Health and Human Services
With the following exceptions and additions, the terms in this Agreement have the same definitions as those terms appearing in Oregon Administrative Rules (OARs) 309-012-0140, 309-032-0535, 309-033-0210, 410-120-0000, and 410-141-0000. The order of preference for these definitions is this Agreement, Oregon Health Plan Rules of OMAP, General Rules of OMAP, and Mental Health Rules of Division.
Abuse: Any death caused by other than accidental or natural means; any physical injury caused by other than accidental means or that appears to be at variance with the explanation given of the injury; willful infliction of physical pain or injury; and sexual harassment or exploitation, including but not limited to, any sexual contact between an employee of a facility or community program and an OMAP Member. In residential programs, Abuse includes other intentional acts or absence of action that interfere with the mental, emotional or physical health of the resident.
Acute Care: Intensive, psychiatric services provided on a short-term basis to a person experiencing significant symptoms of a mental disorder that interfere with the person's ability to perform activities of daily living.
Acute Inpatient Hospital Psychiatric Care: Acute Care provided in a psychiatric hospital with 24-hour medical supervision.
Adult and Family Services Division (AFSD): The Division with primary responsibility to assist poor families in meeting their basic needs and to help them become more self sufficient. To achieve these outcomes, the Division provides income maintenance payments to poor families; contracts with providers for employment training and placement of eligible clients; provides payments for supportive services, such as day care and transportation; and provides eligibility determination for the OHP Medicaid Demonstration Project and Children’s Health Insurance Program.
Allied Agencies: See definition for Local and/or Regional Allied Agencies.
Alternative Site: A place where services are provided other than the service provider’s office, clinic or other regular place of business. Alternative Sites are used to assure more accessible and effective delivery of the service and include, but are not limited to, a school, community center, foster home, Nursing Home, physician’s office, home or other natural setting.
Americans with Disabilities Act (ADA): Federal law promoting the civil rights of persons with disabilities, including mental illness. The purpose of the law is "to provide a clear and comprehensive national mandate for the elimination of discrimination against individuals with disabilities and to provide clear, strong, consistent, enforceable standards addressing discrimination against individuals with disabilities." The ADA requires that accommodations be made in employment, service delivery and accessibility of facilities and/or services.
Appropriate: The extent to which a particular procedure, treatment, test, or service is documented to be effective, clearly indicated, not excessive, adequate in quantity, and provided in the setting best suited to the needs of the OMAP Member.
Assessment: The determination of a person's need for Covered Services. It involves the collection and evaluation of data pertinent to the person's mental history and current problem(s) obtained through interview, observation, and record review. The Assessment concludes with one of the following: (1) documentation of a DSM Diagnosis providing the clinical basis for a written Treatment Plan; or (2) a written statement that the person is not in need of Covered Services. Other disposition information such as to whom the person was referred is included in the Clinical Record.
Benchmark: The level of performance or standard against which attainment of specific objectives is measured.
Capacity: The ability to make Covered Services available in a given geographic area relative to the size, location and unique needs of the OMAP Membership within it. Indicators of Capacity may be represented as ratios between the number of Participating Providers per 1,000 OMAP Members for a given geographic area (county or zip code); as ratios between the number of Participating Providers per 1,000 OMAP Members; as ratios between various types of Participating Providers (psychiatrists, case managers) per a set number of OMAP Members with specific diagnoses, unique characteristics and/or special needs; as ratios between the number of Participating Providers per the total of OMAP Members and other patients; as a function of travel time or distance between the OMAP Member’s residence and the Participating Provider; as a function of waiting time for regular appointments, urgent care, emergency care and specialty care; as a function of office waiting time; and as a function of 24-hour care. Measurement of Capacity must consider factors such as geographic or physical barriers (mountains or rivers) which preclude access, service utilization patterns (services being sought outside the immediate vicinity), language or cultural barriers, and needs of migrant or seasonal workers.
Capitation: A payment model which is based on prospective payment for services, irrespective of the actual amount of services provided, generally calculated on a per OMAP Member per month basis.
Capitation Payment: The amount paid by Division through OMAP to Contractor on a per OMAP Member per month basis in advance of and as payment for the OMAP Member's actual receipt of Covered Services under this Agreement.
Case Management: Services provided to OMAP Members who require assistance to ensure access to benefits and services from Local, Regional and/or State Allied Agencies or other service providers. Services provided may include: advocating for the OMAP Member's treatment needs; providing assistance in obtaining entitlements based on mental or emotional Disability; referring OMAP Members to needed services or supports; accessing housing or residential programs; coordinating services including educational or vocational activities; and establishing alternatives to inpatient hospital services.
Case Rate: A flat rate paid per person for a specific range of services. A Case Rate may be paid for each referral made to a provider or for each admission made to a hospital. The provider receiving the payment assumes the risk of providing all Covered Services for the full range of services for each OMAP Member for whom the payment was made.
CCC Chair: A QMHP with experience in children's mental health treatment designated by the CMHP director in each county to coordinate LTPC screenings.
Chemical Dependency Provider: A practitioner approved by OADAP to provide publicly funded alcohol and drug abuse rehabilitative services.
Child Acuity of Psychiatric Illness (CAPI): An assessment tool used to measure the severity of a child's psychiatric symptoms, functioning and systems support. The tool was developed and published by John Lyons, Ph.D., Northwestern University Medical School.
Child and Adolescent Treatment Services (CATS): The CATS program at Oregon State Hospital for children under age 18.
Children Global Assessment Scale (CGAS): A scale used to measure and condense different aspects of a child's biopsychosocial functioning into a single, clinically meaningful index of severity. The CGAS is an adaptation of the Diagnostic and Statistical Manual Global Assessment Scale for adults by the Department of Psychiatry, Columbia University, published in November 1982. The CGAS is recommended for use with children 4 through 16. The CGAS scores are numerically quantified on Axis Five of the DSM multi-axial Diagnosis.
Children’s Health Insurance Program: A Federal and State funded portion of the Medical Assistance Program established by Title XXI of the Social Security Act, as amended, administered in Oregon by the Department of Human Services.
Civil Commitment Process: The legal process of involuntarily placing a person, determined by the Circuit Court to be a mentally ill person as defined in ORS 426.005 (1) (d), in the custody of Division. The Division has the sole authority to assign and place a committed person to a treatment facility. The Division has delegated this responsibility to the CMHP Director. Civil commitment does not automatically allow for the administration of Medication without informed client consent. Additional procedures described in administrative rule must be followed before Medication can be involuntarily administered.
Client Process Monitoring System (CPMS): The Division's client information system for community based services.
Clinical Reviewer: The entity jointly chosen to resolve disagreements related to an OMAP Member's need for Long Term Psychiatric Care immediately following an Acute Inpatient Hospital Psychiatric Care stay.
Clinical Record: The individual client service record. For the purpose of confidentiality, it is considered the medical record defined in ORS Chapter 179.
