justicedao/ipfs_state_laws huggingface dataset:
410-153-0085 Appeals (1) Certified Community Behavioral Health Clinics (CCBHC) may appeal Oregon Health Authority (Authority) adverse actions relating to bundled daily rate setting, cost reconciliation, scope of service adjustments, or supplemental payment determinations. (2) CCBHC appeals of an Authority decision must be made in writing and filed with the Authority consistent with the procedures in Oregon Administrative Rules (OAR) 410-120-1560 to OAR 410-120-1600. CCBHC appeals of a CCO decision must be filed with the CCO. (3) The CCBHC’s appeals must: (a) Be filed timely, as required under OAR 410-120-1560; (b) Clearly identify the action being appealed; (c) State the grounds for appeal; and (d) Include supporting documentation. (4) The Authority must issue a final order in contested case proceedings consistent with applicable Oregon Administrative Procedures Act (APA) requirements and OAR chapter 410, division 120. (5) CCBHC may appeal other Authority determinations as outlined in OAR chapter 410, division 120. 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
410-160-0000 Definitions For the purposes of OAR 410-160-0000 through 410-160-0100, the following definitions shall apply: (1) LEMLA means the Law Enforcement Medical Liability Account. (2) LEMLA Patient means a person who has suffered injuries related to law enforcement activity. (3) Injuries Related to Law Enforcement Activity means injuries sustained prior to booking, citation in lieu of arrest or release instead of booking that occur during and as a result of efforts by a law enforcement officer to restrain or detain, or to take or retain custody of, the individual. Whether injuries related to law enforcement activity have occurred shall be determined by the law enforcement agency. (4) Release Date means the date the LEMLA patient was released from actual physical custody, as determined by the law enforcement agency. (5) Cost of Such Services means "usual charge" as defined in OAR 410-120-0000. (6) Hospital means a hospital as defined in OAR 410-120-0000. (7) Overpayment means payment made by LEMLA to a claimant in excess of the amount due for the covered services and items billed. (8) Claimant means a Medicaid provider. (9) Medicaid Provider means a provider who has been issued a provider number by the Division and is not currently subject to sanction by the Division. (10) Prior Payment Amount means the total of all payments received by the claimant from all other sources, including the LEMLA patient, prior to submitting a LEMLA claim. (11) LEMLA Claim Amount means the total cost of such services provided to a LEMLA patient that are directly connected to injuries related to law enforcement activity. It shall not include any charges for services provided to a LEMLA patient for a preexisting disease or condition, or services that are unrelated to the "injuries related to law enforcement activities." Statutory/Other Authority: ORS 413-042 & ORS 414.065 Statutes/Other Implemented: ORS 414.805 — ORS 414.815 History: Renumbered from 461-012-0100, DMAP 9-2011, f. 6-6-11, cert. ef. 7-1-11 AFS 10-2002, f. & cert. ef. 7-1-02 AFS 24-1993, f. 10-27-93, cert. ef. 11-1-93 AFS 6-1992, f. & cert. ef. 3-9-92 AFS 1-1992, f. 1-14-92, cert. ef. 2-1-92
410-165-0000 Basis and Purpose (1) These rules (OAR chapter 410, division 165) govern the Oregon Health Authority (Authority), Health Systems Division (Division), Medicaid Electronic Health Record (EHR) Incentive Program. The Medicaid EHR Incentive Program provides incentive payments consistent with federal law concerning such payments to eligible providers participating in the Medicaid program who adopt, implement, upgrade, or successfully demonstrate meaningful use of certified EHR technology and who are qualified by the program. (2) The Medicaid EHR Incentive Program is implemented pursuant to: (a) The American Reinvestment and Recovery Act of 2009, Pub. L. No. 111-5, section 4201; (b) The Centers for Medicare and Medicaid Services (CMS) federal regulation 42 CFR Part 495 (2010, 2012, 2014, and 2015) pursuant to the Social Security Act sections 1903(a)(3)(F) and 1903(t); (c) The Division’s General Rules program, OAR chapter 410, division 120; (d) The Authority’s Provider Rules, OAR chapter 943, division 120. (3) The following retroactive effective dates apply to these rules: (a) For all sections in these rules that refer to pediatric optometrists, the effective date is July 1, 2016; (b) For rule 410-165-0080 that refers to: (A) CMS federal regulation 42 CFR Part 495 (2016), the effective date is January 1, 2017; (B) CMS federal regulation 42 CFR Part 495 (2017), the effective date is October 1, 2017; (C) CMS federal regulation 42 CFR Part 495 (2018), in the FY 2019 Hospital Inpatient PPS Final Rule, sections 495.4, 495.24, 495.40, and 495.100, the effective date is October 1, 2018; (D) CMS federal regulation 42 CFR Part 495 (2018) in the CY 2019 Medicare Physician Fee Schedule Final Rule, sections 495.4 and 495.24, the effective date is January 1, 2019. (c) For all sections in these rules that refer to naturopathic physicians, the effective date is May 2, 2017; (d) For eligible hospitals, except for sections and references in these rules applicable under section (3)(a) or (b) above, the effective date is October 1, 2013, which is also the start date for program year 2014; (e) For eligible professionals, except for sections and references in these rules applicable under section (3)(a) or (b) above, the effective date is January 1, 2014, which is also the start date for program year 2014; (f) For rule 410-165-0060 that refers to the grace period for program year 2017, the effective date is February 5, 2018. Statutory/Other Authority: ORS 413.042 Statutes/Other Implemented: ORS 413.042 & 414.033 History: DMAP 4-2019, amend filed 03/08/2019, effective 03/08/2019 DMAP 13-2018, amend filed 03/08/2018, effective 04/01/2018 DMAP 46-2017, temporary amend filed 11/02/2017, effective 11/02/2017 through 04/30/2018 DMAP 18-2017, f. 5-31-17, cert. ef. 6-2-17 DMAP 3-2017(Temp), f. & cert. ef. 2-2-17 thru 7-31-17 DMAP 47-2016, f. 7-18-16, cert. ef. 8-1-16 DMAP 21-2016(Temp), f. 5-11-16, cert. ef. 5-13-16 thru 11-8-16 DMAP 20-2015, f. & cert. ef. 4-8-15 DMAP 2-2015(Temp), f. 1-30-15, cert. ef. 2-3-15 thru 8-1-15 DMAP 56-2013, f. & cert. ef. 10-22-13 DMAP 20-2013(Temp), f. & cert. ef. 4-26-13 thru 10-23-13 DMAP 13-2011, f. 6-29-11, cert. ef. 7-1-11
410-165-0120 Appeals (1) The appeals process for the Program is governed by 42 CFR 495.370 and the Authority’s Provider Appeals Rules in chapter 410, division 120. (2) Pursuant to 42 CFR 495.312 and 42 CFR 495.370, the Authority may have CMS conduct the audits and handle any subsequent appeals of whether eligible hospitals are meaningful EHR users. (3) A provider who applies for a Medicaid EHR incentive payment may appeal the Program’s decision. Appeals are governed by the Division’s Provider Appeal Rules OAR chapter 410, division 120. The provider’s appeal shall note the specific reason for the appeal, due to one or more of the following issues: (a) An incentive payment; (b) An incentive payment amount; (c) A provider eligibility determination; (d) The demonstration of adopting, implementing, or upgrading; or (e) Meaningful use eligibility other than a meaningful use eligibility issue where CMS handles the appeal, as provided in section (2) of this rule. Statutory/Other Authority: ORS 413.042 Statutes/Other Implemented: ORS 413.042 & 414.033 History: DMAP 47-2016, f. 7-18-16, cert. ef. 8-1-16 DMAP 21-2016(Temp), f. 5-11-16, cert. ef. 5-13-16 thru 11-8-16 DMAP 56-2013, f. & cert. ef. 10-22-13 DMAP 20-2013(Temp), f. & cert. ef. 4-26-13 thru 10-23-13 DMAP 13-2011, f. 6-29-11, cert. ef. 7-1-11
