Or. Admin. R. 411-370-0020 - Provider Requirements
(1) These
rules cover all programs and services of the Department's community services
programs for recipients with developmental disabilities (hereinafter referred
to as community services programs). All providers seeking payment from the
Department for the provision of covered services to eligible service recipients
of community services programs must comply with these rules and the applicable
rules, standards, and procedures of the specific programs or services defined
as community services programs in OAR
411-370-0010.
(2) COVERED PROVIDER AGREEMENTS. Agreements
with providers for community services programs may include:
(a) Direct contracts with the Department;
(b) Contracts with Department
designees, including CDDPs; or
(c)
Provider enrollment agreements with the Department.
(3) Covered services paid for with state,
Medicaid (Title XIX), or other funds by the Department for community services
programs are also subject to federal and state Medicaid rules and requirements.
In interpreting these rules and program-specific rules, the Department shall
construe them as much as possible in a manner that shall comply with federal
and state laws and regulations, and the terms and conditions of federal waivers
and the state plans.
(4) A
provider paid with state or Medicaid funds for community services programs must
comply with all applicable federal and state laws and regulations pertaining to
the provision of Medicaid services under the Medicaid Act, Title XIX, 42 United
States Code (USC) 1396 et seq.
(5)
Payment for any service by a provider of community services programs may not be
made by or through (directly or by power of attorney) any individual or
organization, such as a collection agency or service bureau, that advances
money to a provider for accounts receivable that the provider has assigned,
sold, or transferred to the person or organization for an added fee or a
deduction of a portion of the accounts receivable.
(6) The Department shall make community
services programs provider payments to only the following:
(a) The provider who actually performed the
service;
(b) In accordance with a
reassignment from the provider to a government agency or reassignment by a
court order; or
(c) To an enrolled
billing provider, such as a billing service or an accounting firm that, in
connection with the submission of claims, receives or directs payments in the
name of the provider, if the billing provider's compensation for this service
is:
(A) Related to the cost of processing the
billing; and
(B) Not related on
percentage or other basis to the amount that is billed or collected and not
dependent upon the collection of the payment.
(7) Providers must comply with TPR
requirements in Department policies, program-specific rules, provider
enrollment agreements, or contracts.
(8) PROGRAM INTEGRITY.
(a) The Department shall use several
approaches to promote integrity of the community services programs. This
section of the rule describes integrity actions related to:
(A) Provider billings and payments, including
actions and expectations contained within service element standards and
procedures, program-specific rules, or contracts with Department
representatives including CDDPs or brokerages. The program integrity goal is to
pay the correct amount to a properly enrolled provider for covered services
provided to an eligible recipient according to these rules and the
program-specific services in effect on the date of the service; and
(B) Provider performance in the delivery of
services to recipients as well as general program practices. The program
integrity goal includes approaches to assure the provision of appropriate
services for which payment is to be made as well as compliance with these
rules, service element standards and procedures, program-specific rules,
provider enrollment agreements, or contracts.
(b) Program integrity activities include but
are not limited to the following:
(A) Review,
including but not limited to the evaluation of services in accordance with
appropriate service or process, error identification, and prior authorization
processes including all actions taken to determine the provision of services in
accordance with service element standards and procedures, program-specific
rules, provider enrollment agreements, or contract;
(B) Onsite visits to verify compliance with
service element standards and procedures, program-specific rules, provider
enrollment agreements, or contracts;
(C) Quality improvement activities;
(D) Coordination with the
Department of Justice MFCU and other oversight authorities including law
enforcement; and
(E) For provider
billings and payments:
(i) Implementation of
transaction standards to improve accuracy and timeliness of claims processing;
(ii) Cost report settlement
processes;
(iii) Audits; and
(iv) Investigation of false
claims, fraud, or prohibited business relationships.
(F) For provider service delivery:
(i) Provider licensing or certification
required responsibilities and activities; and
(ii) Specific service monitoring and
evaluation activities provided in program-specific rules or Department policy.
(c) The
following may engage in program integrity activities including but not limited
to general monitoring of the provider's performance in service delivery,
reviewing a request for services, or auditing a claim of services, before or
after payment, for assurance that the specific care or service was provided in
accordance with the program-specific rules and the generally accepted standards
of performance:
(A) Department staff or
designees, including staff of a CDDP or brokerage; and
(B) Federal or state oversight authority.
(d) Payment may be
denied or may be subject to recovery if the review or audit determines the
service was not provided in accordance with provider rules, program-specific
rules, provider enrollment agreements or contracts, or does not meet the
criteria for quality or appropriateness of the service or payment.
(e) If the Department or other federal or
state oversight authorities determine that an overpayment has been made to a
provider, the amount of overpayment is subject to recovery.
(f) The provider may face other sanctions or
penalties, including termination of provider enrollment agreements or contracts
as allowed by program-specific or Department rules.
(g) The Department may communicate with and
coordinate any program integrity actions with the MFCU, USDHHS, other federal
or state oversight authorities including law enforcement, or Department
designees including CDDPs and brokerages.
Notes
Stat. Auth.: ORS 409.050, 410.070, 411.060 & 430.640
Stats. Implemented: ORS 427.005, 427.007, 430.215, 430.610 to 430.695 & 443.400 to 443.455
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