Or. Admin. Code § 410-170-0110

Current through Register Vol. 63, No. 12, December 1, 2024

Section 410-170-0110 - Billing and Payment for Services and Placement-Related Activities

Effective July 1, 2023:

(1) The BRS contractor is compensated for a billable care day (service and placement-related activities rates) on a fee-for-service basis, except as otherwise provided for in these rules. The Authority does not make payments for any calendar day that does not meet the definition of a billable care day under this rule.

(2) Billable care day rates are provided in the "BRS Rates Table," dated July 1, 2023, which is adopted as Exhibit 1 and incorporated by reference into this rule. The BRS Rates Table is available at http://www.oregon.gov/oha/HSD/OHP/Pages/Policy-BRS.aspx. A printed copy may be obtained from the agency. BRS contractors not meeting the QRTP requirements will be paid at the non-QRTP rate.

(3) Billable Care Day:

(a) For purposes of computing a billable care day, the BRS client must be in the direct care of the BRS contractor or BRS provider at 11:59 p.m. of that day, be on runaway status as defined in this rule or be on an authorized home or transitional visit in accordance with section (4) of this rule;

(b) A billable care day does not include any day where the BRS client is in detention, an inpatient in a hospital, or has not yet entered or is discharged from the BRS contractor's or BRS provider's program;

(c) A billable care day does not include any day in which a BRS client is on runaway status and the BRS contractor or BRS provider was responsible for less than an accumulated period of 8 hours for the primary care, support, safety, and well-being of the BRS client.

(4) Home and Transitional Visits:

(a) The BRS contractor and BRS provider shall include only a maximum of eight (8) calendar days of a combination of home and transitional visits in a month, as billable care days;

(b) In order to qualify as an authorized home or transitional visit day, the BRS contractor and BRS provider must:

(A) Ensure that the home or transitional visit is tied to the BRS client's service plan;

(B) Work with the BRS client and the BRS client's family, including fictive kin, or aftercare resource on goals for the home or transitional visit and receive regular reports from the family or aftercare resource on the BRS client's progress while on the visit;

(C) Have staff available to answer calls from the BRS client and BRS client's family, including fictive kin, or aftercare resource and to provide services to the BRS client during the time planned for the home or transitional visit if the need arises;

(D) Document communications with the BRS client's family, including fictive kin, or aftercare resource; and

(E) Document the BRS client's progress on goals set for the home or transitional visits.

(5) Invoice form:

(a) The BRS contractor shall submit a monthly billing form to the agency in a format acceptable to the agency on or after the first day of the month following the month in which it provided services and placement-related activities to the BRS client. The billing form must specify the number of billable care days provided to each BRS client in that month;

(b) The BRS contractor shall provide upon request, in a format that meets the agency's approval, written documentation of each BRS client's location for each day claimed as a billable care day;

(c) The BRS contractor shall submit only claims for billable care days consistent with the agency's prior authorization.

(6) Payment for a Billable Care Day:

(a) The agency shall pay the service and placement related activities rates to the BRS contractor for each billable care day in accordance with the BRS Rates Table described in section (2) of this rule;

(b) Notwithstanding section (6)(a) of this rule, the Authority shall pay only the service rate for each billable care day to a public child-caring agency who by rule or contract provides the local match share for Medicaid claims under OAR 410-120-0035 and 42 CFR 433 Subpart B. The Authority may not pay the placement related activities rate for each billable care day to these types of public child-caring agencies;

(c) To the extent the payment for services is funded by Medicaid and CHIP funds:

(A) The BRS contractor and the BRS provider are subject to Medicaid billing and payment requirements in these rules and the Authority's general rules (OAR Chapter 410, Division 120);

(B) Payment using Medicaid and CHIP funds may be made only to the originating BRS contractor and not to the aftercare resource.

(d) To be eligible as a QRTP and receive the QRTP rate, the BRS contractor and the BRS provider are required to:

(A) Meet the QRTP definition in OAR 410-170-0020; and

(B) Submit accreditation documentation in writing annually to the contract administrator; and

(C) Maintain compliance as described in OAR 410-170-0030(11)(L).

(7) Third Party Resources:

(a) The Authority's BRS contractors must make reasonable efforts to obtain payment first from other resources consistent with OAR 410-120-1280;

(b) The Department's and OYA's BRS contractors are not required to review or pursue third party resources. The Department and OYA must make reasonable efforts to obtain payment first from other resources consistent with OAR 410-120-1280 for Medicaid-eligible BRS clients.

(8) Public child-caring agencies who are responsible by rule or contract for the local match share portion of eligible Medicaid claims must comply with OAR 410-120-0035 and 42 CFR 433 Subpart B.

(9) In cases where the BRS contractor is not also the BRS provider, the BRS contractor is responsible for compensating the BRS provider for billable care days pursuant to the agency-approved subcontract between the BRS contractor and the BRS provider.

(10) The Authority may not be financially responsible for the payment of any claim that the Centers for Medicare and Medicaid Services (CMS) disallows under the Medicaid or CHIP program. If the Authority previously paid the agency or BRS contractor for any claim that CMS disallows, the payment shall be recouped pursuant to OAR 410-120-1397. The Authority shall recoup or recover any other overpayments as described in OAR 410-120-1397 and 943-120-0350 and 943-120-1505.

Or. Admin. Code § 410-170-0110

DMAP 63-2013, f. 11-14-13, cert. ef. 1-1-14; DMAP 42-2015(Temp), f. & cert. ef. 8-11-15 thru 2-6-16; DMAP 4-2016(Temp), f. 2-5-16, cert. ef. 2-7-16 thru 8-4-16; DMAP 8-2016, f. & cert. ef. 2/23/2016; DMAP 25-2016(Temp), f. & cert. ef. 6-3-16 thru 11-29-16; DMAP 64-2016, f. 11-23-16, cert. ef. 11/29/2016; DMAP 30-2017(Temp), f. & cert. ef. 7-25-17 thru 1-20-18; DMAP 3-2018, amend filed 01/10/2018, effective 01/10/2018; DMAP 118-2018, amend filed 12/26/2018, effective 1/1/2019; DMAP 22-2019, temporary amend filed 06/21/2019, effective 7/1/2019 through 12/27/2019; DMAP 45-2019, amend filed 11/06/2019, effective 11/14/2019; DMAP 30-2020, temporary amend filed 06/26/2020, effective 07/01/2020 through 12/27/2020; DMAP 34-2020, temporary amend filed 07/01/2020, effective 7/1/2020 through 12/27/2020; DMAP 60-2020, amend filed 12/10/2020, effective 12/27/2020; DMAP 32-2021, temporary amend filed 07/22/2021, effective 07/22/2021 through 01/17/2022; DMAP 5-2022, amend filed 01/12/2022, effective 1/12/2022;DMAP 53-2023, temporary amend filed 06/30/2023, effective 7/1/2023through 12/27/2023; DMAP 92-2023, amend filed 12/21/2023, effective 12/27/2023

To view attachments referenced in rule text, click here to view rule.

Statutory/Other Authority: ORS 413.042 & ORS 414.065

Statutes/Other Implemented: ORS 414.065