Or. Admin. Code § 333-004-3160 - Reproductive Health Access Fund Reviews and Audits

(1) A Reproductive Health Program (RH Program) staff person, contractor, or auditor may review enrollment form documents to determine compliance with client eligibility and enrollment requirements.

(2) A RH Program staff person, contractor, or auditor may review a claim for assurance that:

(a) Specific medical services, drugs, devices, or supplies were provided to enrollees by an agency in accordance with OAR 333-004-3090 (Client Eligibility for the RH Access Fund); and

(b) The services, drugs, devices, or supplies were provided in accordance with RH Program rules.

(3) To determine the number of inappropriate claims, and subsequently the overpayment amount, the RH Program may review a statistically valid random sample of claims with sufficient sample size for a confidence interval of 95 percent.

(4) The RH Program may deny payment or seek recovery of payment if a review or audit determines the visit does not include a covered services(s) referred to in OAR 333-004-3200 (Grounds for Agency Sanctions; Sanctions).

(5) The RH Program may deny payment or seek recovery of payment if a review or audit determines non-compliance with enrollment requirements.

(6) The RH Program shall notify the agency, in writing, of the improper billing findings and subsequent actions to be taken by the agency to correct the identified findings and any sanctions that may be imposed by the RH Program.

Notes

Or. Admin. Code § 333-004-3160

PH 84-2020, adopt filed 12/18/2020, effective 1/1/2021; PH 191-2022, minor correction filed 09/07/2022, effective 9/7/2022; PH 117-2024, amend filed 12/13/2024, effective 1/1/2025

Statutory/Other Authority: ORS 413.042, ORS 414.432, ORS 431.147, ORS 431.149, ORS 435.205 & ORS 435.230

Statutes/Other Implemented: ORS 414.432, ORS 431.147, ORS 413.032, ORS 435.205 & ORS 435.230