OAR 411-070-0028
Bariatric Authorization and Payment


(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 (Bariatric Criteria and Services). 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 (Bariatric Criteria and Services), 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 (Bariatric Criteria and Services). 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 (Bundled Rate)) 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.

Source: Rule 411-070-0028 — Bariatric Authorization and Payment, https://secure.­sos.­state.­or.­us/oard/view.­action?ruleNumber=411-070-0028.

411‑070‑0000
Purpose
411‑070‑0005
Definitions
411‑070‑0010
Conditions for Payment
411‑070‑0015
Denial, Termination or Non-Renewal of Provider Agreement
411‑070‑0020
On-Site Reviews
411‑070‑0025
Basic Flat Rate Payment (Basic Rate)
411‑070‑0027
Complex Medical Add-On Payment
411‑070‑0028
Bariatric Authorization and Payment
411‑070‑0029
Pediatric Rate
411‑070‑0033
Post Hospital Extended Care Benefit
411‑070‑0035
Complex Medical Add-On Effective Start and End Dates and Administrative Review
411‑070‑0040
Screening, Assessment, and Resident Review
411‑070‑0043
Pre-Admission Screening and Resident Review (PASRR)
411‑070‑0045
Facility Payments
411‑070‑0050
Days Chargeable
411‑070‑0075
Rates - Facilities in Oregon
411‑070‑0080
Out-of-State Rates
411‑070‑0085
Bundled Rate
411‑070‑0087
Bariatric Criteria and Services
411‑070‑0091
Complex Medical Add-On Services
411‑070‑0092
Ventilator Assisted Program - Medicaid Payment
411‑070‑0095
Resident Funds
411‑070‑0100
Audit of Personal Incidental Funds
411‑070‑0105
Resident Property Records
411‑070‑0110
Temporary Absence from Facility (Bedhold)
411‑070‑0115
Transfer of Residents
411‑070‑0120
Discharge of Residents
411‑070‑0125
Medicare, (Title XVIII)
411‑070‑0130
Medicaid Payment in Hospitals
411‑070‑0140
Hospice Services
411‑070‑0300
Filing of Financial Statement
411‑070‑0302
Filing of Revised Financial Statements
411‑070‑0305
Accounting and Record Keeping
411‑070‑0310
Auditing
411‑070‑0315
Maximum Allowable Compensation of Administrator
411‑070‑0320
Consultants
411‑070‑0330
Owner Compensation
411‑070‑0335
Related Party Transactions
411‑070‑0340
Chain Operations
411‑070‑0345
Allocation of Home Office and Regional Office Costs
411‑070‑0350
Management Fees
411‑070‑0359
Allowable Costs
411‑070‑0365
Capital Assets
411‑070‑0370
Depreciable Assets
411‑070‑0375
Depreciation Basis
411‑070‑0385
Depreciation Lives
411‑070‑0400
Equity
411‑070‑0415
Offset Income
411‑070‑0417
Treatment of Complex Medical Add-Ons
411‑070‑0420
Base Year Cost Finding
411‑070‑0425
Resident Days
411‑070‑0430
Allocation Methods
411‑070‑0435
Appeals
411‑070‑0437
Quality and Efficiency Incentive Program
411‑070‑0439
COVID-19 Emergency Response Incentive Program
411‑070‑0442
Calculation of the Basic Rate, Complex Medical Rate, Bariatric Rate and Ventilator Assisted Program Rate
411‑070‑0452
Pediatric Nursing Facilities
411‑070‑0464
Final Report
411‑070‑0465
Uniform Chart of Accounts
411‑070‑0470
Nursing Assistant Training and Competency Evaluation Programs Request for Reimbursement
Last Updated

Jun. 8, 2021

Rule 411-070-0028’s source at or​.us