 |
|
|
Department of Human Services 410-138-0000 (1) Babies First/Cocoon Targeted Case Management (TCM) Services is a medical program operated by public health authorities, which matches public funds with matching Federal Funds for Oregon Health Plan (OHP) Medicaid eligible clients. These rules are to be used in conjunction with the General Rules governing the OMAP Programs (OAR 410 Division 120). The TCM Services rules are a user's manual designed to assist the TCM Provider Organization in matching State and Federal Funds for TCM services defined by Section 1915(g) of the Social Security Act, 42 USC (1396n)(g). (2) The rules of the Babies First/Cocoon — Targeted Case Management Plan define Oregon Medicaid's program to reimburse the services provided under Babies First/Cocoon. This program expands preventive services for all infants and pre-schoolers (0 through 3 years) covered by Medicaid who are at risk of poor health outcome as outlined in OAR 410-138-0040, Risk Factors, provided by an enrolled Babies First/Cocoon—TCM provider consistent with these rules. (3) Services include management of non-medical services, which address health, psychosocial, economic, nutritional and other services. Home visits constitute a significant part of the delivery of services. Stat. Auth.: ORS 409.010 & 409.110 Stats. Implemented: ORS 414.085 Hist.: HR 20-1992, f. & cert. ef. 7-1-92; OMAP 61-2004, f. 9-10-04, cert. ef. 10-1-04 410-138-0020 (1) "Assessment" — The systematic ongoing collection of data to determine current status and identify needs in physical, environmental, psychosocial, developmental, educational, behavioral, emotional, and mobility areas. Data sources include interviews, existing available records, needs assessment, the use of standardized assessment tools (i.e., NCAST and Regional X Screening Standards), and contacts with the primary care provider, other professionals, and other parties on behalf of the client. (2) "Case Management" — Activities which will assist the client in gaining access to and effectively utilizing needed health, psychosocial, nutritional, and other services. (3) "Intervention":
(4) "Screening" — Use of a single tool(s) or procedure(s) to identify a potential problem. Screening is not designed to diagnose the problem, but to sort the target population into two groups: Those at risk for a particular problem and those not at risk. Stat. Auth.: ORS 409.010 & ORS 409.110 Stats. Implemented: ORS 409.010 Hist.: HR 20-1992, f. & cert. ef. 7-1-92; OMAP 50-2004, f. 9-9-04, cert. ef. 10-1-04 410-138-0040 (1) Medical Risk Factors for infants and preschool children:
(2) Social Risk Factors:
(3) Very High Risk Medical Factors:
(4) Established Risk Categories:
(5) Developmental Risk Factors:
Stat. Auth.: ORS 409 Stats. Implemented: ORS 414.065 Hist.: HR 20-1992, f. & cert. ef. 7-1-92; HR 37-1994, f. 12-30-94, cert. ef. 1-1-95; OMAP 50-2004, f. 9-9-04, cert. ef. 10-1-04 410-138-0060 (1) Babies First/Cocoon — Targeted Case Management (TCM) organizations must be a public health authority and must meet the following criteria:
(2) The case manager must be:
Stat. Auth.: ORS 409 Stats. Implemented: ORS 414.065 Hist.: HR 20-1992, f. & cert. ef. 7-1-92; HR 37-1994, f. 12-30-94, cert. ef. 1-1-95; OMAP 50-2004, f. 9-9-04, cert. ef. 10-1-04 410-138-0080 (1) Payment will be made to the enrolled Targeted Case Management Provider as the performing provider for those Case Management services provided by the employed staff person: (2) Signing the Provider Enrollment Agreement sets forth the relationship between the State of Oregon, Department of Human Services and the TCM provider and constitutes agreement by the provider to comply with all applicable rules of the Medical Assistance Program, federal and state laws or regulations; (3) The TCM provider will bill according to OAR 410 division 138 rules. Payments will be made through the Medical Management Information System (MMIS). The TCM provider must have a trading partner agreement with DHS prior to submission of electronic transactions; (4) Targeted Case Management authorized under these rules is a cost-sharing (Federal Financial Participation matching) program. In addition to the requirements set forth in this rule, and pursuant to 42CFR433.10, DHS may monthly, but will no less than quarterly, invoice the TCM provider for their non-federal matching share based on the current Federal Medical Assistance Percentage (FMAP) rate. The TCM provider shall pay the amount stated in the invoice within 30 days of the date of the invoice;
(5) Failure to timely remit the non-federal share described in subsection (4) will constitute an overpayment and will make the provider subject to overpayment recoupment or other remedy pursuant to OMAP General Rules, OAR 410-120-1400 through 410-120-1685. (6) OMAP shall not be financially responsible for payment of any claim that the Centers for Medicare and Medicaid Services (CMS) disallows under the Medicaid program. If OMAP has previously paid the TCM provider for any claim which CMS disallows, the TCM provider shall reimburse OMAP the amount of the claim that OMAP has paid to the TCM provider, less any amount previously paid by the TCM provider to OMAP for purposes of reimbursing OMAP the non-federal match portion for that claim. (7) Billing criteria for this program is as follows:
