Or. Admin. Code § 410-136-3300

Current through Register Vol. 63, No. 10, October 1, 2024

Section 410-136-3300 - Reports and Documentation

(1) Brokerages shall maintain documentation of rides denied and rides provided to clients. This documentation shall include, but is not limited, to:

(a) The name of the client and the person requesting the ride on behalf of the client, if applicable;

(b) The client's Oregon Health Plan (OHP) medical care identification number;

(c) The date and time of the request for transportation;

(d) The mode of transport authorized for the client and a justification for authorizing a mode of transport that is not reasonably understandable;

(e) The location for picking-up the client and the destination;

(f) The medical reason for the appointment;

(g) The availability of other transportation resources and the justification for authorizing a ride when the client has other resources;

(h) The subcontractor assigned to give the ride and the date and time the brokerage notified the subcontractor of the assignment;

(i) The name of the employee who approved a ride and the name of the driver for the ride, as applicable; and

(j) In the case of a denial of a ride:

(A) The name of the employee who denied a ride;

(B) The name of the employee who performed the secondary review before denying the ride;

(C) The reason for the denial and the applicable OAR that supports the denial;

(D) The date on the notice of action the brokerage mailed to the client;

(E) Documentation on the brokerage's review, resolution, or disposition of the matter, if applicable, including the reason for the decision and the date of the resolution or disposition; and

(F) Notations of oral and written communications with the client and documentation of the outcome of any appeal of a denied service.

(2) The brokerage shall retain the documentation on denials of rides for three calendar years, even if the brokerage is no longer a Medicaid enrolled provider before the end of the three years. The Authority may request this information at any time during the three year retention period.

(3) The brokerage shall maintain service and billing files organized by subcontractor that justify the number of transports and with cross references to actual rides and specific clients. The record keeping system developed and maintained by brokerages and their subcontractors shall include sufficient detail and clarity to permit internal and external review to validate claim submissions and to assure NEMT services are provided consistent with the documented needs of the client. Brokerages information for actual rides shall include the date, mode of transport, the driver's first and last name.

(4) The brokerages shall report monthly on estimated revenue and expenses that affect the balance of the working capital reserve amount. The report must contain the following costs as they pertain to providing NEMT services:

(a) Sub-totals of administrative expenses, including:

(A) Salaries and wages of the brokerage's employees;

(B) Payroll related expenses for the brokerage's employees;

(C) Other employee related expenses, such as recruitment and advertising;

(D) Computer hardware and software purchased, leased or licensed;

(E) Office supplies such as stamps, paper or printing;

(F) Non-computer related equipment purchased, leased or licensed;

(G) Telephone;

(H) Administrative support and other indirect charges;

(I) Education and training;

(J) Building expenses such as leases, rents, security, janitorial services and repairs that retain the property's operating condition but do not add to the permanent value of the property;

(K) Subcontractor identification and drug testing, such as fingerprinting and drug analysis;

(L) Legal expense not related to the Authority, such as attorney fees; fines or penalties;

(M) Indirect expenses, such as accounting, human resources, risk management or insurance;

(N) Sub-contracts for operations or temporary employees;

(O) Required driver training, if applicable;

(P) The client satisfaction survey, if applicable;

(Q) Software maintenance, if applicable; and

(R) Details of other administrative expenses not specified above.

(b) The number and costs of the following:

(A) Stretcher car rides;

(B) Wheelchair rides;

(C) Ambulatory rides;

(D) Secured transports;

(E) Bus tickets;

(F) Bus passes;

(G) NEMT ambulance transports;

(H) Reimbursements to clients; and

(I) Commercial transports.

(c) The amount of credits to subcontractors.

(d) Information on the brokerage's working capital reserve, including:

(A) The Authority-calculated working capital reserve;

(B) The estimated working capital reserve as of the beginning of the fiscal year;

(C) The estimated working capital reserve as of this report; and

(D) The difference between above sub-sections (B) and (C) of this rule.

(5) The financial reports must show the number of rides that volunteer drivers provide.

(6) Brokerages must submit the financial report required in Section (4) of this rule within 45 days of the end of the reporting month.

(7) Brokerages shall submit a cost allocation plan that includes anticipated expenses, certified by the brokerage's Chief Financial Officer, to the Authority no later than April 1 of each year for the upcoming fiscal year.

(8) Brokerages must report monthly on data that meets the delivery and content specifications as defined by the Authority.

(a) monthly data for quality assurance must include at minimum the following:

(A) Driver Cancellations reported as a numeric value of the total number of times within the reporting period that a driver cancels a ride less than 24 hours in advance, resulting in client not receiving scheduled ride;

(B) Driver No-Shows reported as a numeric value of the total number of times within the reporting period that a driver was not at pick up location as pre-arranged resulting in client not receiving scheduled ride;

(C) Client Cancellations reported as a numeric value of total number of times within the reporting period that a clients cancel a ride less than 24 hours in advance;

(D) Client No-Shows reported as a numeric value of the total number of times within the reporting period that a client was not at pick up location as pre-arranged, after the allowed 15-minute window of time, resulting in a ride cancellation;

(E) Late Rides reported as a numeric value of the total number of rides within the reporting period where driver arrived 15 minutes or more past scheduled pick-up time.

(F) Rides scheduled reported as a numeric value of the total number of rides scheduled in the reporting period regardless of whether driver/member no-show or cancelled.

(G) Rides denied reported as a numeric value of the total number of rides denied by brokerage during the reporting period.

(b) Brokerages must submit monthly data quality assurance report to the Authority no later than 45 days after the end of each month within each calendar year.

(9) Brokerages must maintain written policies and procedures outlining the activities of NEMT services for ongoing monitoring, evaluation, and improvement of the quality and appropriateness of NEMT services, and with procedures for processes.

(10) Brokerages must submit written policies and procedures to the Authority no later than December 1 of each year for the upcoming calendar year.

(11) Brokerages must develop and conduct a client satisfaction survey, including at minimum the following:

(a) Processes for conducting client satisfaction surveys at least annually;

(b) Satisfaction surveys must be sent to a minimum of five percent of all clients who scheduled NEMT rides;

(c) Submit completed client satisfaction survey results to the Authority, at least annually, for review of results to identify potential areas of enhancement or improvement within the program.

(12) Brokerages must maintain a log of all OHA Client grievances, complaints that are referred by brokerage to the Authority, and of which brokerage receives notice from subcontractors or the Authority. The log shall identify at minimum:

(a) Client name;

(b) Date of the grievance;

(c) The allegation or grievance;

(d) Resolution; and

(e) Date of resolution.

(13) The Authority may request, and the brokerage shall provide, other reports or information not specified in sections 1 through 11 of this rule. OHA has the right to request all NEMT documentation, information, reports, phone call recordings, grievances or other complaints submitted, policies and procedures, systems, facilities that provide or otherwise relate to NEMT services for purposes of determining compliance.

Or. Admin. Code § 410-136-3300

DMAP 36-2013, f. 6-27-13, cert. ef. 7-1-13; DMAP 95-2023, amend filed 12/22/2023, effective 1/1/2024

Statutory/Other Authority: ORS 413.042

Statutes/Other Implemented: ORS 414.065