. 2-24-94 MHD 6-1989, f. & cert. ef. 11-17-89 MHD 7-1987, f. & ef. 12-30-87 MHD 3-1985, f. & ef. 2-25-85 MHD 10-1984(Temp), f. & ef. 12-21-84 MHD 21-1983, f. & ef. 12-5-83 MHD 17-1983(Temp), f. 9-30-83, ef. 10-1-83
309-015-0052 Provider Sanctions (1) Basis for sanctioning. The Division will follow the Division of Medical Assistance Program rules OAR 410-120-0000 through 410-120-1980 and Section 1902 of the Social Security Act for provider sanctions. The basis for sanctioning will include: (a) Criminal convictions; (b) Exclusion, by the Secretary of Health and Human Services, from participation in the Medicare program; (c) Not meeting the federal regulatory requirements for services in an institution for mental diseases or a psychiatric hospital as set forth at 42 CFR 435.1009 and 42 CFR 441, Subparts C and D; (d) Having deficiencies which immediately jeopardize, or may jeopardize, the health and safety of patients; (e) Abuse and misutilization, as described in OAR 410-120-0000 through 410-120-1980; (f) Termination: (A) From another governmental health/medical program; (B) For failure to repay identified overpayments; or (C) Due to commission, by a provider formerly suspended by the Division, of additional abuse or misutilization. (2) Sanctions. The following sanctions may be imposed on a provider by the Division, based on grounds specified in this rule and may include: (a) Termination from participation in Oregon’s Medical Assistance Program and possible initiation of appropriate civil or criminal proceedings; (b) Suspension from participation in Oregon’s Medicaid Assistance Program; (c) Suspension or withholding of payments to a provider; (d) Required attendance at provider education sessions. (3) Notice to providers. The Division will notify a deficient provider of action the Division plans to take at least 15 days prior to commencement of the action; the notification will include an explanation of the provider’s right to appeal the proposed action (see OAR 309-015-0055). Statutory/Other Authority: ORS 413.042 Statutes/Other Implemented: ORS 414.025 & 414.065 History: MHD 2-1994, f. & cert. ef. 2-24-94 MHD 12-1990, f. & cert. ef. 10-15-90 MHD 6-1989, f. & cert. ef. 11-17-89
309-015-0055 Appeals (1) Rate appeals. A letter will be sent notifying the provider of the interim per diem rate, the year-end settlement rate, or the final settlement rate. A provider shall notify the Division in writing within 15 days of receipt of the letter if the provider wishes to appeal the rate. Letters of appeal must be postmarked within the 15-day limit and addressed to the Assistant Administrator, Administrative Services (the Medicaid Intermediary). (2) The Medicaid Intermediary will forward all rate appeals to the Manager of the Division’s Audit Section for initial consideration. If no resolution is forthcoming, the provider will be given an opportunity for administrative review or a contested case hearing as outlined in OAR 410-120-1400 through 410-120-1600, except that final orders shall be issued by the Administrator of the Division. (3) Monetary recovery, sanctions, or other appeals. A provider may appeal the Division’s proposed action by letter within the same 15-day period as allowed for rate appeals above; address the letter to the Assistant Administrator, Administrative Services (the Medicaid Intermediary). Statutory/Other Authority: ORS 413.042 Statutes/Other Implemented: ORS 414.025 & 414.065 History: MHD 2-1994, f. & cert. ef. 2-24-94 MHD 12-1990, f. & cert. ef. 10-15-90 MHD 6-1989, f. & cert. ef. 11-17-89 MHD 7-1987, f. & ef. 12-30-87 MHD 21-1983, f. & ef. 12-5-83 MHD 17-1983(Temp), f. 9-30-83, ef. 10-1-83
309-015-0060 Emergency Services in Non-Participating Hospitals Reimbursable services. Emergency services provided in licensed psychiatric hospitals not participating in Medicaid will be reimbursed if the Division determines they meet federal requirements for Medicare reimbursement of emergency services as outlined in Subpart G, Part 424 of the Medicare regulations. Statutory/Other Authority: ORS 413.042 Statutes/Other Implemented: ORS 414.025 & 414.065 History: MHD 2-1994, f. & cert. ef. 2-24-94 MHD 6-1989, f. & cert. ef. 11-17-89 MHD 7-1987, f. & ef. 12-30-87
