Or. Admin. Code § 410-172-0840
Current through Register Vol. 63, No. 11, November 1, 2024
Section 410-172-0840 - Personal Care Attendant Payment Limitations(1) The number of personal care service hours authorized through the BH PCA program for an individual per 14-day service period is based on projected amounts of time to perform specific personal care services to the eligible individual. (a) Authorization of hours does not guarantee hours or payment;(b) The total of these hours is limited to 270 hours per individual per calendar year;(c) The hour cap identified in the CBA; and(d) Individuals whose assessed service needs exceed the 270-hour limit may receive approval from the Division for additional hours.(2) The Authority will pay for medically necessary and appropriate personal care services only when provider enrollment standards in OAR 410-120-1260, OAR Chapter 418 Division 020, and this rule have been verified as fully met, and both the employer and provider have been formally notified in writing that payment by the Authority is authorized. Documentation submitted when requesting prior authorization shall support the medical appropriateness for the service. Prior authorization requests for personal care services must meet the requirements in OAR 410-172-0650.(3) The Division shall make payment for personal care services through the BH PCA program to the PCA provider on an eligible individual's behalf. Payment for services is not guaranteed. (a) To request and receive payment the PCA must be an enrolled provider as required by OAR 410-120-1260, be a qualified provider, meet all requirements of this rule and the Division must verify that an individual's PCA provider meets the qualifications set forth in OAR chapter 418, division 020.(b) The Authority will only make payment to a PCA for personal care services when those personal care services are fully documented as required by this rule, comply with all State and Federal EVV requirements, and Authority rules for Medicaid payment and recordkeeping OAR 410-120-1280, OAR 410-120-1340, and OAR 410-120-1360.(c) Only valid claims are paid to PCA providers. To request and receive payment the PCA must use an Authority approved EVV method to verify all personal care services.(d) The EVV solution and all personal care services records are subject to Authority pre-payment and post-payment review. The Authority will review billings, EVV or other medical information for accuracy, medical appropriateness, level of service, correct coding, or for other reasons subsequent to payment of the claim.(e) Payment to PCA may be denied or subject to adjustment or recovery if billing errors or improper payment are identified by a pre-payment or post-payment review OAR 410-120-1396 and OAR 410-120-1397.(4) In accordance with OAR 410-120-1300, all provider claims for payment shall be submitted within 12 months of the date of service. For personal care services delivered by a PCA the Authority will pay the standardized rate as described in the CBA in effect on the date of service. PCA providers must submit accurate and complete claims and adequately document services via the Division approved EVV method and as required by OAR 410-120-1260 to receive payment from the Division.(5) Payment may not be claimed by a provider until the hours authorized for the payment period have been completed, as directed by an eligible individual or the individual's representative.(6) Payments made to a provider are calculated to a single attendant and a single eligible individual. A PCA provider shall not bill or receive payment for two or more individuals at the same time on the same day of service. A PCA provider shall not request or receive payment at the same time, on the same day of service, as more than one Agency enrolled provider.(7) Payments will not be made to a PCA provider for personal care services during time periods coinciding with an individual's facility, or hospital stay.(8) PCA providers' billing for personal care services must meet Authority rules for Medicaid payment. PCA providers and IQA are required to disclose any billing errors and return any payments received for them. Personal care services must meet the requirements in OAR 410-120-1280 and following to be considered valid: (a) The individual was eligible to receive Medicaid personal care services on the date of service.(b) The service billed was included in the individual's approved service plan.(c) The services were provided and recorded using an EVV method.(d) The services were provided in a community setting and location approved in the individual's service plan.(e) The PCA provider was qualified to deliver the service.(9) All payments to PCA are subject to pre-payment and post-payment review. The Authority will review billings, EVV, work schedule records or other medical or financial information for accuracy, medical appropriateness, level of service, or for other reasons subsequent to payment of the claim.(a) Payment by the Division does not restrict or limit the Authority or any state or federal oversight entity's right to review or audit a claim before or after the payment.(b) Claim payment may be denied or subject to recovery if medical review, audit, or other post-payment review determines the service was not provided in accordance with applicable rules or does not meet the criteria for quality of care or medical appropriateness of the care or payment.(c) The Authority will conduct post-payment reviews as described in OAR 410-120-1396.(10) PCA providers and any entity billing the Division on behalf of the PCA provider must submit true, accurate, and complete claims and encounters to the Authority. The Authority treats the submission of a claim or encounter, whether on paper or electronically, as certification by the provider of the following: "This is to certify that the foregoing information is true, accurate, and complete. I understand that payment of this claim or encounter will be from federal and state funds, and that any falsification or concealment of a material fact maybe prosecuted under federal and state laws."(11) PCA providers, IQA and PCA Service Coordinators must comply with OAR 410-120-1510, OAR 461-195-0601 and the requirements therein for prompt reporting of fraud, waste and abuse in the Medicaid program. Information on how to report may be found online at all times: https://www.oregon.gov/oha/FOD/PIAU/Pages/Report-Fraud.aspx(12) A person debarred, excluded, suspended, or terminated from participation in a federal or state medical program, such as Medicare or Medicaid, or whose license or certification to practice is suspended or revoked by a state licensing board may not submit claims for payment, either personally or through claims or encounters submitted by any billing agent/service, billing provider, Managed Care Entity (MCE) or other provider for any services or supplies provided under Oregon's medical assistance programs, in compliance with OAR 410-120-1380.(13) The Authority may suspend a PCA provider and provider payments in the event it has determined there is suspected fraud or abuse as described in OAR 410-120-1500. Authority will suspend PCA provider enrollment and any payments, in whole or in part, when a credible allegation of fraud exists pursuant to federal law under 42 CFR 455.23, whether presented to the Authority, Oregon Department of Human Services (ODHS), Department Of Justice (DOJ), Medicaid Fraud Control Units (MFCU), or law enforcement entity; unless there is a pending investigation and good cause exists to continue payment.Or. Admin. Code § 410-172-0840
DMAP 85-2014(Temp), f. 12-24-14, cert. ef. 1-1-15 thru 6-29-15; DMAP 32-2015, f. 6-24-15, cert. ef. 6/26/2015; DMAP 36-2021, temporary amend filed 09/14/2021, effective 9/14/2021 through 3/12/2022; DMAP 38-2022, amend filed 03/23/2022, effective 3/23/2022Statutory/Other Authority: ORS 413.042 & 430.640
Statutes/Other Implemented: ORS 413.042, 414.025, 414.065, 430.640, 430.705 & 430.715