Or. Admin. R. 410-133-0140 - School Medical Provider Enrollment Provisions
(1) This rule applies only to providers
seeking reimbursement from the Division, except as otherwise provided in OAR
410-120-1295.
(2) Only Educational
Agency (EA) providers of SBHS that meet the criteria for the provision of
special education programs approved by the State Superintendent of Public
Instruction qualifying such programs for state reimbursement under OAR
581-015-2005 will be enrolled with the Division as school medical (SM)
providers allowed to seek reimbursement for the provision of covered health
services pursuant to a Medicaid eligible child's Individualized Education
Program (IEP) or Individualized Family Service Plan (IFSP).
(3) The provider enrollment process will
consist of: The completion and submission of the School Medical (SM) provider
enrollment application and the required attachments, disclosure documents, and
provider agreement with the Division of Medical Assistance Programs.
(4) An approved enrollment application by the
Division or the Authority unit responsible for enrolling the SM provider is a
contractual agreement that binds the SM provider to comply with the Authority
administrative rules OAR 943-120-0300 through 943-120-0380, the Division
General Rules 410-120-1260 and School-Based Health Services (SBHS)
rules.
(5) Signing the SM provider
agreement enclosed in the application package constitutes agreement by
performing, and billing providers for provision of SBHS to comply with all
applicable rules of the Medical Assistance Program and federal and state laws
and regulations.
(6) An SM provider
is a performing provider . A performing provider is the provider of a service or
item. A billing provider is an individual, agent , business, corporation,
clinic, group, institution, or other entity who in connection with the
submission of claims to the Authority, receives or directs the payment (either
in the name of the performing provider or the name of the billing provider)
from the Authority, on behalf of a performing provider and has been delegated
the authority to obligate or act on behalf of the performing provider (See OAR
410-120-1260):
(a) A billing provider is
responsible for identifying to the Division and keeping current the
identification of all performing providers for whom they bill, or receive or
direct payments. This identification must include the providers' names,
Authority provider numbers, NPIs, and either the performing provider's Social
Security Number (SSN) or Employer Identification Number (EIN). The SSN or EIN
of the performing provider cannot be the same as the Tax Identification Number
(TIN) of the billing provider. In order to facilitate timely claims processing
and claims payment consistent with applicable privacy and security
requirements, the Authority requires billing providers to be enrolled
consistent with the provider enrollment process described in OAR
410-120-1260(7);
(b) If the SM
performing provider uses electronic media to conduct transactions with the
Authority , or authorizes a billing provider to conduct such electronic
transactions, the SM performing provider must comply with the Electronic Data
Interchange (EDI). Enrollment as a SM performing provider or billing provider
is a necessary requirement for submitting electronic claims, but the provider
must also register as a trading partner and identify the EDI
Submitter;
(c) A school medical
(SM) performing provider that uses electronic media to conduct transaction with
the Authority or authorizes a billing provider to conduct such electronic
transactions, must comply with the electronic data interchange (EDI).
Enrollment as an SM performing provider or billing provider is a necessary
requirement for submitting electronic claims. If the SM provider intends to use
an electronic data interchange (EDI) submitter, the SM performing provider must
register with the Authority as a trading partner and shall complete the
"Trading Partner Authorization of EDI Submitter" and the EDI submitter
information required in the application in compliance with the trading partner
requirements of identifying the authority of the EDI submitter to submit claims
on its behalf. The EDI submitter must sign the EDI certification and meet other
Authority EDI submission requirements pursuant to the EDI rules, before the
Authority may accept an electronic submission from the EDI submitter on behalf
of the performing provider. Information about the EDI transaction requirements
is available on the Authority 's web site.
(7) To be enrolled and able to bill as an SM
provider , an EA, must meet applicable licensing and regulatory requirements set
forth by federal and state statutes, regulations, and rules and must comply
with all Oregon statutes and regulations for provision of Medicaid and State
Children's Health Insurance program (SCHIP) services. In addition, all
providers of services within the State of Oregon must have a valid Oregon
business license if such a license is a requirement of the state, federal,
county or city government to operate a business or to provide
services.
(8) An EA, individual, or
organization that is currently subject to sanction by the Medical Assistance
Program or Federal government is not eligible for enrollment.
(9) The Authority requires compliance with
the National Provider Identification (NPI) requirements in 45 CFR Part 142.