309-018-0100 Purpose and Scope (1) Purpose: These rules prescribe minimum standards for services and supports provided by addictions and mental health providers approved by the Health Systems Division of the Oregon Health Authority. (2) Scope: In addition to applicable requirements in OAR 410-120-0000 through 410-120-1980 and 943-120-0000 through 943-120-1550, these rules specify standards for services and supports provided in: (a) Residential Substance Use Disorders Treatment and Recovery Services; and (b) Residential Problem Gambling Treatment and Recovery Services. Statutory/Other Authority: ORS 161.390, 413.042, 430.256, 428.205 - 428.270, 430.640 & 443.450 Statutes/Other Implemented: ORS 109.675, 179.505, 413.520 - 413.522, 430.010, 430.205 - 430.210, 430.254 - 430.640, 430.850 - 430.955, 443.400 - 443.460, 443.991, 461.549, 743A.168, 813.010 - 813.055 & 813.200 - 813.270 History: MHS 17-2016, f. 11-28-16, cert. ef. 11-30-16 MHS 10-2016(Temp), f. 6-29-16, cert. ef. 7-1-16 thru 12-27-16 MHS 3-2014, f. & cert. ef. 2-3-14 MHS 10-2013(Temp), f. 8-8-13, cert. ef. 8-9-13 thru 2-5-14
309-018-0107 Certification Required Entities providing or seeking to provide residential treatment services under these rules shall also hold or successfully obtain from the Division a certificate to provide behavioral health treatment services under OAR 309-008-0100 to 309-008-1600 if they intend to provide an outpatient service regulated by the Division’s service delivery rules. Statutory/Other Authority: ORS 413.042, 428.205 - 428.270, 430.640 & 443.450 Statutes/Other Implemented: ORS 109.675, 161.390 - 161.400, 179.505, 430.010, 430.205 - 430.210, 430.240 - 430.640, 430.850 - 430.955, 443.400 - 443.460, 443.991, 461.549 & 743A.168 History: MHS 4-2018, amend filed 02/27/2018, effective 03/01/2018 MHS 10-2017(Temp), f. 9-15-17, cert. ef. 9-15-17 thru 3-13-18 MHS 17-2016, f. 11-28-16, cert. ef. 11-30-16 MHS 10-2016(Temp), f. 6-29-16, cert. ef. 7-1-16 thru 12-27-16
309-018-0165 Residential Problem Gambling Treatment Services Residential problem gambling treatment services shall include group, individual, and family treatment consistent with the following requirements: (1) Service sessions shall address the challenges of the individual as they relate, directly or indirectly, to the problem gambling behavior. (2) Providers may provide telephone counseling when person-to-person contact involves an unwise delay, as follows: (a) Individuals shall be currently enrolled in the problem gambling treatment program; (b) Phone counseling shall be provided by a qualified program staff within their scope of practice; (c) Service notes for phone counseling shall follow the same criteria as face-to-face counseling and identify the session was conducted by phone and the clinical rationale for the phone session; (d) Telephone counseling shall meet HIPAA and 42 CFR standards for privacy; and (e) There shall be an agreement of informed consent for phone counseling that is discussed with the individual and documented in the individual’s service record. (3) Family counseling includes face-to-face or non-face-to-face service sessions between a program staff member delivering the service and a family member whose life has been negatively impacted by gambling: (a) Service sessions shall address the problems of the family member as they relate directly or indirectly to the problem gambling behavior; and (b) Services to the family shall be offered even if the individual identified as a problem gambler is unwilling or unavailable to accept services. (4) Twenty-four hour crisis response shall be accomplished through agreement with other crisis services, on-call program staff, or other arrangement acceptable to the Division. (5) A financial assessment shall be included in the entry process and documented in the assessment. (6) The service plan shall include a financial component, consistent with the financial assessment. (7) A risk assessment for suicide ideation shall be included in the entry process and documented in the assessment as well as appropriate referrals made. (8) The service plan shall address suicidal risks if determined within the assessment process or throughout services. (9) For individuals at risk, the service notes shall contain documented evidence that suicidal risk is continually assessed and that follow-up safety plan activities are being monitored. Statutory/Other Authority: ORS 428.205 - 428.270, 430.640 & 443.450 Statutes/Other Implemented: ORS 430.010, 430.205 - 430.210, 430.254 - 430.640, 430.850 - 430.955, 443.400 - 443.460, 443.991, 461.549, 743A.168, 813.010 - 813.055 & 813.200 - 813.270 History: MHS 4-2018, amend filed 02/27/2018, effective 03/01/2018 MHS 10-2017(Temp), f. 9-15-17, cert. ef. 9-15-17 thru 3-13-18 MHS 3-2014, f. & cert. ef. 2-3-14 MHS 10-2013(Temp), f. 8-8-13, cert. ef. 8-9-13 thru 2-5-14
