Current through Register Vol. 63, No. 9, September 1, 2024
(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.
Statutory/Other Authority: ORS
413.042
Statutes/Other Implemented: ORS
414.065