(8) Duplicate billings are not allowed and duplicate payments will be recovered. Services will be considered as duplicate if the same services are billed by more than one entity to meet the same need. Medical services must be provided and billed separately from Case Management Services. (9) A unit of service can only be billed once under one procedure code, under one provider number. Stat. Auth.: ORS 409 Stats. Implemented: ORS 414.065 Hist.: HR 20-1992, f. & cert. ef. 7-1-92; HR 37-1994, f. 12-30-94, cert. ef. 1-1-95; OMAP 61-2004, f. 9-10-04, cert. ef. 10-1-04 410-138-0080 (1) Payment will be made to the enrolled Targeted Case Management Provider as the performing provider for those Case Management services provided by the employed staff person: (2) Signing the Provider Enrollment Agreement sets forth the relationship between the State of Oregon, Department of Human Services and the TCM provider and constitutes agreement by the provider to comply with all applicable rules of the Medical Assistance Program, federal and state laws or regulations; (3) The TCM provider will bill according to OAR 410 division 138 rules. Payments will be made through the Medical Management Information System (MMIS). The TCM provider must have a trading partner agreement with DHS prior to submission of electronic transactions; (4) Targeted Case Management authorized under these rules is a cost-sharing (Federal Financial Participation matching) program. In addition to the requirements set forth in this rule, and pursuant to 42CFR433.10, DHS may monthly, but will no less than quarterly, invoice the TCM provider for their non-federal matching share based on the current Federal Medical Assistance Percentage (FMAP) rate. The TCM provider shall pay the amount stated in the invoice within 30 days of the date of the invoice;
(5) Failure to timely remit the non-federal share described in subsection (4) will constitute an overpayment and will make the provider subject to overpayment recoupment or other remedy pursuant to OMAP General Rules, OAR 410-120-1400 through 410-120-1685. (6) OMAP shall not be financially responsible for payment of any claim that the Centers for Medicare and Medicaid Services (CMS) disallows under the Medicaid program. If OMAP has previously paid the TCM provider for any claim which CMS disallows, the TCM provider shall reimburse OMAP the amount of the claim that OMAP has paid to the TCM provider, less any amount previously paid by the TCM provider to OMAP for purposes of reimbursing OMAP the non-federal match portion for that claim. (7) Billing criteria for this program is as follows:
(8) Duplicate billings are not allowed and duplicate payments will be recovered. Services will be considered as duplicate if the same services are billed by more than one entity to meet the same need. Medical services must be provided and billed separately from Case Management Services. (9) A unit of service can only be billed once under one procedure code, under one provider number. Stat. Auth.: ORS 409 Stats. Implemented: ORS 414.065 Hist.: HR 20-1992, f. & cert. ef. 7-1-92; HR 37-1994, f. 12-30-94, cert. ef. 1-1-95; OMAP 61-2004, f. 9-10-04, cert. ef. 10-1-04 410-138-0500 (1) Pregnant Substance Abusing Women and Women with Young Children (PWWC) — Targeted Case Management (TCM) Services is a medical program operated by public health authorities, which matches public funds with matching Federal Funds for Oregon Health Plan (OHP) Medicaid eligible clients. These rules are to be used in conjunction with the General Rules governing the OMAP Programs (OAR 410 Division 120). The TCM Services rules are a user's manual designed to assist the TCM Provider Organization in matching State and Federal Funds for TCM services defined by Section 1915(g) of the Social Security Act, 42 USC (1396n)(g). (2) The rules of the Targeted Case Management Program for Pregnant Substance Abusing Women and Women with Young Children define Oregon Medicaid's Program to reimburse the services provided under this program. This Program expands services to Medicaid eligible women living in Marion, Polk, Linn, Benton, Jackson, and Yamhill Counties, provided by an enrolled PWWC — TCM provider consistent with these rules. (3) Services include screening and assessment, case plan development, and intervention/implementation of non-medical services, which address health, educational, vocational, mental health, housing, child care and other services necessary to help this target group remain clean and sober. Stat. Auth.: ORS 409 Stats. Implemented: ORS 414.065 Hist.: HR 19-1993, f. & cert. ef. 8-13-93; OMAP 41-1999, f. 10-15-99, cert. ef. 10-20-99; OMAP 61-2004, f. 9-10-04, cert. ef. 10-1-04 410-138-0520 (1) "Screening and Assessment" — The gathering of information to assess the client's need for various services, foremost being treatment for alcohol and drug abuse/addiction. Information