410-165-0140 Oversight and Audits (1) A provider who qualifies for a Medicaid Electronic Health Record (EHR) incentive payment under the Program is subject to audit or other post-payment review procedures pursuant to OAR 943-120-1505. (2) The Authority and the Department of Human Services may recover overpayments from the person or entity who received an incentive payment from the Program. (3) As authorized in 42 CFR 495.312, the Authority designates CMS to conduct audits on hospitals’ meaningful use attestations through program year 2014. For program year 2015 and later, the Authority and the Department of Human Services shall conduct these audits. (4) The person or entity who received a Medicaid EHR incentive overpayment must repay the amount specified within 30 calendar days from the mailing date of written notification of the overpayment as prescribed by OAR 943-120-1505. Statutory/Other Authority: ORS 413.042 Statutes/Other Implemented: ORS 413.042 & 414.033 History: DMAP 4-2019, amend filed 03/08/2019, effective 03/08/2019 DMAP 47-2016, f. 7-18-16, cert. ef. 8-1-16 DMAP 21-2016(Temp), f. 5-11-16, cert. ef. 5-13-16 thru 11-8-16 DMAP 56-2013, f. & cert. ef. 10-22-13 DMAP 20-2013(Temp), f. & cert. ef. 4-26-13 thru 10-23-13 DMAP 13-2011, f. 6-29-11, cert. ef. 7-1-11
410-170-0000 Administration of the Behavior Rehabilitation Services (BRS) Program (1) All BRS contractors shall, and ensure that their BRS providers, comply with the Medical Assistance programs rules in OAR Chapter 410, Division 120. (2) All BRS contractors shall, and ensure that their BRS providers, comply with the BRS program general rules in OAR Chapter 410, Division 170. (a) BRS contractors shall, and ensure that their BRS providers, comply with OAR Chapter 413, Division 095 to provide services or placement-related activities to BRS clients who receive prior authorization from the Department of Human Services; (b) BRS contractors shall, and ensure that their BRS providers, comply with OAR Chapter 416, Division 335 to provide services or placement-related activities to BRS clients who receive prior authorization from the Oregon Youth Authority. (3) The Oregon Health Authority may delegate authority to another agency or a unit of government to carry out some of its obligations under these rules. Statutory/Other Authority: ORS 413.042 & 414.065 Statutes/Other Implemented: ORS 414.065 History: DMAP 60-2020, amend filed 12/10/2020, effective 12/27/2020 DMAP 30-2020, temporary amend filed 06/26/2020, effective 07/01/2020 through 12/27/2020 DMAP 118-2018, amend filed 12/26/2018, effective 01/01/2019 DMAP 63-2013, f. 11-14-13, cert. ef. 1-1-14
410-170-0010 Purpose The purpose of the Behavior Rehabilitation Services (BRS) Program is to remediate the BRS client’s debilitating psychosocial, emotional, and behavioral disorders by providing such services as behavioral intervention, counseling, and skills-training. Services are delivered in a way that integrates a gender-responsive, culturally-sensitive, trauma-informed, and age-appropriate or developmentally-appropriate approach. These rules describe the general program requirements for the BRS program, prior authorization process, services and placement-related activities, BRS contractor and BRS provider requirements, reimbursement rates, and compliance and oversight activities. Statutory/Other Authority: ORS 413.042 & 414.065 Statutes/Other Implemented: ORS 414.065 History: DMAP 118-2018, amend filed 12/26/2018, effective 01/01/2019 DMAP 63-2013, f. 11-14-13, cert. ef. 1-1-14
410-172-0610 Provider Enrollment (1) Providers shall be enrolled with the Division as a behavioral health provider. Paid providers of behavioral health services shall possess a current and valid license, letter, or certificate. (2) Providers shall provide services within the scope of professional standards and practice defined by the providers licensing board or certifying organization. (3) Providers shall meet all requirements in OAR 410-120-1260 (Medical Assistance Programs Provider Enrollment), OAR 943-120-0310 (Provider Requirements), and OAR 943-120-0320 (Provider Enrollment). (4) Providers shall not be included on any US Office of Inspector General Exclusion lists. Statutory/Other Authority: ORS 413.042 & 430.640 Statutes/Other Implemented: ORS 413.042, 414.025, 414.065, 430.640, 430.705 & 430.715 History: DMAP 32-2015, f. 6-24-15, cert. ef. 6-26-15 DMAP 85-2014(Temp), f. 12-24-14, cert. ef. 1-1-15 thru 6-29-15
