FAQ: KEPRO & residential placement

A person's hands holding another person's hands.

Closeup shot of two unrecognizable people holding hands in comfort

Hospitals and residential treatment facilities often do not provide community integration. DRO supports efforts to integrate people with disabilities into the community and to place people in the proper level of care.

DRO has concerns about how the Oregon Health Authority (OHA) reviews placements.  Concerns have  come up with the company that reviews placements for OHA called KEPRO.[1]

Know Your Rights

People who have been reviewed for continued eligibility in a residential placement have the following rights:

  • A clear, written notice of the eligibility decision
  • Information about how to request a hearing if they disagree with the decision
  • Information about how to stay in their residence during appeal and transition
  • A person-centered plan, so that transition is driven by the person’s needs and desires
  • Appropriate services and supports

Below are some frequently asked questions and answers.

Eligibility Reviews

Q: What is an “eligibility review”?

An “eligibility review” is when KEPRO reviews if your placement is medically appropriate.[2] It helps determine your level of care.

Q: What is a “request for authorization”?

A “request for authorization” is a service provider requesting payment for services.[3]

Q: What if my request for authorization is “denied”?

Your provider has 10 days to submit documents to support the request. They should provide the information to KEPRO.[4]

Q: Is the eligibility evaluation in-person?

Yes.  KEPRO should conduct in-person evaluations for eligibility.[5]

Due Process

Q: What does it mean if I get a denial notice?

A denial notice means KEPRO found your current placement medically inappropriate. Medicaid funds will no longer pay for that level of care.  You may still qualify for a different level of care.

Q: How do I find out why my placement was denied?

The reason for the denial should be listed on the notice.

Q: Who should be notified of a denial?

  • You
  • Your service provider
  • Your guardian or authorized representative

Q: Can you appeal a notice of denial?

Yes. If you disagree with KEPRO’s decision, you can request a hearing. You have 60 days to request a hearing.  To request a hearing, contact the Oregon Health Authority (OHA). Requests are by phone, in writing, or directly to an OHA/DHS employee.  You can deliver “Administrative Hearing Request” forms to OHA’s Medical Hearings Unit.[6]

OHA Medical Hearings Unit

500 Summer St. NE E49

Salem, OR 97301

Phone: 503-945-5785

Fax: 503-945-6035

It’s always best to put your hearing request in writing.  Here is a link to the form.

Q: Can I continue to stay in the placement during an appeal?

Yes.  You can ask to continue services you already are receiving.  When you request a hearing, indicate that you want continued services.

Q: Who should I contact if I want help at the hearing?

Friends, family, advocates, doctors, or lawyers may help you at the hearing.[7]

 

Transition Planning

Q: What should my transition planning look like?

Your transition plan should be person-centered. It should weigh your unique interests and needs.  The plan should identify a new placement that meets your medical needs. Your plan may also state any other supports needed during the transition. That may include more staffing or visits to the new placement.

Q: How much time do I have for transition planning?

During transition, OHA should keep your placement for up to 60 days.  DRO cannot guarantee that OHA will fund your placement for 60 days past the eligibility decision.  Talk to your community mental health case manager or the transition coordinator. You can request continued services, while they complete a person-centered transition plan.[8]

 

Person-centered Planning

Q: What is a person-centered plan?

Person-centered planning  is a process that identifies your unique needs and interests. It helps develop an understanding of a person’s history, culture, and preferences.  It is an important first step to selecting other services and activities.  Person-centered planning may be time consuming.  It should be responsive to changing needs.  If you wish, this plan may include input from friends and family. [9]

Other Questions? Contact Us.

If you have other questions, please contact us.

Disability Rights Oregon

503-243-2081

511 SW 10th Avenue, Suite 200

Portland, Oregon 97205

Web Intake Form

[1] Information from KEPRO contract/MS Memo

[2] Information from KEPRO Contract page 25

[3] OHA “Template Denial Letter”/Common Knowledge

[4] OHA “Template Denial Letter”

[5] Information from MS Memo

[6] Information from “Mary Smith” Denial Template

[7] Info from Notice of Hearings Rights

[8]  OAR 410-172-0720

[9] Language from Sarah Used for I&R letter to KEPRO Client (JB)

, , , , ,