will be gathered from the criminal justice system, the Housing Authority, and other sources as appropriate. A uniform assessment tool will be used for screening clients and identifying needed services. (2) "Case Plan Development" — The development of an individualized case plan utilizing the input of a treatment team that will consist of the case manager, alcohol and drug treatment counselor, criminal justice system representatives, prenatal care provider, and others instrumental in the client's life. The case plan will include components for alcohol and other drug abuse treatment, medical care, housing, education, child care, parenting, vocational, and mental health services. Goals and objectives will be written, and resources will be identified to meet the client's needs in a coordinated, integrated fashion. The case plan will be refined, and the client's progress in meeting goals and objectives will be assessed, in periodic meetings of the treatment team as treatment progresses. (3) "Intervention/Implementation" — The linking of the client with appropriate community agencies and services identified in the case plan through calling or visiting these resources. The case manager will facilitate implementation of agreed-upon services through assisting the client, increasing the services and through assuring that the clients and providers fully understand how these services support the agreed-upon case plan. Stat. Auth.: ORS 409.010 & ORS 409.110 Stats. Implemented: ORS 414.010 Hist.: HR 19-1993, f. & cert. ef. 8-13-93; OMAP 50-2004, f. 9-9-04, cert. ef. 10-1-04 410-138-0530 (1) Pregnant or have children under the age of five; and, (2) Are in need of treatment for the abuse of alcohol and other drugs. Stat. Auth.: ORS 409 Stats. Implemented: ORS 414.065 Hist.: OMAP 61-2004, f. 9-10-04, cert. ef. 10-1-04 410-138-0540 (1) (PWWC) — Targeted Case Management (TCM) organizations must be a public health authority and must meet the following criteria:
(2) The case manager must be:
Stat. Auth.: ORS 409.010 & ORS 409.110 Stats. Implemented: ORS 414.065 Hist.: HR 19-1993, f. & cert. ef. 8-13-93; OMAP 50-2004, f. 9-9-04, cert. ef. 10-1-04 410-138-0560 (1) Payment will be made to the enrolled Targeted Case Management Provider as the performing provider for those Case Management services provided by the employed staff person: (2) Signing the Provider Enrollment Agreement sets forth the relationship between the State of Oregon, Department of Human Services and the TCM provider and constitutes agreement by the provider to comply with all applicable rules of the Medical Assistance Program, federal and state laws or regulations; (3) The TCM provider will bill according to OAR 410 division 138 rules. Payments will be made through the Medical Management Information System (MMIS). The TCM provider must have a trading partner agreement with DHS prior to submission of electronic transactions; (4) Targeted Case Management authorized under these rules is a cost-sharing (Federal Financial Participation matching) program. In addition to the requirements set forth in this rule, and pursuant to 42CFR433.10, DHS may monthly, but will no less than quarterly, invoice the TCM provider for their non-federal matching share based on the current Federal Medical Assistance Percentage (FMAP) rate. The TCM provider shall pay the amount stated in the invoice within 30 days of the date of the invoice;
(5) Failure to timely remit the non-federal share described in subsection (4) will constitute an overpayment and will make the provider subject to overpayment recoupment or other remedy pursuant to OMAP General Rules, OAR 410-120-1400 through 410-120-1685. (6) OMAP shall not be financially responsible for payment of any claim that the Centers for Medicare and Medicaid Services (CMS) disallows under the Medicaid program. If OMAP has previously paid the TCM provider for any claim which CMS disallows, the TCM provider shall reimburse OMAP the amount of the claim that OMAP has paid to the TCM provider, less any amount previously paid by the TCM provider to OMAP for purposes of reimbursing OMAP the non-federal match portion for that claim. (7) Billing criteria for this program is as follows:
(8) Duplicate billings are not allowed and duplicate payments will be recovered. Services will be considered as duplicate if the same services are billed by more than one entity to meet the same need. Medical services must be provided and billed separately from Case Management Services. (9) A unit of service can only be billed once under one procedure code, under one provider number. Stat. Auth.: ORS 409.010 & 409.110 Stats. Implemented: ORS 414.065 Hist.: HR 19-1993, f. & cert. ef. 8-13-93; OMAP 61-2004, f. 9-10-04, cert. ef. 10-1-04 The official copy of an Oregon Administrative Rule is contained in the Administrative Order filed at the Archives Division, 800 Summer St. NE, Salem, Oregon 97310. Any discrepancies with the published version are satisfied in favor of the Administrative Order. The Oregon Administrative Rules and the Oregon Bulletin are copyrighted by the Oregon Secretary of State. |
|