410-172-0620 Documentation Standards (1) OHP providers shall maintain records that fully support the extent of services for which payment has been requested and provide the records to the Division upon request. (2) All records shall document the specific service provided, the number of services comprising the service provided, the extent of the service provided, the dates on which the service was provided, and the individual who provided the service. (3) Clinical records shall document the recipient’s diagnosis and the medical need for the service. (4) The record shall be annotated each time a service is provided and be signed or initialed by the individual providing the service. (5) Information contained in the record shall be appropriate in quality and quantity to meet the professional standards applicable to the provider and any additional standards for documentation found in these rules, other Division rules, and pertinent contracts. (6) For AMH certified providers, in addition to meeting the requirements in this rule, clinical documentation for behavioral health services shall also comply with the requirements in OAR 309-019-0135 through OAR 309-019-0140, and clinical documentation standards for substance use disorder services shall comply with OAR 309-018-0140 through OAR 309-018-0150. Statutory/Other Authority: ORS 413.042, 430.640, 430.705 & 430.715 Statutes/Other Implemented: ORS 414.025, 414.065 & 430.640 History: DMAP 32-2015, f. 6-24-15, cert. ef. 6-26-15 DMAP 85-2014(Temp), f. 12-24-14, cert. ef. 1-1-15 thru 6-29-15
410-172-0630 Medically Appropriate (1) In addition to the definition of medically appropriate in OAR 410-120-0000 for behavioral health services, “medically appropriate” means the services and supports required to diagnose, stabilize, care for, and treat a behavioral health condition. (2) The Division shall make payment for medically appropriate behavioral health services when the services or supports are: (a) Rendered by a provider whose training, credentials, or license is appropriate to treat the identified condition and deliver the service; (b) Based on the standards of evidence-based practice, and the services provided are appropriate and consistent with the diagnosis identified in the behavioral health assessment; (c) Provided in accordance with an individualized service plan and appropriate to achieve the specific and measurable goals identified in the service plan; (d) Not provided solely for the convenience of the recipient, the recipient’s family, or the provider of the services or supplies; (e) Not provided solely for recreational purposes; (f) Not provided solely for research and data collection; (g) Not provided solely for the purpose of fulfilling a legal requirement placed on the recipient. Statutory/Other Authority: ORS 413.042 & 430.640 Statutes/Other Implemented: ORS 413.042, 414.025, 414.065, 430.640, 430.705 & 430.715 History: DMAP 32-2015, f. 6-24-15, cert. ef. 6-26-15 DMAP 85-2014(Temp), f. 12-24-14, cert. ef. 1-1-15 thru 6-29-15
410-172-0640 Behavioral Health Services Fee Schedule (1) The Division shall pay providers based on the Behavioral Health Services Fee Schedule (fee-for-service (FFS) payment rates for behavioral health services) posted on the Authority web site. (2) Payment shall be made at each provider’s usual and customary charge or the Division’s published reimbursement upper payment limit, whichever is less, minus payments received or due from other payers. Payments to other specified providers shall be made according to other approved schedules. (3) The Division’s maximum allowable rate-setting process uses a methodology that is based on the existing Medicaid fee schedule with adjustments for legislative changes and payment levels. (4) Limitations contained in the Behavioral Health Services Fee Schedule, such as the maximum rate and the amount, duration, and scope of services provided, are subject to