OAR 836-053-1403
Definitions of Coordinated Care and Case Management for Behavioral Health Care Services

As used in ORS 743A.168 (Treatment of chemical dependency, including alcoholism, and mental or nervous conditions):
(1) The definitions set forth in section 5 of Section 4, Chapter 273, Oregon Laws 2017 apply to the use of those terms in these rules.
(2) “Caring contacts” mean brief communications with a patient that start during care transition such as discharge or release from treatment, or when a patient misses an appointment or drops out of treatment, and continues as long as a qualified mental health professional deems necessary.
(3) “Case management” means the management of services that are provided to assist an individual in accessing medical and behavioral health care, social and educational services, public assistance and medical assistance and other needed community services identified in the individual’s patient-centered care plan.
(4) “Coordination of care” means the process of coordinating patient care activities as well as the facilitation of ongoing communication and collaboration with lay caregivers by community resource providers, health care providers, and agencies to meet the multiple needs of a patient by:
(a) Organizing and participating in team meetings; and
(b) Ensuring continuity of care during each transition of care.
(5) “Crisis stabilization plan” means an individually tailored plan provided to a patient and the patient’s lay caregiver that:
(a) Is based on the patient’s behavioral health assessment and physical health assessment; and
(b) Describes the patient’s specific short-term rehabilitation objectives and proposed crisis interventions.
(6) “Lay caregiver” means:
(A) For a patient who is younger than 14 years of age, a parent or legal guardian of the patient.
(B) For a patient who is at least 14 years of age or older, an individual designated by the patient or a parent or legal guardian of the patient to the extent permitted under ORS 109.640 (Right to medical or dental treatment without parental consent) and 109.675 (Right to diagnosis or treatment for mental or emotional disorder or chemical dependency without parental consent).
(C) For a patient who is at least 14 years of age or older, and who has not designated a caregiver, an individual to whom a health care provider may disclose protected health information without a signed authorization under ORS 192.567 (Disclosure without authorization form).
(7) “Lethal means counseling” means counseling strategies designed to reduce the access by a patient who is at risk for suicide to lethal means, including but not limited to firearms.
(8) “Medically appropriate treatment” means the services and supports necessary to diagnose, stabilize, care for and treat a behavioral health condition.
(9) “Patient centered care” means care provided in a manner that:
(a) Is respectful of and responsive to a patient’s preferences, needs and values; and
(b) Ensures that all clinical decisions are guided by the patient’s values.
(10) “Peer delivered services” means an array of support services provided by agencies or community- based organizations to patients or family members of patients:
(a) Using peer support specialists; and
(b) That are designed to support the needs of patients and their families.
(11) “Peer support specialist” means a Peer Wellness Specialist or a Peer Support Specialist, including Family Support Specialist and Youth Support Specialist, as defined in ORS 414.025 (Definitions for ORS chapters 411, 413 and 414) and 414.665 (Traditional health workers utilized by coordinated care organizations) and certified under OAR 410-180-0310 (Community Health Worker, Peer Wellness Specialist, Personal Health Navigator Certification Requirements) to 410-180-0312 (Peer Support Specialist Certification Requirements).
(12) “Qualified mental health professional” means an individual meeting the minimum qualification criteria adopted by the Oregon Health Authority by rule for a qualified mental health professional.
(13) “Safety plan” means a written plan developed by a patient in collaboration with the patient’s lay caregiver, if any, as facilitated by a health care provider that identifies strategies for the patient or lay caregiver to use when the patient’s risk for suicide is elevated or following a suicide attempt.
(14) “Transition of care” means the process of transferring a patient from one provider or care setting to another provider or care setting.
(15) Coordination of Care and Case Management processes shall ensure coordination and management of services when indicated by a behavioral health assessment conducted by a behavioral health clinician, including, but not limited to:
(a) A best practices risk assessment and, if indicated, a safety plan and lethal means counseling;
(b) A determination of the patient’s clinical needs and recommendations, if within the scope of the provider’s practice, for medically appropriate treatment including but not limited to one or more of the following:
(A) Adjusting or prescribing medication;
(B) Therapeutic services;
(C) Other medically appropriate treatment; or
(D) Peer delivered services.
(c) Caring contacts.
(d) Recommendations as required or permitted under ORS 192.567 (Disclosure without authorization form), 441.196 and 441.198 to the patient, lay caregiver and health care provider.
(e) Informing the patient, lay caregiver and health care provider of the practitioners who can provide the recommended services and how to access the practitioners and other community-based resources.
(f) Explaining to the patient and the lay caregiver crisis stabilization planning and patient centered care and establishing a goal of convening a care team.
(g) Identifying a person to provide coordination of care who:
(A) Is part of a patient centered behavioral health home, as defined in ORS 414.025 (Definitions for ORS chapters 411, 413 and 414), a patient centered primary care home, as defined in ORS 414.025 (Definitions for ORS chapters 411, 413 and 414), or a patient centered medical home recognized by the National Committee for Quality Assurance;
(B) Is appropriately licensed or certified;
(C) Will communicate directly with the patient and the lay caregiver; and
(D) When possible or requested, will meet personally with the patient and the lay caregiver.
(h) Creating with the patient and the lay caregiver a plan for the transition of care and sharing the plan with the patient’s health care providers and care team.

