OAR 411-323-0065: Payment to Agency Providers

(1) Service authorization by a case management entity or the Department for payment in the appropriate electronic payment system must occur prior to the delivery of services. (2) Payment shall only be made after services are delivered. (3) An agency is responsible for verification of the type and amount of support delivered by agency staff and may not require an individual or an individual's representative or family member to verify support. (4) For a service to be eligible for payment, the service must be included in a written agreement that specifies, at a minimum, the type and amount of services to be delivered. The written agreement must be signed by the individual’s case manager, the individual or their designated representative, and the executive director of the agency or their designee. The written agreement may be: (a) The individual ISP; or (b) A Service Agreement specific to the individual. (5) The agency must request payment authorization from the case management entity for services provided during an unforeseeable emergency on the first business day following the emergency service. A case manager must determine if the service is eligible for payment. (6) The Department does not reimburse an agency for travel time of agency staff to reach a setting where services are delivered, when not directly providing services to an individual. (7) Payment by the Department for a service is considered full payment for the services rendered under Medicaid. An agency may not demand or receive additional payment for services rendered under Medicaid from the individual, parent, guardian, or any other source, under any circumstances. (8) Department funds are the payer of last resort. An agency must bill all third- party resources until all third-party resources are exhausted. (9) The Department reserves the right to make a claim against any third-party payer before or after making payment to the agency. (10) Upon submission of a request for payment, an agency must comply with: (a) All applicable rules in OAR chapter 407 and OAR chapter 411; (b) 45 CFR Part 84 which implements Title V, Section 504 of the Rehabilitation Act of 1973 as amended; (c) Title II and Title III of the Americans with Disabilities Act of 1991; and (d) Title VI of the Civil Rights Act of 1964. (11) All billings must be for services provided within the licensure and certification of the agency. (12) The agency must submit true and accurate information with request for payment. (13) An agency may not submit the following to the Department: (a) A false request for payment; (b) A request for payment that has been, or is expected to be, paid by another source; or (c) Any request for payment for services that have not been provided. (14) The Department only makes payment to an enrolled agency who actually performs the services. Federal regulations prohibit the Department from making payment to a collection agency. (15) Payment is denied if any provisions of these rules, the rules in OAR chapter 411, division 004, or the program rules associated with an endorsement are not complied with. (16) The Department may recoup overpayments as described in OAR chapter 407, division 120. (17) In order to be eligible for payment, requests for payments must be submitted to the Department within 12 months of the delivery of services. (18) To be eligible to receive payments, an agency and agency providers must meet all requirements in OAR 411-370-0030 about provider enrollment and OAR 411-370-0020 about provider requirements. (19) Each licensed site where direct services are to be delivered must be assigned a Medicaid Performing Provider Number by the Department as described in OAR chapter 411, division 370. (20) Payment is only made to an agency with a current certificate and only for services for which the agency has a current endorsement. (21) The rate for a service is determined exclusively by the Department. (22) The Department may impose required actions on an agency that has been approved for a rate that is higher than the standard rate for the service as published in the Expenditure Guidelines. Failure to implement the required actions may result in a rate decrease.