change at the discretion of the Division. Updates and changes are posted on the Behavioral Health Services Fee Schedule website at www.oregon.gov/OHA/HSD/OHP/Pages/Fee-Schedule.aspx . (5) Payment shall be made for services listed in the Medicaid Behavioral Health Procedure Fee Schedule that are rendered to Medicaid-eligible individuals by a qualified provider during the period in which the provider is enrolled with the Division. (6) For cost-reimbursed services, the provider shall maintain adequate records to thoroughly explain how the amounts reported on the cost statement were determined. The records shall be accurate and in sufficient detail to substantiate the data reported. Providers whose rates are paid based on a collective bargaining agreement are not exempt from this requirement. (7) In accordance with 42 CFR § 405.506, a charge that exceeds the customary charge of the physician or other person who rendered the medical or other health service, or the prevailing charge in the locality, or an applicable lowest charge level may be found to be reasonable, but only where there are unusual circumstances, or medical complications requiring additional time, effort, or expense that support an additional charge, and only if it is acceptable medical or medical service practice in the locality to make an extra charge in such cases. The mere fact that the physician’s or other person’s customary charge is higher than prevailing would not justify a determination that it is reasonable. (8) Payment by the Division does not limit the Authority or any state or federal oversight entity from reviewing or auditing a claim before or after the payment. Payment may be denied or subject to recovery if medical review, audit, or other post-payment review determines that payment for the service was not provided in accordance with applicable Oregon Administrative Rules or the service does not meet the criteria for quality or medical appropriateness of the care. Statutory/Other Authority: ORS 413.042 & 430.640 Statutes/Other Implemented: ORS 413.042, 414.025, 414.065, 430.640, 430.705 & 430.715 History: DMAP 66-2018, minor correction filed 05/25/2018, effective 05/25/2018 DMAP 32-2015, f. 6-24-15, cert. ef. 6-26-15 DMAP 85-2014(Temp), f. 12-24-14, cert. ef. 1-1-15 thru 6-29-15
410-172-0680 Residential Treatment Services for Children (1) Paid providers of children’s psychiatric residential treatment services shall: (a) Hold a Certificate of Approval Pursuant to OAR 309-012-0130 through 309-012-0220 from AMH; and (b) Be accredited as a psychiatric residential treatment facility for children under age 18 by JCAHO, CARF, or any other accrediting organization with comparable standards that is recognized by the State of Oregon; (c) Be licensed by the Office of Licensing and Regulatory Oversight (OLRO); (2) Residential Treatment Services for Children shall provide a program consistent with standards set by JCAHO, CARF, or any other accrediting organization with comparable standards that is recognized by the state. Statutory/Other Authority: ORS 413.042 & 430.640 Statutes/Other Implemented: ORS 413.042, 414.025, 414.065, 430.640, 430.705 & 430.715 History: DMAP 32-2015, f. 6-24-15, cert. ef. 6-26-15 DMAP 85-2014(Temp), f. 12-24-14, cert. ef. 1-1-15 thru 6-29-15
410-172-0690 Admission Procedure for Psychiatric Residential Treatment Services for Children (1) Admission procedures for children eligible for Medicaid shall be reviewed through an independent psychiatric review process established by the Division to certify the need for services. (2) Referral to psychiatric residential treatment services shall be because: (a) Medically appropriate treatment of the child’s psychiatric condition requires services on a 24-hour residential basis under the direction of a Licensed Medical Practitioner (LMP) as defined in OAR 309-019-0105; and (b) The services can reasonably be expected to improve the child’s condition or prevent further regression so that the services will no longer be needed. (3) The referring source shall