OAR 411-070-0035: Complex Medical Add-On Effective Start and End Dates and Administrative Review

(1) Effective Complex Medical Add-On Start and End Dates (a) Complex Medical Add-On Start Date: (A) Admission of any Medicaid resident whose condition or service needs meet the criteria for a complex medical add-on procedure code; or (B) A current Medicaid resident whose condition or service needs change and now meets the criteria for a complex medical add-on procedure code. This includes a readmission or return of a Medicaid resident following a leave of absence from the nursing facility whose needs meet add-on criteria. (b) Complex Medical Add-On End date — For a resident whose condition or service needs meet a complex medical add-on procedure code, the complex medical add-on is effective only until the last date the resident’s condition or need continues to meet complex medical add-on procedure code criteria. (2) ADMINISTRATIVE REVIEW. If a provider disagrees with the decision of APD’s Complex Medical Add-On Coordinator to make or deny an adjustment in the complex medical add-on payment for a Medicaid resident, the provider may request from APD an administrative review of the decision. The provider must submit its request for review in writing within 30 days of receipt of the notice to make or deny the adjustment. The provider must submit documentation, as requested by APD, to substantiate its position. 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. APD’s informal decision shall be an order in other than a contested case and subject to review pursuant to ORS 183.484. (3) OVERPAYMENT FOR COMPLEX MEDICAL ADD-ONS. APD shall collect monies that were overpaid to a facility for any period APD determines the resident’s condition or service needs did not meet the criteria for the complex medical add-on, or determines the facility did not maintain the required documentation.