Providers that obtain an NPI should update their records with the Division
Provider Enrollment. Provider applicants that have been issued an NPI must
include that NPI number with the Division provider enrollment
application.
(10) A performing
provider number will be issued to an EA providing covered health care services
or items upon:
(a) Completion of the
application and submission of the required School-Based Health Services SM
Provider Attachment, disclosure documents, and provider agreement;
(b) The signing of the SM provider
application by the authorized representative for the EA to bind the EA SM
provider to compliance with these rules;
(c) Verification of licensing or
certification. Loss of the appropriate licensure or certification or failure to
meet the criteria for the provision of special education programs approved by
the State Superintendent of Public Instruction qualifying such programs for
state reimbursement under OAR 581-015-2005 will result in immediate
dis-enrollment of the provider and recovery of payments made subsequent to the
loss of licensure or certification;
(d) Approval of the application and required
documentation for an SM provider by the Division or the Division responsible
for enrolling the provider .
(11) An SM performing provider may be
enrolled retroactive to the date services were provided to a medical assistance
client/child if:
(a) The SM provider met the
criteria for the provision of special education programs approved by the State
Superintendent of Public Instruction qualifying such programs for state
reimbursement under OAR 581-015-2005, was appropriately licensed, certified,
and otherwise met all Medical Assistance Program requirements at the time
services were provided; and
(b)
Services were provided less than 12 months prior to the date of application for
medical assistance provider status as evidenced by the first date stamped on
the paper claims(s) submitted with application materials for those services
either manually or electronically; or
(c) Extenuating circumstances existed outside
the control of the EA SM provider consistent with federal Medicaid regulations,
with approval of the Division's Provider Services Unit Manager.
(12) Issuance of an
Authority -assigned SM provider number establishes enrollment of an EA as a
provider for limited categories of services for the Medical Assistance Program
applicable to the provision of Medicaid covered School-Based Health Services
(SBHS).
(13) An SM provider is
required for providing and continuing to provide to the Authority accurate,
complete and truthful information regarding their qualification for enrollment.
The SM provider is responsible for notifying the Division in writing of a
material change in any status or condition that relates to their qualifications
or eligibility to provide SBHS including but not limited to change in any of
the following information: changes address, business affiliation, licensure,
ownership, certification, NPI, billing agents or Federal Tax Identification
Number (TIN), change in status for meeting the criteria for the provision of
special education programs approved by the State Superintendent of Public
Instruction qualifying the EA's programs for state reimbursement under OAR
581-015-2005, if the SM provider or a person with an ownership or control
interest, or an agent or managing employee of the SM provider has been
convicted of a criminal offense related to that person's involvement in any
program under Medicare, Medicaid, or Title XX services program, the SM provider
must notify the Division in writing within 30 calendar days of the change:
(a) Failure to notify the Division of a
change of federal tax identification number (TIN) may result in the imposing of
a $50 fine;
(b) Changes in business
affiliation, ownership and control of information, criminal convictions, NPI,
or federal tax identification number may require the submission of a new
application;
(c) Payments made to
providers who have not furnished such notification as required by this rule or
to a provider that has failed to submit a new application as required by this
rule and OAR 410-120-1260 may be denied or recovered.
(14) For information regarding enrollment of
Billing Providers (BP) and issuance of an Authority assigned BP Provider ID in
compliance with Provider Rules see OAR 943-120-0300 through 943-120-1505,
410-120-1260 and 943-120-0100 through 943-120-0200.
(15) Provider termination:
(a) The SM provider may terminate enrollment
at any time. The request must be in writing, via certified mail, return receipt
requested. The notice shall specify the provider number to be terminated and
the effective date of termination. Termination of the SM provider enrollment
does not terminate any obligations of the SM provider for dates of services
during which the enrollment was in effect;
(b) The Division provider terminations or
suspensions may be for, but are not limited to the following:
(A) Breaches of provider agreement;
(B) Failure to comply with the statutes,
regulations and policies of the Authority , Federal and State regulations that
are applicable to the provider;
(C)
When no claims have been submitted in an 18-month period. The provider must
reapply for enrollment.
(16) When one or more of the requirements
governing a provider 's participation in the medical assistance program are no
longer met, the provider's medical assistance program provider number may be
immediately suspended. The provider is entitled to a contested case hearing as
outlined in 410-120-1600 to determine whether the provider's medical assistance
program number will be revoked.
