OAR 411-048-0200
Additional Documentation Requirements
(1)
An RN must meet the documentation, record keeping, and communication standards as required by the Department in addition to the documentation, record keeping, and communication standards as required by the OSBN in OAR chapter 851. Compliance with these standards ensures communication between an RN and an individual’s case manager and caregiver.(2)
The documentation standards in this rule and on Department approved forms provided by the Department do not replace or substitute for the documentation requirements in the:(a)
Rules for professional nursing standards as prescribed by the OSBN in OAR chapter 851, divisions 045, 047, and 48;(b)
Medicaid provider rules governing provider requirements as described in OAR chapter 407, division 120; and(c)
As applicable, the Medicaid General Rules described in OAR chapter 410, division 120.(3)
An RN is expected to complete the Department approved forms specified by the Department to support the long term care community nursing services in these rules. The Department may approve the use of alternative but equivalent forms.(4)
An RN must send copies of the completed Department approved forms to the case manager prior to or at the time of invoice submission. Documentation must support the long term care community nursing services billed and adhere to the timeframes noted in these rules.(a)
An individual’s case manager must receive the required Department approved forms and documentation to pay a claim.(b)
Failure to comply with the documentation standards in this rule may result in the determination of overpayment for which restitution may be sought.(5)
All documentation must be provided in HIPAA secured format.(6)
The self-employed RN that is enrolled as a Medicaid provider or an agency enrolled as a Medicaid provider as described in OAR 411-048-0210 (Qualifications for Enrolled Medicaid Providers) must maintain a record of all long term care community nursing services provided to each assigned individual and the individual’s caregiver.(a)
The record must include copies of all documentation provided to the local office as well as any additional documentation the RN or agency maintained to meet OSBN or Medicaid provider rules.(b)
The RN must retain the record until the RN no longer provides long term care community nursing services to the individual, at which time the RN or agency must provide the individual’s case manager a copy of any part of the record not previously provided.(c)
The RN or agency must retain original records for each individual following HIPAA practices for a period of seven years.
Source:
Rule 411-048-0200 — Additional Documentation Requirements, https://secure.sos.state.or.us/oard/view.action?ruleNumber=411-048-0200.