Clinical Services Coordination: Coordinating the access to, and provision of, services from multiple agencies according to the Treatment Plan; establishing crisis service linkages; advocating for the person's treatment needs; and providing assistance to obtaining entitlements based on mental or emotional Disability.
Community Coordinating Committee: A committee composed of representatives from the local Community Mental Health Program, State Office for Services to Children and Families, Juvenile Court, local education district, and Oregon State Hospital, Children and Adolescent Treatment (CATS) program. The committee performs the intake function to assure a child’s need for Long Term Psychiatric Care at the CATS Program.
Community Coordinating Committee (CCC) Care Path Plan: A written plan for discharge from CATS to a least restrictive appropriate setting with specific discharge criteria. Discharge criteria are linked to resolution of symptoms and behaviors that justified admission to CATS. The CCC Care Path Plan provides an opportunity for those parties most familiar with the treatment needs of the child to develop a care path plan.
Community Emergency Service Agencies: These include, but are not limited to, hospital emergency rooms, crisis centers, protective services of Senior and Disabled Services Division and SOSCF, OYA, local juvenile justice, police, homeless shelters, CMHPs, and civil commitment investigators.
Community Mental Health Program (CMHP): The organization of all services for persons with mental or emotional disorders and developmental disabilities operated by, or contractually affiliated with, a LMHA, operated in a specific geographic area of the state under an intergovernmental agreement or direct contract with Division.
Community Services Section (CSS): The organizational section within Division responsible for integrating mental health services into the OHP Medicaid Demonstration Project and Children’s Health Program.
Community Standard: Expectations for access to the health care delivery system in the OMAP Member’s community of residence. Except where the Community Standard is less than sufficient to ensure quality of care, the Division requires that the health care delivery system available to Contractor’s OMAP Members take into consideration the Community Standard and be adequate to meet the needs of OMAP Members.
Complaint: An OMAP Member’s written and filed expression of dissatisfaction.
Condition/Treatment Pair: Conditions described in the International Classification of Diseases Clinical Modifications, 9th edition (ICD-9 CM) and treatments described in the current version of the American Medical Association’s Physicians’ Current Procedural Terminology (CPT) and BA Codes established by the Division which, when paired by the HSC, constitute the line items in the Prioritized List of Health Services. Condition/Treatment Pairs may contain many diagnoses and treatments. The pairs are listed in OAR 410-141-0520, Prioritized List of Health Services.
Consultation: Professional advice or explanation given concerning a specific OMAP Member to others involved in the treatment process, including Family members, staff members of other human services agencies (such as Senior and Disabled Services Division, AFSD, schools, SOSCF, OYA, juvenile justice) and care providers (such as Nursing Homes, foster homes, or residential care facility staff).
Consumer: An OMAP Member with a mental or emotional disorder who receives Covered Services. This term is also used in reference to any person receiving services through a Community Mental Health Program which are not Covered Services.
Continuity of Care: The ability to sustain services necessary for a person's treatment. Continuity of Care is a concern when an OMAP Member is transferred from one service provider to another.
Contractor Representative: The individual within the Contractor organization responsible for handling Complaint and Hearing issues. The role of this person is described in Exhibit G, Oregon Health Plan Mental Health Services Complaint and Hearings Process.
Covered Services: Services included in the Capitation Payment paid to Contractor under this Agreement with respect to an OMAP Member under this Agreement whenever services are Medically Appropriate for the OMAP Member. Services included in the Capitation Payment are described in Attachment 1, State of Oregon, Oregon Health Plan Service Categories for Per Capita Costs, October 1997 through September 1998. The Capitation Payment is based on the number of condition/treatment pair lines of the List of Prioritized Health Services funded by the Legislature and adopted in OAR 410-141-0520. The Covered Services described in Attachment 1 shall be substituted with and/or expanded to include Flexible Services and Flexible Service Approaches identified and agreed to by Contractor, the OMAP Member, and, as appropriate, the family of the OMAP Member as being an efficacious alternative. Covered Services are limited in accordance with OAR 410-141-0500, Excluded Services and Limitations for Oregon Health Plan Clients.
Credentialing: The authorization process by which the MHO ensures that professionals and other providers who will deliver services to OMAP Members are licensed to practice, or otherwise qualified for their respective positions. Authorization is determined by comparison of practitioner qualifications with applicable requirements for education, licensure, professional standing, experience, service availability and accessibility, and conformance with MHO Utilization and quality management requirements.
Culturally Competent: The Capacity to provide services in an effective manner that is sensitive to the culture, race, ethnicity, language and other differences of an individual. Such services may include, but are not limited to, use of bilingual and bicultural staff, provision of services in culturally appropriate alternative settings, and use of bicultural Paraprofessionals as intermediaries with professional staff.
Current Procedural Terminology (CPT): A listing of descriptive terms and identifying codes for reporting medical services and procedures performed by physicians. The purpose of the terminology is to provide a uniform language that accurately describes medical, surgical, and diagnostic services, and thereby provides an effective means for reliable nationwide communication among physicians, patients, and third parties.
Daily Structure and Support: Structured developmental or rehabilitative programs designed to improve an adult's basic functioning in daily living and community living. Programs include a mixture of Individual Therapy and Group Therapy activities, therapeutic treatment oriented toward developing emotional and physical capability in areas of daily living, community integration, and interpersonal functioning. Service needs are identified in the Assessment and prescribed in the Treatment Plan.
Day and Residential Treatment Services (DARTS) Psychiatric Day Treatment: Community-based day or residential treatment services for children in a psychiatric treatment setting which conforms to established state-approved standards.
Declaration for Mental Health Treatment: A written statement of a person's decisions concerning his or her mental health treatment. The declaration is made when the person is able to understand and make decisions related to such treatment. It is honored when the person is unable to make such decisions.
Department of Human Services (DHS): The Department comprised of seven divisions and two major program offices: AFSD; SOSCF; Health Division; MHDDSD; Senior and Disabled Services Division; Vocational Rehabilitation Division; and the Office of the Director, which includes OMAP and OADAP.
**Where DHS appears in this Agreement, DHS shall mean Department of Human Resources (DHR) until July 1, 2000; thereafter shall mean DHS.**
Descending Daily Rate: A rate paid which decreases over time. For example, the rate paid on the first day of a hospital admission would be higher than that paid on the second day and all subsequent days.
Diagnosis or DSM Diagnosis: The principal mental disorder listed in the most recently published edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM), that is the Medically Appropriate reason for clinical care and the main focus of treatment for an OMAP Member. The Principal Diagnosis is determined through the mental health Assessment and any examinations, tests, procedures, or Consultations suggested by the Assessment. Neither a DSM "V" code disorder, substance use disorder or mental retardation may be considered the Principal Diagnosis, although these conditions or disorders may co-occur with the diagnosable mental disorder.
Disabling Condition: A physical or mental impairment that substantially limits one or more major life activities (such as caring for oneself, performing manual tasks, walking, seeing, hearing, speaking, breathing, learning and working) It includes a record of having such an impairment or being regarded as having such an impairment.