309-018-0185 Medical Protocols in Residential Substance Use Disorders Treatment Programs Medical protocols shall be approved by a medical director under contract with a program or written reciprocal agreement with a medical practitioner under managed care. The protocols shall: (1) Require a medical history be included in the assessment; (2) Designate those medical symptoms and conditions that, when found, require further investigation, physical examinations, treatment, or laboratory testing; (3) Require that individuals admitted to the program who are currently injecting or intravenously using a drug, or have injected or intravenously used a drug within the past 30 days, or who are at risk of withdrawal from a drug, or who may be pregnant, shall be referred for a physical examination and appropriate lab testing within 30 days of entry to the program. This requirement may be waived by the medical director if these services have been received within the past 90 days and documentation is provided; (4) Require pregnant women be referred for prenatal care within two weeks of entry to the program; (5) Require that the program provide HIV and AIDS, TB, sexually transmitted disease, Hepatitis, and other infectious disease information and risk assessment, including any needed referral, within 30 days of entry; (6) Specify the steps for follow up and coordination with physical health care providers in the event the individual is found to have an infectious disease or other major medical problem. Statutory/Other Authority: ORS 413.042, 428.205 - 428.270, 430.640 & 443.450 Statutes/Other Implemented: ORS 430.010, 430.205 - 430.210, 430.254 - 430.640, 430.850 - 430.955, 443.400 - 443.460, 443.991, 461.549 & 743A.168 History: MHS 4-2018, amend filed 02/27/2018, effective 03/01/2018 MHS 10-2017(Temp), f. 9-15-17, cert. ef. 9-15-17 thru 3-13-18 MHS 3-2014, f. & cert. ef. 2-3-14 MHS 10-2013(Temp), f. 8-8-13, cert. ef. 8-9-13 thru 2-5-14
309-018-0190 Administration of Medications The following guidelines shall be followed in policies on administration of medications in residential programs: (1) Medications prescribed for one individual may not be administered to or self-administered by another individual or program staff. (2) When an individual self-administers medication in a residential program, self-administration shall be approved in writing by a physician and closely monitored by the residential program staff. (3) No unused, outdated, or recalled drugs shall be kept in a program. On a monthly basis any unused, outdated, or recalled drugs shall be disposed of in a manner that assures they cannot be retrieved. (4) A written record of all disposal of prescription drugs in a residential program shall be maintained in the program and shall include: (a) A description of the drug, including the amount; (b) The individual for whom the medication was prescribed; (c) The reason for disposal; and (d) The method of disposal. (5) All prescription drugs stored in the residential program shall be kept in a locked stationary container. Medications requiring refrigeration shall be stored in a refrigerator using a locked container. (6) Written documentation of medications prescribed for the individual by an LMP shall be maintained in the Service Record. Documentation for each medication prescribed shall include the following: (a) A copy or detailed written description of the signed prescription order; (b) The name of the medication prescribed; (c) The prescribed dosage and method of administration; (d) The date medications were prescribed, reviewed, or renewed; (e) The date and the signature and credentials of program staff administering or prescribing medications; (f) Observed side effects including laboratory findings; and (g) Medication allergies and adverse reaction. Statutory/Other Authority: ORS 413.042, 428.205 - 428.270, 430.640 & 443.450 Statutes/Other Implemented: ORS 430.010, 430.205 - 430.210, 430.254 - 430.640, 430.850 - 430.955, 443.400 - 443.460, 443.991, 461.549 & 743A.168 History: MHS 4-2018, amend filed 02/27/2018, effective 03/01/2018 MHS 10-2017(Temp), f. 9-15-17, cert. ef. 9-15-17 thru 3-13-18 MHS 3-2014, f. & cert. ef. 2-3-14 MHS 10-2013(Temp), f. 8-8-13, cert. ef. 8-9-13 thru 2-5-14