Source: Rule 836-053-1403 — Definitions of Coordinated Care and Case Management for Behavioral Health Care Services, https://secure.­sos.­state.­or.­us/oard/view.­action?ruleNumber=836-053-1403.

836–053–0000
Applicability of January 1, 2014 Amendments to OAR Chapter 836, Division 53 836–053–0001
Modification of Health Benefit Plan Not Subject to Level of Coverage Requirements 836–053–0002
Modification of a Health Benefit Plan Subject to Levels of Coverage Requirements 836–053–0003
Prohibition of Exclusion Period for Pregnancy 836–053–0004
Compliance with Federal and State Law 836–053–0005
Prescription Drug Identification Cards 836–053–0007
Approval and Certification of Associations, Trusts, Discretionary Groups and Multiple Employer Welfare Arrangements 836–053–0008
Essential Health Benefits for Plan Years 2014, 2015 and 2016 836–053–0009
Oregon Standard Bronze and Silver Health Benefit Plans for Plan Years 2014, 2015 and 2016 836–053–0011
Standard Bronze Plan Health Savings Account Eligible Requirement 836–053–0012
Essential Health Benefits for Plan Years Beginning on and after January 1, 2017 836–053–0013
Oregon Standard Bronze and Silver Health Benefit Plans 836–053–0014
Standards and Process for Shortened Period of Market Prohibition 836–053–0015
Definition of Small Employer 836–053–0017
Additions to Essential Health Benefits for Plan Years Beginning on and after January 1, 2022 836–053–0019
Purpose 836–053–0021
Plans Offered to Oregon Small Employers 836–053–0030
Marketing of a Health Benefit Plan to Small Employers 836–053–0050
Trade Practices Relating to Small Employer Health Benefit Plans 836–053–0063
Rating for Nongrandfathered Small Group Plans 836–053–0065
Rating for Grandfathered Small Group Plans 836–053–0066
Rating for Transitional Health Benefit Plans Offered to Small Employers 836–053–0070
Multiple Employer Welfare Arrangements 836–053–0100
Work Related Injuries or Disease 836–053–0105
Coordination of Payment for Interim Medical Services 836–053–0211
Underwriting, Enrollment and Benefit Design Requirements Applicable to A Group Health Benefit Plan Including A Small Group Health Benefit Plan 836–053–0221
Participation, Contribution, and Eligibility Requirements for Group Health Benefit Plans Including Small Group Health Benefit Plans 836–053–0230
Underwriting 836–053–0300
Purpose 836–053–0310
Network Adequacy Definitions for OAR 836-053-0300 to 836-053-0350 836–053–0320
Annual Report Requirements for Network Adequacy 836–053–0330
Nationally Recognized Standards for Use in Demonstrating Compliance with Network Adequacy Requirements 836–053–0340
Factor-Based Evidence of Compliance with Network Adequacy Requirements 836–053–0350
Provider Directory Requirements for Network Adequacy 836–053–0410
Purpose 836–053–0415
Cancellation of an Individual Health Benefit Plan Coverage 836–053–0418
Definition of Insurer for Reimbursement of Expenses Related to Disease Outbreak or Epidemic 836–053–0431
Underwriting, Enrollment and Benefit Design 836–053–0435
Health Benefit Plan Coverage of Well-woman Preventive Care Services 836–053–0465
Rating for Individual Health Benefit Plans 836–053–0472
Statutory Authority and Implementation 836–053–0473
Required Materials for Rate Filing for Individual or Small Employer Health Benefit Plans 836–053–0474
Process For Rate Filing for Individual and Small Employer Health Benefit Plans 836–053–0475