Disability: A physical or mental impairment that substantially limits one or more major life activities (such as caring for oneself, performing manual tasks, walking, seeing, hearing, speaking, breathing, learning and working) It includes a record of having such an impairment or being regarded as having such an impairment.
Disenrollment: The act of discharging an OMAP Member from a MHO’s responsibility. After the effective date of Disenrollment an OHP Client is no longer required to obtain Covered Services from the MHO, nor be referred by the MHO.
Division: The Mental Health and Developmental Disability Services Division of the Department of Human Services.
Division Representative: The individual within the Mental Health and Developmental Disability Services Division designated to handle MHDDSD Administrative Hearings requested by OMAP Members. The role of the Division Representative is described in Exhibit G, Oregon Health Plan Mental Health Services Complaint and Hearings Process.
DSM-IV Code: The numerical code, including modifiers, which identifies psychiatric disorders defined in the American Psychiatric Association’s Diagnostic and Statistical Manual, Fourth Edition, 1994.
Early Intervention: Provision of Covered Services directed at preventing or ameliorating a mental disorder or potential disorder during the earliest stages of onset or prior to onset for individuals at high risk of a mental disorder.
Emergency Psychiatric Hold: Pursuant to ORS Chapter 426, physical retention of a person taken into custody by a peace officer, health care facility, Oregon State Hospital, hospital or nonhospital facility as ordered by a physician or a CMHP director.
Emergency Response System: The coordinated method of triaging the mental health service needs of OMAP Members and providing Covered Services when needed. The system operates 24-hours a day, 7-days a week and includes, but is not limited to, after hours on call staff, telephone and in person screening, Outreach, and networking with hospital emergency rooms and police.
Emergency Service: Covered Services that are needed immediately or appear to be needed immediately because of an injury, sudden illness, or exacerbation of an illness that would have meant risk of permanent damage to the OMAP Member's health. See definition for Twenty-four (24) Hour Urgent and Emergency Services.
Emergency Situation: A Mental Health condition manifesting itself by acute symptoms of sufficient severity such that a prudent layperson, with an average knowledge of health and medicine, could reasonably expect the absence of immediate medical attention to result in (1) serious jeopardy to the health of the OMAP Member, (2) serious impairment of bodily function, or (3) serious dysfunction of any bodily organ or part.
Encounter: An outpatient contact or Acute Inpatient Hospital Psychiatric Care admission for Covered Services provided to an OMAP Member.
Encounter Data System: An automated information system which is maintained by OMAP and includes data submitted by Prepaid Health Plans for OMAP Members receiving Covered Services. The data set resembles a "claims" data set in order to use existing or familiar data sets such as the HCFA-1500, UB-92, and OMAP 501-D. Encounter data is often referred to as "dummy claims," "pseudo claims," "shadow claims, " or "encounter claims."
Encounter Minimum Data Set: Reporting of OMAP Member contacts using the National Standard Format (also known as HCFA-1500) for outpatient services and the UB-92 format for Acute Inpatient Hospital Psychiatric Care services for OMAP Member specific Covered Services.
Enhanced Care Services: Services, which are not Covered Services, defined in OAR 309-032-720 through 309-032-830 as provided to eligible persons who reside at facilities licensed by the Senior and Disabled Services Division.
Enrollment: The assignment of OHP Clients to MHOs per OAR 410-141-0060, Oregon Health Plan Managed Care Enrollment Requirements. Once the OHP Client becomes an OMAP Member, the person must receive all Covered Services from the MHO or be referred by the MHO to Mental Health Practitioners.
Evaluation: A psychiatric or psychological Assessment used to determine the need for mental health services. The Evaluation includes the collection and analysis of pertinent biopsychosocial information through interview, observation, and psychological and neuropsychological testing. The Evaluation concludes with a five axes Diagnosis of a DSM-IV multiaxial Diagnosis, prognosis for rehabilitation, and treatment recommendations.
Extended Care Management: Overseeing the Utilization of extended care resources.
Extended Care Management Unit (ECMU): The unit within OMHS of Division responsible for providing the clinical Assessment, consultation, and placement of adults age 18 to 64 with severe and persistent mental illness who require long term structure, support, rehabilitation, and supervision within designated Extended Care Projects; the utilization review of those projects and the screening of all requests for admission to Long Term Psychiatric Care.
Extended Care Project: State-funded program designed to provide necessary services for adults in a least restrictive environment, utilizing a range of hospital, residential, and community resources. These programs include secure residential facilities, residential psychiatric treatment, Geropsychiatric Treatment Program at Oregon State Hospital, Oregon State Hospital, Senior and Disabled Services Division enhanced care and PASSAGES Projects, "365" Plans, Psychiatric/Vocational Projects and enhanced foster care programs.
Extended Medication Adjustment: Regulation and adjustment of medications lasting more than 21 to 28 days due to significant complications arising from severe side effects of Medications.
Family: Parent or parents, legal guardian, siblings, grandparents, spouse and other primary relations whether by blood, adoption, legal or social relationship.
Family Support Services: Services provided to the Family members of an OMAP Member under treatment that helps such Family members cope with the symptoms of the OMAP Member's mental disorder.
Family Therapy: Planned treatment actively involving the immediate or extended Family to remediate significant impairments to functioning that are related to a mental disorder diagnosed on Axis I or II of a DSM-IV multi-axial Diagnosis and identified by the mental health Assessment. Family Therapy is individualized to meet specific goals and Measurable Objectives in the Treatment Plan. The intended outcome of Family Therapy for a child is to achieve and maintain the best possible, developmentally appropriate, level of functioning. The intended outcome of Family Therapy for an adult is to manage, reduce or resolve the identified mental health problems thereby allowing the adult to function more independently and competently in daily life.
Fee-For-Service (FFS): The payment for reimbursable services retrospectively based upon agreed rates and the amount of service provided.
Flexible Service: A service that is an alternative or addition to a Traditional Service that is as likely or more likely to effectively treat the mental disorder as documented in the OMAP Member’s Clinical Record. Flexible Services may include, but are not limited to: Respite Care, Partial Hospitalization, Subacute Psychiatric Care, Family Support Services, Parent Psychosocial Skills Development, Peer Counseling, and other nonTraditional Services identified.
Flexible Service Approach: The delivery of any Covered Service in a manner or place different from the traditional manner or place of service delivery. A Flexible Service Approach may include delivering Covered Services at Alternative Sites such as schools, residential facilities, nursing facilities, OMAP Members' homes, emergency rooms, offices of DHS, other community settings; offering flexible clinic hours; offering Covered Services through Outreach or a Home-Based Approach; and using Peers, Paraprofessionals and persons who are Culturally Competent to engage difficult-to-reach OMAP Members.
Fully Capitated Health Plans (FCHPs): Prepaid Health Plans that contract with OMAP to provide physical health care services under the OHP Medicaid Demonstration Project and Children’s Health Insurance Program.
