Or. Admin. R. 411-323-0065 - Payment to Agency Providers

(1) Authorization for payment in the appropriate electronic payment system must occur prior to the delivery of services
(2) Payment is made after services are delivered.
(3) For a service to be eligible for payment it must be included on a written agreement that specifies, at a minimum, the type and amount of services to be delivered. The written agreement must be signed by the provider and may be:
(a) The individual ISP; or
(b) A service agreement specific to the individual.
(4) A provider must request payment authorization from the case management entity for services provided during an unforeseeable emergency on the first business day following the emergency service. A case manager must determine if the service is eligible for payment.
(5) Travel time of the provider to reach the setting where services are delivered, when not directly providing services to the individual, is not reimbursable.
(6) Payment by the Department for a service is considered full payment for the services rendered under Medicaid. A provider may not demand or receive additional payment for services rendered under Medicaid from the individual, parent, guardian, or any other source, under any circumstances.
(7) Medicaid funds are the payer of last resort. A provider must bill all third party resources until all third party resources are exhausted.
(8) The Department reserves the right to make a claim against any third party payer before or after making payment to the provider.
(9) Upon submission of a request for payment, a provider must comply with:
(a) All applicable rules in OAR chapter 407 and OAR chapter 411;
(b) 45 CFR Part 84 which implements Title V, Section 504 of the Rehabilitation Act of 1973 as amended;
(c) Title II and Title III of the Americans with Disabilities Act of 1991; and
(d) Title VI of the Civil Rights Act of 1964.
(10) All billings must be for services provided within the licensure and certification of the provider.
(11) The provider must submit true and accurate information with request for payment.
(12) An agency may not submit the following to the Department:
(a) A false request for payment;
(b) A request for payment that has been, or is expected to be, paid by another source; or
(c) Any request for payment for services that have not been provided.
(13) The Department only makes payment to an enrolled provider who actually performs the services or the enrolled provider organization. Federal regulations prohibit the Department from making payment to a collection agency.
(14) Payment is denied if any provisions of these rules, the rules in OAR chapter 411, division 004, or the associated program rules are not complied with.
(15) The Department may recoup overpayments as described in OAR 407-120.
(16) In order to be eligible for payment, requests for payments must be submitted to the Department within 12 months of the delivery of services.


Or. Admin. R. 411-323-0065
APD 25-2016, f. & cert. ef. 6/29/2016

Stat. Auth.: ORS 409.050

Stats. Implemented: ORS 427.005, 427.007, 430.215

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