OAR 411-070-0035
Complex Medical Add-On Effective Start and End Dates and Administrative Review

(1)

Effective Complex Medical Add-On Start and End Dates

(a)

Complex Medical Add-On Start Date:

(A)

Admission of any Medicaid resident whose condition or service needs meet the criteria for a complex medical add-on procedure code; or

(B)

A current Medicaid resident whose condition or service needs change and now meets the criteria for a complex medical add-on procedure code. This includes a readmission or return of a Medicaid resident following a leave of absence from the nursing facility whose needs meet add-on criteria.

(b)

Complex Medical Add-On End date — For a resident whose condition or service needs meet a complex medical add-on procedure code, the complex medical add-on is effective only until the last date the resident’s condition or need continues to meet complex medical add-on procedure code criteria.

(2)

ADMINISTRATIVE REVIEW. If a provider disagrees with the decision of APD’s Complex Medical Add-On Coordinator to make or deny an adjustment in the complex medical add-on payment for a Medicaid resident, the provider may request from APD an administrative review of the decision. The provider must submit its request for review in writing within 30 days of receipt of the notice to make or deny the adjustment. The provider must submit documentation, as requested by APD, to substantiate its position. 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. APD’s informal decision shall be an order in other than a contested case and subject to review pursuant to ORS 183.484 (Jurisdiction for review of orders other than contested cases).

(3)

OVERPAYMENT FOR COMPLEX MEDICAL ADD-ONS. APD shall collect monies that were overpaid to a facility for any period APD determines the resident’s condition or service needs did not meet the criteria for the complex medical add-on, or determines the facility did not maintain the required documentation.

Source: Rule 411-070-0035 — Complex Medical Add-On Effective Start and End Dates and Administrative Review, https://secure.­sos.­state.­or.­us/oard/view.­action?ruleNumber=411-070-0035 (accessed May 26, 2025).

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

May 26, 2025

Rule 411-070-0035's source at or​.us