Geropsychiatric Treatment Service: Four units at Oregon State Hospital serving frail elderly persons with mental disorders, head trauma, advanced dementia, and/or concurrent medical conditions who cannot be served in community programs.
Good Cause: For purposes of this Agreement, Good Cause shall mean that there were circumstances beyond the control of the OMAP Member which prevented a timely Complaint filing, timely MHDDSD Hearing request, or timely request for benefit continuation pending resolution of the Complaint or MHDDSD Hearing issue.
Group Skills Development: An individualized program of interventions designed to meet specific goals and objectives in an OMAP Member’s Treatment Plan and to remediate significant impairments in an OMAP Member’s functioning that are the result of a principal mental or emotional disorder. Treatment is provided within a group of three or more people. Interventions focus on developing and strengthening competencies in the areas of functioning such as skills for reducing anger, managing stress, resolving conflict, allaying fears, improving communication, solving problems, or coping with depression.
Group Therapy: Planned treatment to remediate significant impairments in the functioning that are the result of a principal mental or emotional disorder diagnosed on Axis I or II of a DSM-IV multi-axial Diagnosis and identified by a mental health Assessment. Group Therapy is the treatment of three or more unrelated persons with similar therapeutic issues. It is individualized to meet specific goals and Measurable Objectives in the Treatment Plan. The intended outcome of Group Therapy for a child is to achieve and maintain the best possible, developmentally appropriate, level of functioning. The intended outcome of Group Therapy for an adult is to manage, reduce or resolve the identified mental health problems thereby allowing the client to function more independently and competently in daily life.
Health Care Financing Administration (HCFA): The federal agency responsible for approving the waiver request to operate the OHP Medicaid Demonstration Project.
Health Care Professional: Persons with current and appropriate licensure, certification, or accreditation in a medical, mental health or dental profession, which include but are not limited to: medical doctors (including psychiatrists), osteopathic physicians, psychologists, registered nurses, nurse practitioners, licensed practical nurses, certified medical assistants, physician assistants, QMHAs, QMHPs, dentists, dental hygienists, denturists, and certified dental assistants.
Health Services Commission (HSC): The governing body responsible for the OHP Medicaid Demonstration Project and Children’s Health Insurance Program Prioritized List of Health Services. The HSC determines the Condition/Treatment Pairs to be included on the Prioritized List of Health Services and determines the ranking of each pair.
Hearing Officer: An individual designated by Division to conduct a hearing on the Division’s behalf. The role of the Hearing Officer is defined in OAR 461-025-0365, Role of the Hearing Officer and is described in Exhibit G, Oregon Health Plan Mental Health Services Complaint and Hearings Process.
Home-Based Approach: Providing a service in the OMAP Member’s home or place of residence.
Incurred But Not Reported (IBNR) Expenses: Expenses for services authorized by an agency responsible for their payment, but for which no statement has yet been received by that agency. These are expenses for which the agency is liable and which the agency will need to expect to pay.
Individual Skills Development: An individualized program of interventions designed to meet specific goals and objectives in a person's Treatment Plan and to remediate significant impairments in a person's functioning that are the result of a principal mental or emotional disorder. Treatment is provided on an individual basis. Interventions focus on developing and strengthening competencies in the areas of functioning such as skills for reducing anger, managing stress, resolving conflict, allaying fears, improving communication, solving problems, or coping with depression.
Individual Therapy: Planned treatment to remediate significant impairments in functioning that are the result of a principal mental or emotional disorder diagnosed on Axis I or II of a DSM-IV multi-axial Diagnosis and identified by a mental health Assessment. Therapy is individualized to meet specific goals and Measurable Objectives in the Treatment Plan. The intended outcome of Individual Therapy for a child is to achieve and maintain the best possible, developmentally appropriate, level of functioning. The intended outcome of Individual Therapy for an adult is the management, reduction or resolution of identified mental health problems thereby allowing the client to function more independently and competently in daily life.
Insolvency: Unable to meet debts or discharge liabilities.
Intake: The process of gathering preliminary information about a potential Consumer to determine whether the person is eligible for services, the urgency of the situation or need for services, and the initial provisional Diagnosis. This information is used to schedule the first appointment, if applicable.
Intensive Psychiatric Rehabilitation: The application of concentrated and exhaustive treatment for the purpose of restoring a person to a former state of mental functioning.
Intensive Treatment, Structure and Support: An individualized program of Therapy, psychosocial skills development, psychiatric services and Consultation designed to meet specific goals and objectives in a person's Treatment Plan. Treatment is provided within a structured group setting to remediate significant impairments in a person's functioning that are the result of a principal mental or emotional disorder.
International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM): The numerical coding system which precisely delineates the clinical picture of each patient.
Interpreter Services: Language translation services to assist non-English speaking persons to receive information and communicate when such information and communication is otherwise available only in English. Interpreter Services also include sign language service to persons with hearing impairments.
Involuntary Psychiatric Care: Any psychiatric service, such as forced Medication, which is provided on a basis other than by informed client (or guardian) consent. Involuntary psychiatric services are provided only when authorized by ORS Chapter 426 and in accordance with administrative rules. Generally, a person must be determined to lack the capacity to give informed client consent before involuntary psychiatric services may be administered.
JCAHO: The Joint Commission on Accreditation of Healthcare Organizations.
JCAHO Psychiatric Residential Program: A program which provides non-emergency inpatient (residential) psychiatric services for children under age 21 in residential facilities which are licensed by SOSCF and accreditated by the JCAHO These programs must meet DARTS standards regarding staffing credentials and staffing patterns, the integration of education and treatment, and Family focused, community-based treatment.
Licensed Medical Practitioner (LMP): A person who is a physician, nurse practitioner and/or physician's assistant licensed to practice in the State of Oregon whose training, experience and competence demonstrates the ability to conduct a comprehensive mental health Assessment and provide Medication Management. The LMHA or MHO must document that the person meets these minimum qualifications.
Local Mental Health Authority (LMHA): As defined in ORS 430.620, the county court or board of commissioners of one or more counties who choose to operate a CMHP; or, if the county declines to operate or contract for all or part of a CMHP, the board of directors of a public or private corporation which contracts with Division to operate a CMHP for that county.
Local and/or Regional Allied Agencies: These include, but are not limited to, LMHA, CMHPs, AFSD, Area Agencies on Aging, Commission on Children and Families, Department of Corrections, Senior and Disabled Services Division, SOSCF, OYA, Vocational Rehabilitation Division, housing authorities, local schools, special education, law enforcement agencies, adult criminal justice and juvenile justice, developmental disability Services, Chemical Dependency Providers, residential providers, Oregon State Hospital, and Prepaid Health Plans.
Long Term Psychiatric Care or Long Term Hospitalization: Inpatient psychiatric services delivered in an Oregon State Operated Hospital after Usual and Customary care has been provided in an Acute Inpatient Hospital Psychiatric Care setting or JCAHO Residential Psychiatric Treatment Center for children under age 18 and the individual continues to require a hospital level of care.
