OAR 411-070-0028: Bariatric Authorization and Payment

(1) PRIOR AUTHORIZATION. APD may authorize payment for the bariatric rate when a Medicaid individual’s needs meet the criteria listed in OAR 411-070-0087. A nursing facility must obtain prior authorization from the Department prior to admitting or submitting payment for a bariatric individual using a form designated by the Department. (2) APD shall issue a decision regarding prior authorization within seven business days of receipt of the form described in section (1) of this rule. APD may extend this timeframe for up to ten additional business days pursuant to written notice to the nursing facility if APD requires further information from the nursing facility in order to make a prior authorization determination. If APD does not issue a decision within the timeframes described in this paragraph, prior authorization shall be deemed to be granted on the day the required timeframe expires. (3) Prior authorization provided pursuant to this rule shall be effective as of the date APD issues the decision or prior authorization is deemed to be granted pursuant to section (2) of this rule or, if the nursing facility submits the form described in section (1) of this rule after admitting the resident, on the date of admission if that date occurs no more than seven calendar days prior to submission of the form. (4) PAYMENT. For a Medicaid individual who meets the criteria in OAR 411-070-0087, the bariatric rate will be effective from the date a prior authorization from the Department is in effect to the last date the individual meets the criteria. (5) DOCUMENTATION. The licensed nursing staff of the facility must maintain a weekly nursing note of sufficient documentation pertinent to the bariatric individual in the clinical record to justify the bariatric payment determination in accordance with OAR 411-070-0087. This documentation must be available to APD upon request. (6) Bariatric per diem rates shall cover all services in the bundled rate (OAR 411-070-0085) as well as all services, equipment, supplies and costs related to bariatric services. (7) BARIATRIC RATE PROHIBITED. APD may not provide bariatric payments for a facility with a waiver that allows a reduction of eight or more hours per week from required licensed nurse staffing hours. (8) OVERPAYMENT FOR BARIATRIC MEDICAID PAYMENTS. The Department may collect monies that were overpaid to a facility for any period the Department determines the individual's condition or service needs did not meet the criteria for an eligible individual or determines the facility did not maintain the required documentation per (5) of this rule. The Department shall issue an order to the facility that includes the determination described in this paragraph and the facts supporting the determination as well as the amount of overpayment the Department seeks to recoup. (9) ADMINISTRATIVE REVIEW. (a) If a provider disagrees with the order of the Department regarding authorization pursuant to section (1) of this rule or overpayment pursuant to section (8) of this rule, the provider may either request from APD an informal administrative review of the decision or appeal the order as described in this paragraph. (b) If the provider requests an informal administrative review, the provider must submit its request for review in writing within 30 days of receipt of the notice. (A) The provider must submit documentation, as requested by APD and as the provider may choose to further submit to substantiate its position. (B) 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. (C) APD’s informal decision shall be an order in other than a contested case and subject to review pursuant to ORS chapter 183. (c) A provider who disagrees with the order issued pursuant to section (9) of this rule may appeal the order pursuant to a contested case proceeding. The provider must submit an appeal in writing within 60 days of receipt of the order.