OAR 411-380-0090: Provider Billing and Payment

(1) AUTHORIZATION OF HOURS. Authorization for direct nursing service hours are: (a) Based on acuity levels from the Direct Nursing Services Criteria and documented on an individual's Direct Nursing Service Criteria Memo. (b) Authorized in the ISP by the case management entity. (2) PRIOR AUTHORIZATION. (a) Providers must request electronic authorization for direct nursing service hours through MMIS and have hours prior authorized by the Department. (b) The Department may withdraw, modify, or deny prior authorizations in the event of any of the following: (A) Change in the status of the individual, such as eligibility for direct nursing services, hospitalization, improvement in health status, or death. (B) Decision of the individual, their family, or the legal representative, to change providers. (C) Failure to comply with the delivery of direct nursing services and documentation. (D) Failure to perform other expected duties. (3) CLAIMS. (a) A provider must comply with the rules for timely submission of claims as written in OAR 410-120-1300 and authorization of payment in OAR 410-120-1320. A provider must submit a claim for payment to the case management entity within 12 months of the date of service. (b) A provider must follow all Department required documentation procedures for timesheets, invoices, and signatures and submit true and accurate information. (c) Medicaid funds are the payer of last resort. A provider must bill all third party resources until all resources are exhausted. (d) A provider may not submit any of the following to the Department or case management entity: (A) A false billing form for payment. (B) A billing form for payment that has been, or is expected to be, paid by another source. (C) Any billing form for services that have not been provided. (e) The billing form used to submit a claim must include the prior authorization number. (f) A provider must sign the billing form acknowledging agreement with the terms and conditions of the claim and attesting that the hours were delivered as billed. (g) The case management entity must review the claim and match the number of hours claimed by the provider against the number of hours prior authorized. The case management entity must review, approve, and forward the claim to the Department in a timely manner. (h) Claims for direct nursing services may be paid for nursing ratio other than 1:1 as long as each individual's case does not overlap with another individual's case. Only time spent with each individual may be billed. Claims must be billed in 15 minute units. (4) PAYMENT. (a) Payment for direct nursing services is made in accordance with the following: (A) These rules. (B) OAR 410-120-1300 for timely submission of claims. (C) OAR 410-120-1320 for authorization of payment. (D) OAR 410-120-1340 for payment. (E) OAR 410-120-1380 for compliance with federal and state statutes. (F) OAR 407-120-0300 to 407-120-0400 for provider enrollment and claiming. (G) OAR 407-120-1505 for provider and contractor audits, appeals, and post payment recoveries. (b) Funds may not be used to support, in whole or in part, a provider in any capacity who has been convicted of any of the disqualifying crimes listed in ORS 443.004. (c) Payment for direct nursing services are fee-for-service with payment made subsequent to the delivery of the services. (d) The Department does not pay for services that are not authorized in the ISP. (e) Providers must be present with an individual in the delivery of direct nursing services in order to claim payments. (f) Holidays are paid at the same rate as non-holidays. (g) Overtime hours are not authorized. (h) Payment by the Department for direct nursing services is considered payment in full for the services rendered under Medicaid. A provider may not demand or receive additional payment for direct nursing services from an individual, their family member, foster care provider, agency provider, or any other source, under any circumstances. (i) Payment may be denied based on the provisions of these rules and OAR 410-120-1320. (5) OVERPAYMENT. An overpayment occurs when a provider submits a claim or encounter, or received payment the provider is not properly entitled to. The determination of overpayment is based on OAR 410-120-1397(5)(a)-(h). The Department and OHA recoup all overpayments under OAR 410-120-1397.