Or. Admin. Code § 410-152-0030

Current through Register Vol. 63, No. 11, November 1, 2024

Section 410-152-0030 - Limitations

(1) Community Violence Prevention Services are not covered for individuals:

(a) Solely treated for intimate partner violence;

(b) Identified as a family member, friend, or associate of the individual receiving the service, and does not meet eligibility requirements described in OAR 410-152-0040

(2) Community Violence Prevention services are limited to eighteen (18) months of service per eligible incident for each individual. For each date of service, only those Community Violence Prevention services which are medically appropriate, included in the plan of care, and delivered to an Oregon Health Plan enrolled individual by an enrolled Community Violence Prevention Provider may be authorized.

(3) Community Violence Prevention services are mutually exclusive and shall be provided to one individual by one certified Violence Prevention Professional at a time. Provider shall not submit claims for Community Violence Prevention services that exceed a total of 24 hours per day or 365 days per calendar year, whether the services rendered by one Community Violence Prevention Professional or by several providers to the individual. The Authority may deny or recover overpayments from a provider for overlapping services, billing for unreasonable units of service over a span of time, unreasonable hours per day, and claims that lack adequate supporting documentation.

(4) The community-based organization that employees certified Violence Prevention Professionals must be affiliated with a licensed hospital in Oregon that authorizes the program to provide community violence prevention services to an individual in the hospital.

(5) Claims for Community Violence Prevention services to the Authority for payment may not duplicate other Oregon Health Plan covered services for the same individual at the same point in time.

(6) The provider shall bill the Authority according to the Community Violence Prevention bundled service code rather than itemizing the service under multiple codes. Providers may not "unbundle" services in order to increase the payment.

(7) Community Violence Prevention service shall not duplicate payments made to:

(a) A provider, public agencies or private entities for any other case management activities or covered services provided under the State Plan or Oregon Health Plan, through fee for service, managed care, or other contractual arrangement, that meet the same need for the same client at the same point in time;

(b) A provider by program authorities under different funding authority than Oregon Health Plan, including but not limited to grants and other public health funding;

(c) A provider for administrative expenditures reimbursed under agreement with the Authority or any other program or funding source.

(8) Community Violence Prevention services shall not be provided in lieu of medically necessary covered services.

(9) Community Violence Prevention services shall be age appropriate for the individual and shall be delivered by a certified Violence Prevention Professional with training in developmentally appropriate Community Violence Prevention services.

Or. Admin. Code § 410-152-0030

DMAP 89-2024, adopt filed 05/01/2024, effective 5/1/2024

Statutory/Other Authority: Oregon Medicaid State Plan Amendment, 42 C.F.R 440.130 (c), House Bill 4045 & 2022 Legislative Session

Statutes/Other Implemented: ORS 413.032, 413.042 & 414.065