Measurable Objective : A predetermined statement of a desired and quantifiable outcome.
Medicaid: A federal and state funded portion of the Medical Assistance Program established by Title XIX of the Social Security Act, as amended, and administered in Oregon by DHS. The program provides medical assistance to poor and indigent persons.
Medicaid Authorization Specialist (MAS) : A QMHP designated at the county or regional level to determine the rehabilitative mental health needs of children in state custody referred for certain residential programs or OMAP Members under age 18 requiring services which are not Covered Services.
Medical Assistance Program : A program for payment of medical and remedial care provided to eligible Oregonians that is administered by identified Divisions and the Office of Medical Assistance Programs (OMAP). OMAP has primary responsibility for coordinating the Medical Assistance Program.
Medical Transportation : A service provided to Medicaid-eligible persons pursuant to rules (410-136-0020 et. seq.) promulgated by the OMAP and published in its Medical Transportation Services Guide.
Medically Appropriate : Services and supplies which are required for Prevention (including preventing a relapse), Diagnosis or treatment of mental disorders and which are Appropriate and consistent with the Diagnosis; consistent with treating the symptoms of a mental illness or treatment of a mental disorder; appropriate with regard to standards of good practice and generally recognized by the relevant scientific community as effective; not solely for the convenience of the OMAP Member or provider of the service or supply; and the most cost effective of the alternative levels of Covered Services or supplies which can be safely and effectively provided to the OMAP Member in the Contractor's judgement.
Medication: Any drug, chemical, compound, suspension or preparation in suitable form for use as a curative or remedial substance taken either internally or externally.
Medication Management : Services delivered by a licensed registered nurse or physician related to the prescribing, dispensing, administration and management of Medications as described in the Treatment Plan.
Medication Override Procedure : The administration of psychotropic Medications to a person in an Acute Inpatient Hospital Psychiatric Care setting when the person has refused to accept the administration of such Medications on a voluntary basis. Administration of such Medications is considered a significant procedure. Significant procedures can only be performed after the person has been committed and only when there is good cause. A Medication Override Procedure must meet the requirements of OAR 309-033-0640, Involuntary Administration of Significant Procedures to a Committed Person with Good Cause. These procedures are used as a way to administer treatment to an OMAP Member who is incapable of providing informed consent and is in need of treatment.
Mental Health and Developmental Disability Services Division (MHDDSD or Division): The DHR agency responsible for the administration of the State's mental health and developmental disability services.
Mental Health Information System (MHIS): The information system of the Division that includes the CPMS for community based services and the Oregon Patient/Resident Care System for inpatient and acute services. It provides a statewide client registry and contractor registry for tracking service Utilization and contractor Capacity.
Mental Health Organization (MHO): A Prepaid Health Plan under contract with Division to provide Covered Services under the OHP Medicaid Demonstration Project and Children’s Health Insurance Program. MHOs can be FCHPs, CMHPs or private MHOs or combinations thereof.
Mental Health Practitioner: Persons with current and appropriate licensure, certification, or accreditation in a mental health profession, which include but are not limited to: psychiatrists, psychologists, registered psychiatric nurses, QMHAs, and QMHPs.
MHDDSD Hearing: An administrative hearing before MHDDSD related to a denial, reduction, termination, or suspension of mental health benefits which is held when requested by the OMAP Member or OMAP Member Representative. Such hearing may also be held when requested by an OMAP Member or OMAP Member Representative who believes a claim for services was not acted upon with reasonable promptness or believes the payor took action erroneously.
Multi-Family Treatment Group: The planned treatment of mental health needs identified in the mental health Assessment which occurs in a group setting of at least three children (none of whom are siblings, step-siblings, or live in the same household) and their families. Groups are of limited duration and designed for children and families dealing with similar issues.
Notice of Action: A written document issued to the OMAP Member when a service, benefit, request for service authorization, or request for claim payment is denied. The Notice of Action includes the following elements: (a) a statement of the action, the effective date of such action, and the date the Notice of Action is mailed; (b) the reasons for the action and the specific regulations that support the action; (c) an explanation of the right to file a Complaint with the Contractor and to request an administrative hearing with Division, and the consequences of choices made; (d) a statement referring the OMAP Member to an enclosed informational Notice of Complaint Process form; (e) a statement referring the OMAP Member to an enclosed informational Notice of Hearing Rights form; and (f) the name and telephone number of a person to contact for additional information.
Notice of Intended Action: A written document issued to the OMAP Member at least ten calendar days prior to the effective date of a service or benefit termination, suspension or reduction. The Notice of Intended Action includes all elements of a Notice of Action plus an explanation that if a Complaint is filed or a Hearing is requested before the effective date of the intended action, benefits will be continued until a decision is reached. The Notice of Intended Action also includes an explanation that if the issue is resolved in favor of Contractor, the OMAP Member may be required to reimburse the Contractor for the cost of benefits continued and received after the effective date of an intended action.
Notice of Intended Remedial Action: A written document issued to Contractor when the Division intends to take Remedial Action. The Notice of Intended Remedial Action includes the following elements: (a) a statement of the intended Remedial Action, the effective date of such intended Remedial Action, and the date the Notice of Intended Remedial Action is mailed; (b) the reasons for the intended Remedial Action; (c) an explanation of the Contractor’s right to request an administrative review as described in Subsection C of Section II, Interpretation and Administration of Agreement; (d) an explanation that the intended Remedial Action will be suspended when Contractor requests an administrative review before the effective date of the intended Remedial Action and such request also includes a request to suspend the intended Remedial Action until a decision is reached through the administrative review process; (e) an explanation that if the intended Remedial Action is suspended as described above in (d) and a decision is reached in favor of Division, the intended Remedial Action may be imposed retroactively to effective date stated in the Notice of Intended Remedial Action; and (f) in cases where the Remedial Action includes withholding of Capitation Payments because Contractor has failed to provide Covered Services and/or Division has incurred costs in providing Covered Services, a list of OMAP Members for whom Capitation Payments will be withheld, the nature of the Covered Services denied by Contractor, and costs incurred by Division in providing Covered Services in accordance with this Agreement.
Nursing Home (Same as Nursing Facility) : An establishment with permanent facilities for the comprehensive care of persons who require assistance with activities of daily living and 24-hour nursing care. Nursing services exclude surgical procedures and include complex nursing tasks that cannot be delegated to an unlicensed person. A nursing facility is licensed and operated pursuant to Oregon Revised Statute 441.020(2).
Office of Alcohol and Drug Abuse Programs (OADAP) : The DHS agency that coordinates policy and programs for the state’s chemical dependency prevention, intervention, and treatment services.
Office of Medical Assistance Programs (OMAP) : The Office of DHS responsible for coordinating the Medical Assistance Program for the State of Oregon.
Office of Mental Health Services (OMHS) : The program office of Division responsible for the administration of mental health services for the State of Oregon.