Notes
Stat. Auth.: ORS 413.042 & 414.065
Stats. Implemented: ORS 413.042 & 414.065
State regulations are updated quarterly; we currently have two versions available. Below is a comparison between our most recent version and the prior quarterly release. More comparison features will be added as we have more versions to compare.
(1) This rule applies only to providers seeking reimbursement from the Division, except as otherwise provided in OAR 410-120-1295.
(2) Only Educational Agency (EA) providers of SBHS that meet the criteria for the provision of special education programs approved by the State Superintendent of Public Instruction qualifying such programs for state reimbursement under OAR 581-015-2005 will be enrolled with the Division as school medical (SM) providers allowed to seek reimbursement for the provision of covered health services pursuant to a Medicaid eligible child's Individualized Education Program (IEP) or Individualized Family Service Plan (IFSP).
(3) The provider enrollment process will consist of: The completion and submission of the School Medical (SM) provider enrollment application and the required attachments, disclosure documents, and provider agreement with the Division of Medical Assistance Programs.
(4) An approved enrollment application by the Division or the Authority unit responsible for enrolling the SM provider is a contractual agreement that binds the SM provider to comply with the Authority administrative rules OAR 943-120-0300 through 943-120-0380, the Division General Rules 410-120-1260 and School-Based Health Services (SBHS) rules.
(5) Signing the SM provider agreement enclosed in the application package constitutes agreement by performing, and billing providers for provision of SBHS to comply with all applicable rules of the Medical Assistance Program and federal and state laws and regulations.
(6) An SM provider is a performing provider. A performing provider is the provider of a service or item. A billing provider is an individual, agent, business, corporation, clinic, group, institution, or other entity who in connection with the submission of claims to the Authority, receives or directs the payment (either in the name of the performing provider or the name of the billing provider) from the Authority, on behalf of a performing provider and has been delegated the authority to obligate or act on behalf of the performing provider (See OAR 410-120-1260):
(a) A billing provider is responsible for identifying to the Division and keeping current the identification of all performing providers for whom they bill, or receive or direct payments. This identification must include the providers' names, Authority provider numbers, NPIs, and either the performing provider's Social Security Number (SSN) or Employer Identification Number (EIN). The SSN or EIN of the performing provider cannot be the same as the Tax Identification Number (TIN) of the billing provider. In order to facilitate timely claims processing and claims payment consistent with applicable privacy and security requirements, the Authority requires billing providers to be enrolled consistent with the provider enrollment process described in OAR 410-120-1260(7);
(b) If the SM performing provider uses electronic media to conduct transactions with the Authority, or authorizes a billing provider to conduct such electronic transactions, the SM performing provider must comply with the Electronic Data Interchange (EDI). Enrollment as a SM performing provider or billing provider is a necessary requirement for submitting electronic claims, but the provider must also register as a trading partner and identify the EDI Submitter;
(c) A school medical (SM) performing provider that uses electronic media to conduct transaction with the Authority or authorizes a billing provider to conduct such electronic transactions, must comply with the electronic data interchange (EDI). Enrollment as an SM performing provider or billing provider is a necessary requirement for submitting electronic claims. If the SM provider intends to use an electronic data interchange (EDI) submitter, the SM performing provider must register with the Authority as a trading partner and shall complete the "Trading Partner Authorization of EDI Submitter" and the EDI submitter information required in the application in compliance with the trading partner requirements of identifying the authority of the EDI submitter to submit claims on its behalf. The EDI submitter must sign the EDI certification and meet other Authority EDI submission requirements pursuant to the EDI rules, before the Authority may accept an electronic submission from the EDI submitter on behalf of the performing provider. Information about the EDI transaction requirements is available on the Authority's web site.
(7) To be enrolled and able to bill as an SM provider, an EA, must meet applicable licensing and regulatory requirements set forth by federal and state statutes, regulations, and rules and must comply with all Oregon statutes and regulations for provision of Medicaid and State Children's Health Insurance program (SCHIP) services. In addition, all providers of services within the State of Oregon must have a valid Oregon business license if such a license is a requirement of the state, federal, county or city government to operate a business or to provide services.
(8) An EA, individual, or organization that is currently subject to sanction by the Medical Assistance Program or Federal government is not eligible for enrollment.
