OAR 411-325-0490
Provider Eligibility for Medicaid Service Payment


(1)

In addition to meeting the licensing standards and conditions set forth in these rules, a provider must have an approved prior authorization through the Department payment system for individuals receiving Medicaid-funded services before the provider is eligible to claim for delivering Medicaid-funded services. The prior authorization includes dates of authorized services and the funding amount allocated.

(2)

A provider may only claim for a day of service when:

(a)

An individual sleeps in the home overnight; or

(b)

An individual does not sleep in the home overnight, but intends to return to the home, and the provider was responsible for and provided an accumulated period of eight hours for the primary care, support, safety, and well-being of the individual, including any of the following:

(A)

Providing intermittent physical support or care.

(B)

Providing stand-by support with the ability to respond in person within the response times as outlined in the individual’s ISP.

(C)

Being responsible to communicate reciprocally within the response times agreed upon by the individual’s ISP team and documented in the individual’s ISP, based on the individual’s identified support needs.

(3)

A day of service does not apply when an individual:

(a)

Has been admitted to an acute care hospital unless the individual’s ISP authorizes attendant care for the individual in an acute care hospital and the day of service criteria in section (2)(b) of this rule is met. An ISP may only authorize attendant care for an individual who has been admitted to an acute care hospital when the support is not a duplication of service that the hospital provides and the individual has one of the following:

(A)

Challenging behavior that interferes with getting medical care. The challenging behavior must require specific training or experience to support and must be able to be mitigated by a developmental disability service provider to an extent that medical care is improved.

(B)

An inability to independently communicate with hospital staff that interferes with getting medical care. This must not be solely due to limited or emerging English proficiency.

(C)

Support with one or more activities of daily living that may only be adequately met by someone familiar with the individual.

(b)

Has been admitted to a nursing facility;

(c)

Has been admitted to a mental health facility;

(d)

Is held in detention or jail; or

(e)

Is outside of the United States.

(4)

A provider may only claim for a day of service under section (2)(b) of this rule when an individual is away from the home, accompanied by a provider or staff, for up to 30 consecutive days or 45 calendar days in an ISP year.

(a)

The provider is not paid for the 31st and following consecutive days when an individual is away from the home.

(b)

A provider is not paid for the 46th and following non-consecutive days an individual is not at the licensed home overnight.

(c)

Days not paid do not count in the 45-calendar day total.

Source: Rule 411-325-0490 — Provider Eligibility for Medicaid Service Payment, https://secure.­sos.­state.­or.­us/oard/view.­action?ruleNumber=411-325-0490.

411–325–0010
Statement of Purpose
411–325–0020
Definitions and Acronyms
411–325–0025
Program Management
411–325–0030
Issuance of License
411–325–0040
Application for Initial License
411–325–0050
License Expiration, Termination of Operations, License Return
411–325–0060
License Conditions
411–325–0070
License Renewal
411–325–0090
Change of Ownership, Legal Entity, Legal Status, Management Corporation
411–325–0110
Variances
411–325–0120
Medical Services
411–325–0130
Food and Nutrition
411–325–0140
Physical Environment
411–325–0150
General Safety
411–325–0170
Staffing Requirements
411–325–0180
Individual Summary Sheets
411–325–0185
Emergency Information
411–325–0200
Transportation
411–325–0220
Individual Furnishings
411–325–0230
Emergency Plan and Safety Review
411–325–0240
Assessment of Fire Evacuation Assistance
411–325–0250
Fire Drill Requirements and Fire Safety
411–325–0260
Individual Fire Evacuation Safety Plans
411–325–0270
Fire Safety Requirements for Homes on a Single Property or on Contiguous Property Serving Six or More Individuals
411–325–0280
Fire Safety Requirements for Homes or Duplexes Serving Five or Fewer Individuals
411–325–0290
Fire Safety Requirements for Apartments Serving Five or Fewer Individuals
411–325–0300
Residency Agreements, Individual Rights, Complaints, Notification of Planned Action, and Hearings
411–325–0350
Behavior Supports and Physical Restraints
411–325–0360
Psychotropic Medications and Medications for Behavior
411–325–0370
Individuals’ Personal Property
411–325–0380
Handling and Managing Individuals’ Money
411–325–0390
Entry, Exit, Transfer, and Closure
411–325–0410
Community Living Supports
411–325–0430
Individual Support Plan
411–325–0440
Children’s Direct Contracted Services
411–325–0445
Notification of School District - Homes Serving Five or More Children
411–325–0460
Civil Penalties
411–325–0470
License Denial, Suspension, Revocation, Refusal to Renew
411–325–0480
Criminal Penalties
411–325–0490
Provider Eligibility for Medicaid Service Payment
Last Updated

Jun. 8, 2021

Rule 411-325-0490’s source at or​.us