1. (1) Reimbursement is based on cost-based rate methodology and subject to all rules and laws pertaining to federal financial participation. The Authority’s acceptance of cost data provided by provider organizations for the purpose of establishing rates paid for TCM services does not imply or validate the accuracy of the cost data provided.

2. (2) The cost-based rate shall be derived by considering the following expenditures directly attributable to TCM staff:

   1. (a) TCM staff salaries and other personnel expenses;
   2. (b) Supervisory salaries and other personnel expenses;
   3. (c) Administrative support salaries and other personnel expenses;
   4. (d) Services and supply expenses;
   5. (e) Various overhead expenditures, if not already considered in the indirect rate.
3. (3) The Division shall accept a claim up to 12 months from the date of service. See provider rule OAR 410-120-1300 (Timely Submission of Claims).
4. (4) Providers shall only bill for allowable activities in the TCM programs that assist individuals eligible under the Medicaid State Plan to gain access to needed medical, social, educational, housing, environmental, and other services.
5. (5) The Division may not allow duplicate payments to other public agencies or private entities under other program authorities for TCM services under the eligible client’s care plan. Medical services shall be provided and billed separately from case management services. The Authority shall recover duplicate payments.
6. (6) The Division may not reimburse for TCM services if the services are case management services funded by Title IV-E or Title XX of the Social Security Act. These services shall be billed separately.
7. (7) Any place of service is valid.
8. (8) Prior authorization is not required.

Statutory/Other Authority

ORS 413.042 & 414.065

Statutes/Other Implemented

ORS 414.065

History

DMAP 98-2025, amend filed 12/29/2025, effective 01/01/2026
DMAP 9-2017, f. 3-31-17, cert. ef. 4-1-17
DMAP 4-2017(Temp), f. 2-2-17, cert. ef. 2-10-17 thru 7-11-17
DMAP 2-2017(Temp), f. & cert. ef. 1-13-17 thru 7-11-17
DMAP 76-2016, f. 12-29-16, cert. ef. 1-1-17
DMAP 41-2010, f. 12-28-10, cert. ef. 1-1-11
DMAP 22-2010, f. 6-30-10, cert. ef. 7-1-10
DMAP 43-2008, f. 12-17-08, cert. ef. 12-28-08
DMAP 32-2008(Temp), f. & cert. ef. 10-2-08 thru 3-27-09
DMAP 28-2008(Temp), f. 6-30-08, cert. ef. 7-1-08 thru 12-28-08
OMAP 61-2004, f. 9-10-04, cert. ef. 10-1-04
HR 37-1994, f. 12-30-94, cert. ef. 1-1-95
HR 20-1992, f. & cert. ef. 7-1-92