Home care billing in Oregon

Key facts for Oregon home care billing

Programs that pay for home care in Oregon¹

• Community First Choice (1915(k) K Plan)

  Home and community-based attendant services and supports with activities of daily living, instrumental activities of daily living and health-related tasks, delivered in the home or in a community-based setting by a homecare worker, an in-home care agency or a combination of both.

  This is a state plan option, not a 1915(c) waiver, and it carries the attendant services by homecare workers and in-home care agencies that the waivers below do not list; ODHS's developmental disabilities page and APD's 2025 notice both describe it. Agency with Choice has since started: ODHS's Agency with Choice page says ODDS launched the provider type on January 1, 2026 and APD in July 2026, that APD and OHA were directed to contract with up to two agencies and have selected one, and that the agency employs the direct support workers and runs their hiring, payroll and benefits.

• Aged and Physically Disabled Waiver (0185.R07.00)

  Waiver case management, housing support services and transition services, for people 65 and older and people with physical disabilities ages 18 to 64 who meet a nursing facility level of care.

  It runs with a concurrent 1915(b)(4) authority. APD's notice explains that this selective contracting limits waiver case management to Area Agencies on Aging, APD offices and willing Tribes.

• Adults HCBS Waiver (0375.R05.00)

  Employment path services, individual and small group supported employment, waiver case management, direct nursing, discovery and career exploration, environmental safety modifications, family training, specialized medical supplies and vehicle modification, for adults 18 and older with intellectual or developmental disabilities who meet an ICF/IID level of care.

• Children's Extraordinary Needs Waiver (2386.R00.00)

  Attendant care provided by a legally responsible individual, plus employment path services, supported employment, waiver case management, environmental safety modifications and related supports, for children ages 0 to 17 with physical disabilities, medical fragility or intellectual or developmental disabilities who meet a hospital, nursing facility or ICF/IID level of care.

• Children's HCBS Waiver (0117.R07.00)

  Employment path services, supported employment, waiver case management, discovery and career exploration, environmental safety modifications, family training, specialized medical supplies and vehicle modification, for children ages 0 to 17 with intellectual or developmental disabilities who meet an ICF/IID level of care.

  The Behavioral (ICF/IDD) Model Waiver (40194.R05.00), the Medically Fragile (Hospital) Model Waiver (40193.R05.00) and the Medically Involved Children's Waiver (0565.R04.00) offer the same core list to children at the ICF/IID, hospital and nursing facility levels of care.

Common rejections in Oregon, and the fix

• Agency claim over the weekly authorized units

  The fixMMIS checks each claim against the weekly authorization, and the most common cause is a calendar month that changes mid-week when the agency splits billing by month. The biller builds claims on the Sunday to Saturday week and confirms the units on a multi-week claim stay inside one week's authorization.

• Claim dated outside the plan of care in MMIS

  The fixA POC cannot carry claims after its end date, and a temporary change in hours means the local office ends one POC and creates another. The biller matches every claim to the POC dates on the current 546N and asks the case manager to correct the POC before billing, voiding and splitting any claim that crosses two authorizations.

• Claims billed under the old provider number after an ownership change

  The fixWhen an agency's Medicaid provider number changes, the old service plan and POCs end and new ones are created. The biller backs out any claim sent under the old number before the local office ends the POC and rebills under the new one.

• Assessment claim denied for a missing service eligibility line

  The fixThe initial assessment pays without a POC, but only if the individual has an approved In-Home Care Service Plan, a matching service eligibility line and a current type of assistance in ONE. The biller confirms those with the case manager before submitting the assessment claim.

• Monthly EVV report or attestation missing

  The fixOAR 411-033-0030 requires a monthly report of each consumer's name, Medicaid prime number, dates, locations, start and end times and services, with an attestation that all claims met EVV requirements. The biller produces the report from the agency's EVV system and checks it against the month's paid claims before it is sent.

• Home health visits reported late or entered manually without a reason

  The fixHome health agencies send the EVV Reporting Template no later than 10 days after the end of each month, and a manually captured visit needs a reason code such as a forgotten clock-in or a fob error. The biller reviews the template for manual entries and missing codes before the deadline.

• Home health prior authorization requested too late

  The fixOAR 410-127-0080 has the provider contact the CCO, prepaid health plan or the Division within five working days after services start or continue, with the plan of care and supporting documentation. The biller tracks the start of each episode and the authorizing payer and files the request inside that window.

• Hours paid above the service plan authorization

  The fixOAR 411-030-0070 bars payment beyond the total the Department authorized on the service plan authorization. The biller compares delivered hours to the 546N each week and asks the case manager for a new assessment before extra hours are worked, not after.