OAR 410-172-0730: Payment Limitations for Behavioral Health Services

(1) Services shall be subject to periodic utilization review to determine medical appropriateness. (2) If a review reveals that a recipient received less than active treatment, payment may not be allowed under these rules and prior authorization may be cancelled. (3) The Division may make no payment for services if the Division or designee has determined the service is not medically appropriate. (4) Residential treatment services are provided to Medicaid Title XIX eligible individuals in facilities with 16 or fewer beds. Payment is excluded for individuals in “institutions of mental diseases” (IMD) who are over age 18 and under age 65. IMDs are defined in 42 CFR 435.1010. (5) For residential facilities, the Division shall pay for the day of admission but may not pay for the day of transfer or discharge. (6) Medicaid may not reimburse costs associated with room and board for recipients residing in Authority licensed residential treatment programs.