309-018-0205 Quality Assessment and Performance Improvement Providers shall develop and implement a structured and ongoing process to assess, monitor, and improve the quality and effectiveness of services provided to individuals and their families. Statutory/Other Authority: ORS 413.042, 428.205 - 428.270, 430.640 & 443.450 Statutes/Other Implemented: ORS 430.010, 430.205 - 430.210, 430.254 - 430.640, 430.850 - 430.955, 443.400 - 443.460, 443.991, 461.549 & 743A.168 History: MHS 4-2018, amend filed 02/27/2018, effective 03/01/2018 MHS 10-2017(Temp), f. 9-15-17, cert. ef. 9-15-17 thru 3-13-18 MHS 3-2014, f. & cert. ef. 2-3-14 MHS 10-2013(Temp), f. 8-8-13, cert. ef. 8-9-13 thru 2-5-14
309-018-0215 Variances (1) Variances may be granted to a provider holding a license under this rule: (a) If there is a lack of resources to implement the standards required in these rules; or (b) If implementation of the proposed alternative services, methods, concepts, or procedures results in improved outcomes for the individual. (2) Application for a variance: (a) Providers may submit their variance request directly to the Division; (b) Providers requesting a variance shall submit a written application to the Division; and (c) Variance requests shall contain the following: (A) The section of the rule from which the variance is sought; (B) The reason for the proposed variance; (C) The alternative practice, service, method, concept, or procedure proposed; (D) A proposal for the duration of the variance; and (E) A plan and timetable for compliance with the section of the rule for which the variance applies. (3) The Division shall approve or deny the request for a variance and shall notify the provider in writing of the decision to approve or deny the requested variance within 30 days of receipt of the variance. The written notification shall include the specific alternative practice, service, method, concept, or procedure that is approved and the duration of the approval. (4) Appeal of the denial of a variance request shall be made in writing to the Chief Officer of the Division, whose decision shall be final and shall be provided in writing within 30 days of receipt of the appeal. (5) The LMHA, CMHP, or provider may implement a variance only after written approval from the Division. (6) The provider shall submit a request to extend a variance in writing prior to a variance expiring. Extensions shall be approved in writing by the Division. (7) Granting a variance for one request does not set a precedent that shall be followed by the Division when evaluating subsequent requests for variance. Statutory/Other Authority: ORS 413.042, 428.205 - 428.270, 430.640 & 443.450 Statutes/Other Implemented: ORS 430.010, 430.205 - 430.210, 430.254 - 430.640, 430.850 - 430.955, 443.400 - 443.460, 443.991, 461.549 & 743A.168 History: MHS 4-2018, amend filed 02/27/2018, effective 03/01/2018 MHS 10-2017(Temp), f. 9-15-17, cert. ef. 9-15-17 thru 3-13-18 MHS 17-2016, f. 11-28-16, cert. ef. 11-30-16 MHS 10-2016(Temp), f. 6-29-16, cert. ef. 7-1-16 thru 12-27-16 MHS 3-2014, f. & cert. ef. 2-3-14 MHS 10-2013(Temp), f. 8-8-13, cert. ef. 8-9-13 thru 2-5-14
309-019-0100 Purpose and Scope (1) These rules prescribe minimum service delivery standards for services and supports provided by providers certified by the Health Systems Division (Division) of the Oregon Health Authority (Authority). (2) In addition to applicable requirements in OAR 410-120-0000 through 410-120-1980 and 943-120-0000 through 943-120-1550, these rules specify standards for behavioral health treatment services and supports provided in: (a) Outpatient Community Mental Health Services and Supports for Children and Adults; (b) Outpatient Substance Use Disorders Treatment Services; and (c) Outpatient Problem Gambling Treatment Services. Statutory/Other Authority: ORS 161.390, 413.042, 430.256 & 430.640 Statutes/Other Implemented: ORS 109.675, 161.390 - 161.400, 428.205 - 428.270, 430.010, 430.205 - 430.210, 430.640, 430.850 - 430.955, 461.549 & 743A.168 History: MHS 6-2017, f. & cert. ef. 6-23-17 MHS 18-2016, f. 11-28-16, cert. ef. 11-30-16 MHS 11-2016(Temp), f. 6-29-16, cert. ef. 7-1-16 thru 12-27-16 MHS 4-2014, f. & cert. ef. 2-3-14 MHS 6-2013(Temp), f. 8-8-13, cert. ef. 8-9-13 thru 2-5-14