OMAP Member : As used in this Agreement, an individual found eligible by a Division of DHS to receive health care services under the OHP Medicaid Demonstration Project or Children’s Health Insurance Program and who is enrolled with Contractor under this Agreement.
OMAP Member Representative : A person who can make Oregon Health Plan related decisions for OMAP Members who are not able to make such decisions themselves. An OMAP Member Representative may be, in the following order of priority, a person who is designated as the OMAP Member’s health care representative, a court-appointed guardian, a spouse, or other family member as designated by the OMAP Member, the Individual Service Plan Team (for OMAP Members with developmental disabilities), a DHS case manager or other DHS designee. For OMAP Members in the care or custody of the State Office for Services to Children and Families (SOSCF) or Oregon Youth Authority (OYA), the OMAP Member Representative is SOSCF or OYA. For OMAP Members placed by SOSCF through a Voluntary Child Placement Agreement (SCF form 499), the OMAP Member shall be represented by his or her parent or legal guardian.
Oregon Health Plan (OHP) : Oregon’s health care reform effort consisting of a Medicaid Demonstration Project, Children’s Health Insurance Program, an individual insurance program for persons excluded from health insurance coverage due to pre-existing health conditions, and a group insurance program for small businesses. One objective of this reform effort includes universal coverage for Oregonians. In the context of this Agreement, Oregon Health Plan refers to the OHP Medicaid Demonstration Project and Children’s Health Insurance Program.
Oregon Health Plan (OHP) Client : An individual found eligible by a Division of DHS to receive health care services under the OHP Medicaid Demonstration Project or Children’s Health Insurance Program.
Oregon Health Plan (OHP) Medicaid Demonstration Project : The project which expands Medicaid eligibility to Oregon residents with an income of less than 100% of the Federal Poverty Level and pregnant women and children under age six with incomes up to 133% of the Federal Poverty Level. The OHP Medicaid Demonstration Project relies substantially upon prioritization of health services and managed care to achieve the public policy objectives of access, cost containment, efficacy, and cost effectiveness in the allocation of health resources.
Oregon Patient/Resident Care System (OP/RCS) : The Division's data system for persons receiving services in the Oregon State Hospitals and selected community hospitals providing Acute Inpatient Hospital Psychiatric services under contract with the Division.
Oregon State Hospital (OSH) : The state-operated psychiatric hospital with campuses in Salem and Portland, and the state-operated psychiatric hospital in Pendleton.
Oregon Youth Authority (OYA) : The Department created by the 1995 Legislative Assembly that has responsibility for care and housing of child and adolescent offenders adjudicated and sentenced by juvenile justice to the juvenile correction system.
Other Inpatient Services : Services which are equivalent to Acute Inpatient Hospital Psychiatric Care but which are provided in a nonhospital setting.
Outreach: Services provided away from the service provider’s office, clinic or other place of business in an effort to identify or serve OMAP Members who might not otherwise obtain, keep or benefit from usual appointments. Such services include, but are not limited to, community-based visits with an OMAP Member in an attempt to engage him or her in Medically Appropriate treatment, and providing Medically Appropriate treatment in a setting more natural or comfortable for the OMAP Member.
Paraprofessional: A worker who does not meet the definition of QMHA or QMHP but who assists such associates and professionals.
Parent Psychosocial Skills Development : Theoretically based interventions that focus on developing and strengthening a parent's competencies in areas of functioning such as skills in managing stress and reducing anger.
Partial Hospitalization : As used in this Agreement, an intensive package of time-limited mental health services which are directly supervised by a physician and which are provided as an alternative to or following acute inpatient hospital psychiatric care. Services are usually provided in a hospital or other certified facility but persons receiving partial hospitalization sleep elsewhere.
Participating Provider : An individual, facility, corporate entity, or other organization which provides Covered Services under an agreement with the Contractor and agrees to bill in accordance with such agreement. For Contractors who utilize a staff model and/or provide Covered Services directly, a Participating Provider may also include employees of Contractor.
PASSAGES Projects : One type of Extended Care Project which consists of community-based services for adults with severe and persistent mental illness who have been hospitalized for over six months in an Oregon State Hospital or who have had difficulty maintaining stability in other structured community settings. Placements in these projects are approved by the ECMU of OMHS.
Peer: A person who has equal standing with another as in gender, socio-economic status, age or mental disorder.
Peer Counseling : A mental health service or support provided by trained persons with characteristics similar to the Consumer such as persons in recovery from a major mental illness or persons representing a generational cohort or persons with the same cultural background.
Personal Care in Adult Foster Homes (MED) : Medicaid-covered activities of daily living and support services provided in a licensed Family home or other home for five or fewer persons who are unable to live by themselves without supervision according to standards and procedures defined in OAR 309-040-0000 through 309-040-0100.
Preadmission Screening and Resident Review (PASRR) : Screening and Evaluation services for residents of licensed nursing facilities to determine their need for inpatient psychiatric hospitalization according to federal standards and procedures defined in OAR 309-048-0050 through 309-048-0130.
Prepaid Health Plan (PHP) : A managed care organization that contracts with OMAP and/or Division on a case managed, prepaid, capitated basis under the OHP Medicaid Demonstration Project and Children’s Health Insurance Program. PHPs may be Dental Care Organizations (DCO), FCHP, Chemical Dependency Organizations (CDO), or MHO.
Prevention: Services provided to stop, lessen or ameliorate the occurrence of mental disorders.
Primary Care Practitioner (PCP) : A general practice physician, Family physician, general internist, pediatrician, or gynecologist who is responsible for providing and coordinating the OMAP Member's health care services. This person authorizes referrals to specialists and payment is contingent upon these authorizations.
Principal Diagnosis : The reason that is chiefly responsible for the visit. See DSM-IV, Use of the Manual, page 3.
Prioritized List of Health Services : The listing of condition and treatment pairs developed by the HSC for the purpose of implementing the OHP Medicaid Demonstration Project. See OAR 410-141-0520, Prioritized List of Health Services, for the listing of Condition/Treatment pairs.
Provide: To furnish directly, or authorize and pay for the furnishing of, a Covered Service to an OMAP Member.
Provider: An organization, agency or individual licensed, certified and/or authorized by law to render professional health services to OMAP Members.
Provider Panel : Those Participating Providers affiliated with the MHO who are authorized to provide services to OMAP Members.
Psychiatric Rehabilitation : The application of treatment for the purpose of restoring a person to a former or desired state of overall functioning. See definition of Intensive Psychiatric Rehabilitation.
Psychiatric Security Review Board (PSRB) : The Board authorized under ORS Chapter 161 which has jurisdiction over persons who are charged with a crime and found guilty except for insanity.
Psychiatric Vocational Project : One type of Extended Care Project which includes two community-based projects jointly funded by Vocational Rehabilitation Division and Division. These two projects, Bridges in Washington County and Laurel Hill in Eugene, provide Intensive Psychiatric Rehabilitation Services with a vocational emphasis. Placement in these projects is approved by the ECMU of OMHS.