(9) The Authority requires compliance with the National Provider Identification (NPI) requirements in 45 CFR Part 142. Providers that obtain an NPI should update their records with the Division Provider Enrollment. Provider applicants that have been issued an NPI must include that NPI number with the Division provider enrollment application.
(10) A performing provider number will be issued to an EA providing covered health care services or items upon:
(a) Completion of the application and submission of the required School-Based Health Services SM Provider Attachment, disclosure documents, and provider agreement;
(b) The signing of the SM provider application by the authorized representative for the EA to bind the EA SM provider to compliance with these rules;
(c) Verification of licensing or certification. Loss of the appropriate licensure or certification or failure to meet the criteria for the provision of special education programs approved by the State Superintendent of Public Instruction qualifying such programs for state reimbursement under OAR 581-015-2005 will result in immediate dis-enrollment of the provider and recovery of payments made subsequent to the loss of licensure or certification;
(d) Approval of the application and required documentation for an SM provider by the Division or the Division responsible for enrolling the provider.
(11) An SM performing provider may be enrolled retroactive to the date services were provided to a medical assistance client/child if:
(a) The SM provider met the criteria for the provision of special education programs approved by the State Superintendent of Public Instruction qualifying such programs for state reimbursement under OAR 581-015-2005, was appropriately licensed, certified, and otherwise met all Medical Assistance Program requirements at the time services were provided; and
(b) Services were provided less than 12 months prior to the date of application for medical assistance provider status as evidenced by the first date stamped on the paper claims(s) submitted with application materials for those services either manually or electronically; or
(c) Extenuating circumstances existed outside the control of the EA SM provider consistent with federal Medicaid regulations, with approval of the Division's Provider Services Unit Manager.
(12) Issuance of an Authority-assigned SM provider number establishes enrollment of an EA as a provider for limited categories of services for the Medical Assistance Program applicable to the provision of Medicaid covered School-Based Health Services (SBHS).
(13) An SM provider is required for providing and continuing to provide to the Authority accurate, complete and truthful information regarding their qualification for enrollment. The SM provider is responsible for notifying the Division in writing of a material change in any status or condition that relates to their qualifications or eligibility to provide SBHS including but not limited to change in any of the following information: changes address, business affiliation, licensure, ownership, certification, NPI, billing agents or Federal Tax Identification Number (TIN), change in status for meeting the criteria for the provision of special education programs approved by the State Superintendent of Public Instruction qualifying the EA's programs for state reimbursement under OAR 581-015-2005, if the SM provider or a person with an ownership or control interest, or an agent or managing employee of the SM provider has been convicted of a criminal offense related to that person's involvement in any program under Medicare, Medicaid, or Title XX services program, the SM provider must notify the Division in writing within 30 calendar days of the change:
(a) Failure to notify the Division of a change of federal tax identification number (TIN) may result in the imposing of a $50 fine;
(b) Changes in business affiliation, ownership and control of information, criminal convictions, NPI, or federal tax identification number may require the submission of a new application;
(c) Payments made to providers who have not furnished such notification as required by this rule or to a provider that has failed to submit a new application as required by this rule and OAR 410-120-1260 may be denied or recovered.
(14) For information regarding enrollment of Billing Providers (BP) and issuance of an Authority assigned BP Provider ID in compliance with Provider Rules see OAR 943-120-0300 through 943-120-1505, 410-120-1260 and 943-120-0100 through 943-120-0200.
(15) Provider termination:
(a) The SM provider may terminate enrollment at any time. The request must be in writing, via certified mail, return receipt requested. The notice shall specify the provider number to be terminated and the effective date of termination. Termination of the SM provider enrollment does not terminate any obligations of the SM provider for dates of services during which the enrollment was in effect;
(b) The Division provider terminations or suspensions may be for, but are not limited to the following:
(A) Breaches of provider agreement;
(B) Failure to comply with the statutes, regulations and policies of the Authority, Federal and State regulations that are applicable to the provider;
(C) When no claims have been submitted in an 18-month period. The provider must reapply for enrollment.
(16) When one or more of the requirements governing a provider's participation in the medical assistance program are no longer met, the provider's medical assistance program provider number may be immediately suspended. The provider is entitled to a contested case hearing as outlined in 410-120-1600 to determine whether the provider's medical assistance program number will be revoked.
Notes
Stat. Auth.: ORS 413.042 & 414.065
Stats. Implemented: ORS 413.042 & 414.065