OAR 309-033-0265: The Authority’s Denial of Payment for Services to Persons in Custody or on Diversion

(1) The Authority denial. The Authority shall deny part or all payment for services for a person in custody or on a diversion only when the Authority determines that there is insufficient evidence to reasonably support the belief that the person in custody demonstrated: (a) Living with a mental disorder; and (b) Dangerousness to self or others as evidenced by thoughts, plans, means, actions, history of dangerousness or other indicators of imminent dangerousness which Division believes are within accepted community standards of professional knowledge. (2) The Authority consultation with Licensed Independent Practitioner (LIP). When making a determination under this rule which is primarily based on accepted community standards of professional knowledge, the Authority shall consult with a LIP. (3) Information payer must submit. When making a request for denial of payment, the payer responsible for the services provided to the person in custody or on diversion under ORS 426.241 shall submit the following to the Authority: (a) A statement requesting the Authority review the appropriateness of the hold or diversion for the purpose of approving denial of part or all payment for services rendered; (b) An explanation of why the payer believes the services provided to the person in custody or on diversion do not meet criteria described in ORS 426.232, 426.233 or 426.237; (c) Any documentation which supports the payer’s belief that the services provided to the person in custody or on diversion were inappropriate. (4) Clinical records to be submitted. At the request of the Authority, as provided by ORS 426.241(5)(b), the following shall submit clinical records and other documents requested relating to the services in question to the Division: (a) A hospital or a nonhospital facility approved under OAR 309-033-0530; (b) A LIP or person providing services to the person in custody or on diversion.