Psychoeducational Program : Training conducted for the purpose of creating an awareness of mental disorders and treatment.
Qualified Mental Health Associate (QMHA) : A person delivering services under the direct supervision of a QMHP and meeting the following minimum qualifications as documented by the Contractor: a bachelor’s degree in a behavioral sciences field; or a combination of at least three years’ relevant work, education, training or experience; and has the competencies necessary to communicate effectively; understand mental health Assessment, treatment and service terminology and to apply the concepts; and provide psychosocial Skills Development and to implement interventions prescribed on a Treatment Plan within their scope of practice.
Qualified Mental Health Professional (QMHP) : A LMP or any other person meeting the following minimum qualifications as documented by the Contractor: graduate degree in psychology; bachelor’s degree in nursing and licensed by the State of Oregon; graduate degree in social work; graduate degree in behavioral science field; graduate degree in recreational, art, or music therapy; or bachelor’s degree in occupational therapy and licensed by the State of Oregon; and whose education and experience demonstrates the competencies to identify precipitating events; gather histories of mental and physical disabilities, alcohol and drug use, past mental health services and criminal justice contacts; assess Family, social and work relationships; conduct a mental status examination; document a multiaxial DSM Diagnosis; write and supervise a Treatment Plan; conduct a Comprehensive Mental Health Assessment; and provide Individual Therapy, Family Therapy, and/or Group Therapy within the scope of their training.
Quality Assurance (QA) : A process to promote and confirm consistency of performance and to reduce variance in performance. A Quality Assurance process serves to demonstrate or document the degree of attainment of predetermined goals and Benchmarks.
Quality Assurance/Quality Improvement (QA/QI) Plan : A plan which describes the MHO's QA and QI process.
Quality Improvement (QI) : A process to simultaneously promote consistency of performance and to promote meaningful change in Measurable Objectives. The process seeks to improve performance and to adjust Measurable Objectives and Benchmarks.
Quality of Care : The degree to which services produce desired health outcomes and satisfaction of Consumers, and are consistent with current best practices.
Reasonable Accommodation : Consistent with the ADA and Section 504 of the Rehabilitation Act of 1973, a modification to policies, practices, or procedures when the modification is necessary to avoid discrimination on the basis of Disability unless the service provider can demonstrate that making the modification would fundamentally alter the nature of the service, program or activity. Reasonable Accommodations may include, but are not limited to, activities such as the following: (1) reading, or providing a tape of, material otherwise provided in written format to a person with a visual impairment; (2) providing a service in a more accessible location for a person with a mobility and other impairment; (3) providing assistance to a person with a Disability in completing applications and other paperwork necessary to receipt of services; and (4) modifying a waiting area layout to accommodate a person in a wheelchair.
Recoup: To deduct or withhold (part of something due) for an equitable reason. Recoupment occurs as a deduction on the next month's Capitation Payment and is reflected on the Remittance Advice. Types of actions that can trigger a recoupment include mid-month OMAP Member out of service Area moves, change of Prepaid Health Plans, and retroactive Disenrollment actions.
Rehabilitative Services : Rehabilitative Services are any Medically Appropriate remedial services for the maximum reduction of a mental disability and attainment by the covered individual of his/her best possible functional level.
Reinsurance: To insure by contracting to transfer in whole or in part a risk or contingent liability already covered under an existing contract.
Remedial Action : An action taken by Division when, in its sole judgement, it determines that Contractor is out of compliance with this Agreement. A Remedial Action includes one or more of the following actions: suspension of Enrollment of new OMAP Members, reduction of the number of OMAP Members, or withholding of a portion of Capitation Payments. A Remedial Action continues until such time as the Division determines that Contractor is in compliance with this Agreement and Division has recovered all costs incurred in the provision of Covered Services required by this Agreement.
Request for Proposals (RFP) : The process used by the Division to solicit offers to deliver managed mental health services under the OHP Medicaid Demonstration Project.
Residential/Medical Youth Care Residential Center : A facility providing treatment under a physician approved plan to children and adolescents (ages 3 through 20) with a mental or emotional disorder as identified in a mental health Assessment. These children and adolescents are placed by OYA or SOSCF in cooperation with the county mental health authority. Adolescents receiving this service have a DSM-IV, Axis I Diagnosis and reside in a SOSCF licensed youth care center. This service includes an Appropriate mix and intensity of individual and group therapies and Skills Development to reduce or eliminate the symptoms of the disorder and restore the individual's ability to function, to the best possible level, in home, school and community settings.
Residential Service : The organization of services in a home or facility including room, board, care and other services provided to adults assessed to be in need of such services. Residential Services include, but are not limited to, Residential Care Facilities, Residential Treatment Facilities, Residential Treatment Homes, Crisis Respite Services and Secure Residential Treatment Facilities. Residential Services do not include Supported Housing programs.
Residential Treatment Facility : A facility that is operated to provide supervision, care and treatment on a 24-hour basis for six or more residents consistent with ORS 443.400 through ORS 443.455.
Residential Treatment Home : A home that is operated to provide supervision, care and treatment on a 24-hour basis for five or fewer residents consistent with ORS 443.400 through ORS 443.455.
Respite Care : See definition for "Crisis-Respite Services".
Restricted Reserve Fund : A fund that is separate from ongoing operation accounts and is limited for use to prevent Insolvency. This fund is set up to meet unexpected cash needs and to cover debts when an organization discontinues its role as a Contractor. This fund may not be used to meet expected ongoing obligations such as withholds, incentive payments and the like.
Service: The care, treatment, service coordination or other assistance provided to an OMAP Member.
Service Area : The geographic area in which the MHO is responsible for delivering Covered Services under this Agreement.
Services Coordination : Services provided to OMAP Members who require access to and/or receive services from one or more Local and/or Regional Allied Agencies or program components according to the Treatment Plan. Services provided may include establishing precommitment service linkages; advocating for treatment needs; and providing assistance in obtaining entitlements based on mental or emotional Disability.
Setting: The locations at which Covered Services are provided. Settings include such locations as mental health offices, an individual's home or school or other identified locations.
Skills Training : A program of rehabilitation as prescribed in the Treatment Plan which is designed to improve social functioning in areas important to maintaining or re-establishing residency in community, such as money management, nutrition, food preparation, community awareness, and community mobility. Skills Training can be provided on an individual basis or in a group setting.
Specialized Medication Adjustment : Medication adjustments which because of the complexity or danger, require a level of expertise beyond that of the usual LMP for that setting or client.
Stakeholders: Persons, organizations and groups with an interest in how Covered Services are delivered under the MHO Agreement. Stakeholders may include, but are not limited to, OMAP Members, Consumers, Families, Local and/or Regional Allied Agencies, child psychiatrists, child advocates, advocacy groups, and other groups.
State Hospital : State-operated psychiatric hospitals including Oregon State Hospital in Salem and Portland, and Eastern Oregon Psychiatric Center in Pendleton.
