OAR 410-138-0080
Targeted Case Management Program Billing Policy
(1)
Reimbursement is based on cost-based rate methodology and subject to all rules and laws pertaining to federal financial participation. The Authority’s acceptance of cost data provided by provider organizations for the purpose of establishing rates paid for TCM services does not imply or validate the accuracy of the cost data provided.(2)
The cost-based rate shall be derived by considering the following expenditures directly attributable to TCM staff:(a)
TCM staff salaries and other personnel expenses;(b)
Supervisory salaries and other personnel expenses;(c)
Administrative support salaries and other personnel expenses;(d)
Services and supply expenses;(e)
Various overhead expenditures, if not already considered in the indirect rate.(3)
The Division shall accept a claim up to 12 months from the date of service. See provider rules OAR 943-120-0340 (Claim and PHP Encounter Submission) and OAR 410-120-1300 (Timely Submission of Claims) (Timely Submission of Claims).(4)
Providers shall only bill for allowable activities in the TCM programs that assist individuals eligible under the Medicaid State Plan to gain access to needed medical, social, educational, housing, environmental, and other services.(5)
The Division may not allow duplicate payments to other public agencies or private entities under other program authorities for TCM services under the eligible client’s care plan. Medical services shall be provided and billed separately from case management services. The Authority shall recover duplicate payments.(6)
The Division may not reimburse for TCM services if the services are case management services funded by Title IV-E or Title XX of the Social Security Act, federal or state funded parole and probation, or juvenile justice programs. These services shall be billed separately.(7)
In general, the Medicaid program is the payer of last resort, and a provider is required to bill other resources before submitting the claim to Medicaid. This requirement means that other payment sources, including other federal or state funding sources, shall be used before the Authority may be billed for covered TCM services. However, the following exceptions apply to the requirement to pursue third party resources:(a)
TCM Early Intervention/Early Childhood School Education (EI/ECSE) services are provided under the Individuals with Disabilities Education Act (IDEA), 1903(c) of the Social Security Act and 34 CFR 300.154 Methods of Ensuring Services wherein Medicaid and the Children’s Health Insurance Program (CHIP) are the primary payers before the Oregon Department of Education (ODE) or the Educational Agency (EA) for a covered TCM EI/ECSE service provided to a Medicaid-eligible child receiving Service Coordination/Case Management pursuant to the Medicaid-eligible child’s Individualized Family Service Plan (IFSP). The services are documented as required under the TCM rules and subject to the applicable reimbursement rate;(b)
If TCM EI/ECSE services are provided under Title V of the Social Security Act Maternal and Child Health Services Block Grant, Medicaid-covered TCM services provided by a Title V grantee are paid by Medicaid before the Title V funds;(c)
CMS recognizes that while public education agencies are required to provide IDEA services at no cost to eligible children, Medicaid reimbursement is available for these services because section 1903(c) of the Social Security Act requires Medicaid to be primary to the U.S. Department of Education for payment of covered services that may also be considered special education, related services, or early intervention services, or services provided under IDEA.(8)
Any place of service is valid.(9)
Prior authorization is not required.
Source:
Rule 410-138-0080 — Targeted Case Management Program Billing Policy, https://secure.sos.state.or.us/oard/view.action?ruleNumber=410-138-0080.