make available to the third-party reviewer for the Certificate of Need (CON) process the following information about the referred child: (a) A written psychological or psychiatric evaluation or progress note from a face-to-face service completed by a treating, LMP within the previous 60 days that recommends treatment in a 24-hour facility under the direction of an LMP; (b) A written psychosocial history; (c) Other information from the referral source, other involved community agencies, and the family that are pertinent and appropriate; (d) Identified care coordinator; (e) Identified child and family team members; (f) Service Coordination Plan: (A) Intensive Care Coordination Plan as defined in OAR 410-141-3870; or (B) Wraparound Plan of Care as defined in OAR 309-019-0326; (g) Documentation regarding lower level of care outcomes or justification regarding how 24-hour psychiatric residential based treatment under the care of an LMP will meet the needs of the child; and (h) For fee-for-service members, a letter from Community Mental Health Program (CMHP) approving the referral to this level of care. (4) For emergency admissions, the CON shall be made by the team responsible for a plan of care as described in CFR 441.156 within 14 days from the date of admission. Statutory/Other Authority: ORS 413.042 & 430.640 Statutes/Other Implemented: ORS 413.042, 430.640, ORS 414.025, 414.065, 430.705 & 430.715 History: DMAP 31-2021, amend filed 07/16/2021, effective 07/26/2021 DMAP 4-2021, temporary amend filed 01/28/2021, effective 01/28/2021 through 07/25/2021 DMAP 32-2015, f. 6-24-15, cert. ef. 6-26-15 DMAP 85-2014(Temp), f. 12-24-14, cert. ef. 1-1-15 thru 6-29-15
410-172-0710 Residential Personal Care (1) Personal care services shall be provided to residents of Division licensed residential treatment programs, as developmentally appropriate, as described in the resident’s person-centered service plan and residential plans of care. (2) Personal care services are provided to individuals with behavioral health conditions that enable them to accomplish tasks that they would normally do for themselves if they did not have a behavioral health condition. Assistance may be in the form of hands-on assistance for the resident, supervising, cueing, or redirecting so that the individual performs the task on their own. (3) Personal care services are provided in accordance with an individual’s assessment and the authorized plan for services made by a provider meeting the qualifications of a Qualified Mental Health Professional (QMHP) or Qualified Mental Health Associate (QMHA) as defined in OAR chapter 309 division 019. (4) Personal care assistance relates to performance of activities of daily living (ADLs) and instrumental activities of daily living (IADLs) as defined in these rules. (5) Personal care services may be provided on a continuing basis or on episodic occasion. (a) For residential personal care services the Authority will pay the standardized rate in the behavioral health fee schedule in effect on the date of service. (b) Residential personal care service are included in the per diem rate standardization described in OAR 410-172-0705. (6) Paid providers of residential personal care services shall meet one of the following: (a) Residential Treatment Homes (RTH), Residential Treatment Facilities (RTF), Secure Residential Treatment Facilities (SRTF) and Crisis-Respite Services programs as described in OAR chapter 309 division 35; or (b) Adult Foster Home (AFH) as described in OAR chapter 309 division 40. Statutory/Other Authority: ORS 413.042 & 430.640 Statutes/Other Implemented: ORS 413.042, 430.640, 414.025, 414.065, 430.705 & 430.715 History: DMAP 38-2022, amend filed 03/23/2022, effective 03/23/2022 DMAP 36-2021, temporary amend filed 09/14/2021, effective 09/14/2021 through 03/12/2022 DMAP 59-2016, f. 10-4-16, cert. ef. 10-11-16 DMAP 50-2016(Temp), f. 8-1-16, cert. ef. 8-3-16 thru 10-11-16 DMAP 32-2015, f. 6-24-15, cert. ef. 6-26-15 DMAP 85-2014(Temp), f. 12-24-14, cert. ef. 1-1-15 thru 6-29-15