Oregon Administrative Rules › Chapter 411 - DEPARTMENT OF HUMAN SERVICES, AGING AND PEOPLE WITH DISABILITIES AND DEVELOPMENTAL DISABILITIES › Division 70 - NURSING FACILITIES/MEDICAID GENERALLY AND REIMBURSEMENT › Section 411-070-0028 - Bariatric Authorization and Payment

Current through Register Vol. 63, No. 7, July 1, 2024
(1) PRIOR AUTHORIZATION. APD may authorize
			 payment for the bariatric rate when a Medicaid individual's needs meet the
			 criteria listed in OAR
			 411-070-0087. A nursing facility
			 must obtain prior authorization from the Department prior to admitting or
			 submitting payment for a bariatric individual using a form designated by the
			 Department.
(2) APD shall issue a
			 decision regarding prior authorization within seven business days of receipt of
			 the form described in section (1) of this rule. APD may extend this timeframe
			 for up to ten additional business days pursuant to written notice to the
			 nursing facility if APD requires further information from the nursing facility
			 in order to make a prior authorization determination. If APD does not issue a
			 decision within the timeframes described in this paragraph, prior authorization
			 shall be deemed to be granted on the day the required timeframe
			 expires.
(3) Prior authorization
			 provided pursuant to this rule shall be effective as of the date APD issues the
			 decision or prior authorization is deemed to be granted pursuant to section (2)
			 of this rule or, if the nursing facility submits the form described in section
			 (1) of this rule after admitting the resident, on the date of admission if that
			 date occurs no more than seven calendar days prior to submission of the
			 form.
(4) PAYMENT. For a Medicaid
			 individual who meets the criteria in OAR
			 411-070-0087, the bariatric rate
			 will be effective from the date a prior authorization from the Department is in
			 effect to the last date the individual meets the criteria.
(5) DOCUMENTATION. The licensed nursing staff
			 of the facility must maintain a weekly nursing note of sufficient documentation
			 pertinent to the bariatric individual in the clinical record to justify the
			 bariatric payment determination in accordance with OAR
			 411-070-0087. This documentation
			 must be available to APD upon request.
(6) Bariatric per diem rates shall cover all
			 services in the bundled rate (OAR
			 411-070-0085) as well as all
			 services, equipment, supplies and costs related to bariatric
			 services.
(7) BARIATRIC RATE
			 PROHIBITED. APD may not provide bariatric payments for a facility with a waiver
			 that allows a reduction of eight or more hours per week from required licensed
			 nurse staffing hours.
(8)
			 OVERPAYMENT FOR BARIATRIC MEDICAID PAYMENTS. The Department may collect monies
			 that were overpaid to a facility for any period the Department determines the
			 individual's condition or service needs did not meet the criteria for an
			 eligible individual or determines the facility did not maintain the required
			 documentation per (5) of this rule. The Department shall issue an order to the
			 facility that includes the determination described in this paragraph and the
			 facts supporting the determination as well as the amount of overpayment the
			 Department seeks to recoup.
(9)
			 ADMINISTRATIVE REVIEW.
(a) If a provider
			 disagrees with the order of the Department regarding authorization pursuant to
			 section (1) of this rule or overpayment pursuant to section (8) of this rule,
			 the provider may either request from APD an informal administrative review of
			 the decision or appeal the order as described in this paragraph.
(b) If the provider requests an informal
			 administrative review, the provider must submit its request for review in
			 writing within 30 days of receipt of the notice.
(A) The provider must submit documentation,
			 as requested by APD and as the provider may choose to further submit to
			 substantiate its position.
(B) APD
			 shall notify the provider in writing of its informal decision within 45 days of
			 APD's receipt of the provider's request for review.
(C) APD's informal decision shall be an order
			 in other than a contested case and subject to review pursuant to ORS chapter
			 183.
(c) A provider who
			 disagrees with the order issued pursuant to section (9) of this rule may appeal
			 the order pursuant to a contested case proceeding. The provider must submit an
			 appeal in writing within 60 days of receipt of the order.