Approval, Disapproval or Modification of Premium Rates for Individual or Small Employer Health Benefit Plan 836–053–0510
Evaluating the Health Status of an Applicant for Individual Health Benefit Plan Coverage 836–053–0600
Purpose 836–053–0605
Definitions for OAR 836-053-0600 to 836-053-0615 836–053–0610
Carrier Response to Request for Confidentiality 836–053–0615
Carrier Reporting Requirements 836–053–0825
Rescission of a Group Health Benefit Plan 836–053–0830
Rescission of an Individual Health Benefit Plan or Individual Health Insurance Policy 836–053–0835
Rescission of an Individual’s Coverage under a Group Health Benefit Plan or Group Health Insurance Policy 836–053–0851
Purpose 836–053–0857
Definitions 836–053–0863
Notifications 836–053–0900
Purpose 836–053–0910
Rate Filing 836–053–1000
Statutory Authority and Implementation 836–053–1010
Insurer Policies 836–053–1020
Drug Formularies 836–053–1030
Written Information to Enrollees 836–053–1033
Cultural and Linguistic Appropriateness 836–053–1035
Summary of Benefits and Explanation of Coverage 836–053–1060
Definitions 836–053–1070
Reporting of Grievances 836–053–1080
Tracking Grievances 836–053–1090
Assistance in Filing Grievances 836–053–1100
Internal Appeals Process 836–053–1110
Notice of Complaint Filing with Director 836–053–1130
Annual Summary, Utilization Review 836–053–1140
Appeal and Utilization Review Determinations 836–053–1170
Annual Summary, Quality Assessment Activities 836–053–1180
Format and Instructions for Report Required by ORS 743.818 836–053–1190
Annual Summary, Uniform Indicators of Network Adequacy 836–053–1200
Prior Authorization Requirements for Health Benefit Plans 836–053–1203
Prior Authorization Trade Practices for Health Insurance other than Health Benefit plans 836–053–1205
Uniform Prescription Drug Prior Authorization Request Form 836–053–1300
Purpose and Scope 836–053–1305
Definitions 836–053–1310
Contracting Requirements 836–053–1315
Performance Criteria 836–053–1317
Professional Qualifications 836–053–1320
Conflict of Interest 836–053–1325
Procedures for Conducting External Reviews 836–053–1330
Criteria and Considerations for External Review Determinations 836–053–1335
Procedures for Complaint Investigation 836–053–1337
Preliminary Review by Insurer 836–053–1340
Timelines and Notice for Dispute That is Not Expedited 836–053–1342
Timelines and Notice for Expedited Decision-Making 836–053–1345
Quality Assurance Mechanisms 836–053–1350
Ongoing Requirements for Independent Review Organizations 836–053–1355
Synopses 836–053–1360
External Review Reporting 836–053–1365
Fees for External Reviews 836–053–1400
Format and Instructions for Report Required by ORS 743.748 836–053–1403
Definitions of Coordinated Care and Case Management for Behavioral Health Care Services 836–053–1404
Definitions 836–053–1405
General Requirements for Coverage of Mental or Nervous Conditions and Chemical Dependency 836–053–1407
Prohibited Exclusions 836–053–1408
Required Disclosures 836–053–1409
Definitions 836–053–1410
Procedures 836–053–1415
Instructions 836–053–1500
Purpose 836–053–1505
Definitions for OAR 836-053-1500 to 836-053-1510 836–053–1510
Prominent Carrier Reporting Requirements 836–053–1520
Purpose 836–053–1525
Definitions 836–053–1530
Reporting Requirements 836–053–1600
Purpose 836–053–1605
Definitions for 836-053-1600 to 836-053-1615 836–053–1610
Non-anesthesia-related claims 836–053–1615
Anesthesia-related claims
Last Updated

Jun. 8, 2021

Rule 836-053-1403’s source at or​.us