1. (1) The ACT Program shall complete a Comprehensive Assessment that demonstrates medical appropriateness prior to the provision of this service. If a substantially equivalent assessment is available that reflects current level of functioning and contains standards consistent with OAR 309-019-0135 to include sufficient information and documentation to justify the presence of a diagnosis that is the medically appropriate reason for services, the equivalent assessment may be used to determine admission eligibility for the ACT program.
2. (2) A referral for The ACT Program is managed and coordinated, as defined in these rules and is referred to as the Standardized Referral Process
3. (3) The CCO, Single Point of Contact (SPOC) and or ACT Program shall accept all referrals utilizing the Universal Referral Form provided by the Division and verify the documentation that supports ACT criteria. The referral must include when an approximate, reasonable date of admission and/or Intake for further evaluation for the ACT program is anticipated.

4. (4) Based on the ACT Teams published referral process, the deciding entity shall have 14 calendar days from the date of request to respond to referring party for the purposes of Care Coordination.

   1. (a) Care coordination within the Standardized Referral Process consists of notifying participant and referring party if the referral will be moved forward to the second step or if the referral is denied. Once this communication occurs, the care coordination step has been completed.

      1. (A) if there is insufficient information within the referral that eliminates ability to properly evaluate for next steps, the SPOC or designated ACT Team staff may send the referring party requesting that information.
      2. (B) During Care Coordination step, “pending” a referral can only be used if there is a realistic expectation for the referring party to have access to the additional information.
      3. (C) If additional information is needed from another source, this request would be made during the Screening Phase, or second step in the Standardized Referral Process.
      4. (D) It is recommended to maintain stewardship within the local community and care coordination process by identifying a “date to return by” of no less than 14 calendar days.
      5. (E) If the referral is returned, the Standardized Referral Process will begin all over from (4)(a) of this rule with the exception that pending is no longer an option and a decision needs to be made if the referral moves on to second phase or it is denied. If it is denied, the denial procedures in 309-019-0248 (5) (a-c) of this ruleset must be followed.

   2. (b) If referral is moving forward within the Standardized Referral Process the Screening phase begins immediately. This process can include several orchestrated arrangements made by the ACT Team-staff and is a designated period to gather information as a hypothetical if the individual would be approved for services and require a Strength-Based Treatment plan, however, must include written notification on the Universal Referral Form to the referring party (if HIPAA allows) & individual.

      1. (A) The Screening Phase must at minimum, include a Face-to-Face interview between the designated ACT staff member and the individual applying for services This interview cannot be delegated to a SPOC or third party under any circumstances to ensure ACT Teams maintain as the gatekeeper for all admits.
      2. (B) Collateral information may be sought out as needed from other sources if the designated ACT staff member deems relevant. Collateral information can come by way of verbal/interviews, request for documentation from past treatment providers, judicial staff, etc.
   3. (c) A referral can be reflected as “pending” if there is more than 60 days until discharge from an acute care setting and the ACT Team requests monitoring for progression. If this option is utilized, the ACT program must document and site this OAR while also continuing to be actively involved in care coordination and will ensure to provide a final determination in good faith prior to discharge or end of jurisdiction date to maintain stewardship and due-diligence that their decision does not negatively interfere or impact discharge progress.
5. (5) The final determination on the referral is communicated per best practice standards within 30 calendar days from the date care coordination communication for Screening Phase was initiated. ACT Clinicians may expedite this process based on severity of needs, symptoms and/or the circumstances of the individual.:

6. (6) Final determination must at minimum be completed by the ACT Team member who completed the face-to-face interview;

   1. (a) It shall notify the individual if the final decision is that of admission, waitlist or denial.
   2. (b) The final determination must be in written format per the individuals preferred language and capacity of understanding on the agency letterhead;
   3. (c) The letter must cite applicable administrative rules and criteria to support conclusion and must be signed by the Decision Maker.
7. (7) If individual is approved for admission; the written response must have an anticipated start date less than seven 7 calendar days of letter or discharge date; whichever comes first. In anticipation of entry to services the ACT Program shall, in good faith, coordinate any additional documentation that can legally be provided proactively that will support in Strength based treatment planning. Items considered is verifying medication and/or possible refill needs as close to discharge or entry to services as possible and verify residency or living situation status prior to first official appointment with an ACT Team Member.
8. (8) Given the severity of mental illness symptoms, executive functioning level that ACT services are intended for, if a referral is denied, the care coordination may rest with the CCO.
9. (9) An individual’s decision not to take psychiatric medication cannot be used for denying admission to an ACT program;

10. (10) ACT Program Capacity in a geographic region or identified service area is not a sufficient reason to deny a referral. The referral must adhere to all required steps within the Standardized Referral Process so that level of care and medical necessity may be established timely.

    1. (a) If an individual is deemed ACT eligible but cannot be served or become active in services as a result of an ACT Team being at the max ratio capacity per Team Size in 0225 (22,26,34), the individual will be placed on a Waitlist per OAR 309-019-0225(40).
    2. (b) If an individual is waitlisted, the responsible entity who manages or maintains oversite of the waitlist shall provide the individual or legal representative avenues to monitor the status on the waitlist.
11. (11) While an ACT eligible individual is on the waitlist due to Team size capacity, they shall be offered alternative community-based rehabilitative services as described in the Oregon Medicaid State Plan that includes evidence-based practices to the best extent possible per OAR 410-141-3515(21).
12. (12) The Division shall monitor each regional waiting list until sufficient ACT program capacity is developed to meet the needs of the ACT eligible population per OAR 410-141-3515(21) by means of data collection strategies.
13. (13) In addition, if an individual is denied ACT services, they or their guardian may appeal the decision if they do not agree with the denial. The grievance process will follow OAR 309-019-0215 by filing a grievance directly with the behavioral health agency that provides ACT services. Escalated grievances may resort to appeals per Medicaid standards; however, the objective of the grievance process will be to ensure all Individual Rights are intact and honored equitably.

Statutory/Other Authority

ORS 161.390, 413.042, 430.256 & 430.640

Statutes/Other Implemented

ORS 161.390 - 161.400, 428.205 - 428.270, 430.010, 430.205- 430.210, 430.254 - 430.640, 430.850 - 430.955 & 743A.168

History

BHS 29-2025, amend filed 12/29/2025, effective 01/01/2026
BHS 17-2025, amend filed 06/25/2025, effective 06/29/2025
BHS 32-2024, temporary amend filed 12/27/2024, effective 01/01/2025 through 06/29/2025
BHS 44-2023, amend filed 12/22/2023, effective 01/01/2024
MHS 4-2018, amend filed 02/27/2018, effective 03/01/2018
MHS 10-2017(Temp), f. 9-15-17, cert. ef. 9-15-17 thru 3-13-18
MHS 6-2017, f. & cert. ef. 6-23-17
MHS 1-2017(Temp), f. 1-17-17, cert. ef. 1-18-17 thru 7-16-17
MHS 18-2016, f. 11-28-16, cert. ef. 11-30-16
MHS 11-2016(Temp), f. 6-29-16, cert. ef. 7-1-16 thru 12-27-16