State Office for Services to Children and Families (SOSCF) : This Division serving as Oregon's child welfare agency. Child protective services staff assess reports of child Abuse and neglect, work with families to try to keep children in the home, and place children in foster care or residential treatment if their need for safety and other services requires substitute care. The adoption program serves children who have been released by the courts for permanent placement.
Stop Loss Coverage : Insurance to a provide excess loss coverage protection for catastrophic claims to an agency or provider.
Stop Loss Protection : Provider excess loss coverage for catastrophic claims.
Subacute Psychiatric Care : Care characterized by the commitment of treatment resources toward the resolution or amelioration of a significant, but not serious, mental health problem over a relatively short period of time.
Subcontractor: An individual, facility, corporate entity, or other organization which provides Covered Services under an agreement with the Contractor and agrees to bill in accordance with such agreement.
Supported Housing : Provision of mental health rehabilitation services in the home or other community setting for the purpose of assisting a person to live independently. Such services typically include skill development in money management, nutrition, and community living; assistance with health issues and taking prescribed Medications; and provision of supportive counseling.
Tertiary Treatment : Complementary medical, psychological, or rehabilitative procedures designed to eliminate, relieve or minimize mental or emotional disorders.
Therapeutic Group Home : A home providing planned treatment to a child in a small residential setting. Treatment includes theoretically based individual and group home Skills Development and Medication Management, Individual Therapy and Consultations as needed, to remediate significant impairments in the child's functioning that are the result of a principal mental or emotional disorder diagnosed on Axis I of the DSM-IV multi-axial Diagnosis.
Third Party Resources : Those payments, benefits or resources available from certain categories of resources, including but not limited to the following: under a federal or state worker's compensation law or plan; for items or services furnished by reason of membership in a prepayment plan; for items or services provided or paid for directly or indirectly by a health insurance plan; for items or services provided or paid for directly or indirectly as health benefits from a governmental entity, such as Veteran's Administration, Armed Forces Retirees and Dependent Act (CHAMPVA), Armed Forces Active Duty and Dependents Military Medical Benefits Act (CHAMPUS), and Medicare Parts A and B; to OMAP Members who are eligible for services under another state's Title XIX, Title XXI, or state-funded Medical Assistance Program; through other community resources; or for tort or estate recoveries.
"365" Project : One type of Extended Care Program which is a community-based alternative to Oregon State Hospital services developed on an individualized basis for persons with state hospitalization episodes of one year or longer. These are extended care projects that provide intensive services and supports to enable approved adults to live in community rather than institutional settings. Persons must be approved for placement in these projects by the ECMU of OMHS.
Traditional Service : A Medically Appropriate mental health service defined in Attachment 1, State of Oregon, Oregon Health Plan Service Categories for Per Capita Costs, October 1997 through September 1998. Traditional Services are those services that have historically been used to treat mental disorders and include services for which Medicaid Fee-For-Service billing categories exist. For OMAP Members under 21 years of age Traditional Services include the following: Interpreter Services; Assessment and Evaluation; Consultation; Clinical Services Coordination; Case Management; Medication Management; Individual Therapy, Family Therapy and Group Therapy; Multi-Family Treatment Group; Individual Skills Development and Group Skills Development; Intensive Treatment, Structure and Support; 24-hour Urgent and Emergency Response; and Acute Inpatient Hospital Psychiatric Care. For OMAP Members 21 years of age and older Traditional Services include the following: Interpreter Services; Assessment and Evaluation; Consultation; Case Management; Medication Management; Individual Therapy, Family Therapy and Group Therapy; Daily Structure and Support; Individual and Group Skills Training; 24-hour Urgent and Emergency Response; Acute Inpatient Hospital Psychiatric Care; and Covered Services provided in a variety of residential settings.
Treatment: A planned, Medically Appropriate, individualized program of interactive medical, psychological, or rehabilitative procedures, experiences, and/or activities designed to rehabilitate, relieve or minimize mental or emotional disorders identified through a mental health Assessment.
Treatment Foster Care : A program of rehabilitation as prescribed in the Treatment Plan and provided in the child's foster home. Skill development activities are delivered on an individualized basis and are designed to promote skill development in areas identified in the Treatment Plan. The service requires the use of Treatment Foster Care in coordination with other mental health interventions to reduce symptoms associated with the child's mental or emotional disorder and to provide a structured, therapeutic environment. The service is intended to reduce the need for future services, increase the child's potential to remain in the community, restore the child's best possible functional level, and to allow the child to be maintained in a least restrictive setting.
Treatment Parameters : The set of all variables that may affect the treatment of a client. Included in this set are providers, medical treatments, psychological treatments, and social interventions.
Treatment Plan : A written individualized comprehensive plan based on a completed mental health assessment documenting the OMAP Member's treatment goals, Measurable Objectives, the array of services planned, and the criteria for goal achievement.
Twenty-four (24) Hour Urgent and Emergency Services : Services available 24 hours per day for persons experiencing an acute mental or emotional disturbance potentially endangering their health or safety or that of others, but not necessarily creating a sufficient cause for civil commitment as set forth in OAR 309-033-0200 through 309-033-0340.
Urgent Care : Care which is medically necessary within 48 hours to prevent a serious deterioration in an OMAP Member's mental health.
Urgent Situation : A situation requiring attention within 48 hours to prevent a serious deterioration in an OMAP Member's mental health.
Usual and Customary Charges : A required field in the encounter Minimum Data set which reflects the provider’s charge per unit of service established in accordance to OAR 410-120-000 or other applicable state and federal laws, rules and regulations, not in excess of the provider’s usual and customary charge to the general public.
Usual and Customary Treatment : The application of treatment used to prevent the need for Long Term Psychiatric Care. Treatments include the following: (1) medical screens and Assessments used to rule out a medical condition or identify a medical condition that may be impacting a mental disorder; (2) Appropriate use of psychotropic Medications in therapeutic dosages and adjustments to such dosages to minimize side effects; (3) other cognitive and behavioral therapeutic interventions; and (4) review of options for discharge to nonhospital levels of care. For members who will be admitted to the Geropsychiatric Unit at Oregon State Hospital, Usual and Customary Treatment includes coordination of the stabilization of acute medical problems.
Utilization: The amount and/or pattern of Covered Services used by an OMAP Member, measured, for example, in dollars, units of service, or staff time.
Utilization Guidelines : Guidelines for the amount of Covered Services expected to be used by an OMAP Member with a specific mental disorder over time.
Utilization Management : The process used to regulate the provision of services in relation to the overall Capacity of the organization and the needs of Consumers.
Valid Claim : An invoice received by the MHO for payment of Covered Services rendered to an OMAP Member which can be processed without obtaining additional information from the provider of the service or from a third party; and has been received within the time limitations prescribed in Oregon Administrative Rule 410-120-1300; and is synonymous with the federal definition of a "clean claim" as defined in 42 CFR 447.45 (b).