Or. Admin. Code § 407-120-0310 - Provider Requirements
(1) Scope
of Rule. All providers seeking reimbursement from the Department, a PHP, or a
county pursuant to a county agreement with the Department for the provision of
covered services or items to eligible recipients, must comply with these rules,
OAR 407-120-0300 to
407-120-0400, and the applicable
rules or contracts of the specific programs described below:
(a) Programs administered by DMAP including
the OHP and the medical assistance program that reimburses providers for
services or items provided to eligible recipients, including but not limited to
chapter 410, division 120; chapter 410, division 141; and provider rules in
chapter 410 applicable to the provider's service category;
(b) Programs administered by AMH that
reimburse providers for services or items provided to eligible AMH recipients;
or
(c) Programs administered by SPD
that reimburse providers for services or items provided to eligible SPD
recipients.
(2) Visit
Data. Department programs use visit data to monitor service delivery, planning,
and quality improvement activities. Visit data is required to be submitted by a
program-specific rule or contract. A provider is required to make accurate,
complete, and timely submission of visit data. Visit data is not a HIPAA
transaction and does not constitute a claim for reimbursement.
(3) CHIP and Medicaid-Funded Covered Services
and Items.
(a) Covered services or items paid
for with Medicaid (Title XIX) and CHIP (Title XXI) funds (referred to as the
medical assistance program) are also subject to federal and state Medicaid
rules and requirements. In interpreting these rules and program-specific rules
or contracts, the Department shall construe them as much as possible in a
manner that shall comply with federal and state medical assistance program laws
and regulations, and the terms and conditions of federal waivers and the state
plans
(b) If a provider is
reimbursed with medical assistance program funds, the provider 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., and CHIP services under Title XXI, including
without limitation:
(A) Maintaining all
records necessary to fully disclose the extent of the services provided to
individuals receiving medical assistance and furnish such information to any
state or federal agency responsible for administration or oversight of the
medical assistance program regarding any payments claimed by an individual or
institution for providing Medicaid services as the state or federal agency may
from time to time request;
(C) Maintaining
written notices and procedures respecting advance directives in compliance with
42 USC
1396(a)(57) and (w),
42 CFR
431.107(b)(4), and 42 CFR
489 subpart I;
(D) Certifying that
the information is true, accurate and complete when submitting claims or PHP
encounters for the provision of medical assistance services or items.
Submission of a claim or PHP encounter constitutes a representation of the
provider's understanding that payment of the claim shall be from federal or
state funds, or both, and that any falsification or concealment of a material
fact may result in prosecution under federal or state laws.
(c) Hospitals, nursing facilities,
home health agencies (including those providing personal care), hospices, and
HMOs must comply with the Patient Self-Determination Act as set forth in
Section 4751 of OBRA 1991. To comply with the obligation under the above-listed
laws to deliver information on the rights of the individual under Oregon law to
make health care decisions, the named providers and organizations must give
capable individuals over the age of 18 a copy of "Your Right to Make Health
Care Decisions in Oregon," copyright 1993, by the Oregon State Bar Health Law
Section. Out-of-state providers of these services should comply with Medicare
and Medicaid regulations in their state. Submittal to the Department of the
appropriate claim form requesting payment for medical services provided to a
Medicaid eligible shall be considered representation to the Department of the
medical provider's compliance with the above-listed laws.
(d) Payment for any service or item furnished
by a provider of CHIP or Medicaid-funded services or items 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 individual or organization for an added fee or a deduction
of a portion of the accounts receivable.
(e) The Department shall make medical
assistance provider payments only to the following:
(A) The provider who actually performed the
service or provided the item;
(B)
In accordance with a reassignment from the provider to a government agency or
reassignment by a court order;
(C)
To the employer of the provider, if the provider is required as a condition of
employment to turn over his or her fees to the employer, and the employer is
enrolled with the Department as a billing provider;
(D) To the facility in which the service is
provided, if the provider has a contract under which the facility submits the
claim, and the facility is enrolled with the Department as a billing
provider;
(E) To a foundation, PHP,
clinic, or similar organization operating as an organized health care delivery
system, if the provider has a contract under which the organization submits the
claim, and the organization is enrolled with the Department as a billing
provider; or
(F) 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:
(i) Related to the cost of processing the
billing;
(ii) Not related on
percentage or other basis to the amount that is billed or collected and not
dependent upon the collection of the payment.
(f) Providers must comply with TPR
requirements in program-specific rules or contracts.
(4) Program Integrity. The Department uses
several approaches to promote program integrity. These rules describe program
integrity actions related to provider payments, including provider
reimbursement under program-specific rules, county agreements, and contracts.
The program integrity goal is to pay the correct amount to a properly enrolled
provider for covered services provided to an eligible client according to the
program-specific coverage criteria in effect on the date of service.
(a) Program integrity activities include but
are not limited to the following:
(A) Medical
or professional review including but not limited to following the evaluation of
care in accordance with evidence-based principles, medical error
identification, and prior authorization processes, including all actions taken
to determine the coverage and appropriateness of services or items in
accordance with program-specific rules or contract;
(B) Provider obligations to submit correct
claims and PHP encounters;
(C)
Onsite visits to verify compliance with standards;
(D) Implementation of HIPAA electronic
transaction standards to improve accuracy and timeliness of claims processing
and encounter reporting;
(E)
Provider credentialing activities;
(F) Accessing federal Department of Health
and Human Services (DHHS) database (exclusions);
(G) Quality improvement activities;
(H) Cost report settlement
processes;
(I) Audits;
(J) Investigation of false claims, fraud or
prohibited kickback relationships; and
(K) Coordination with the Department of
Justice Medicaid Fraud Control Unit (MFCU) and other health oversight
authorities.
(b) The
following individuals may review a request for services or items, or audit a
claim or PHP encounter for care, services, or items, before or after payment,
for assurance that the specific care, item, or service was provided in
accordance with the program-specific and the generally accepted standards of a
provider's field of practice or specialty:
(A) Department staff or designee;
(B) Medical utilization and professional
review contractor;
(C) Dental
utilization and professional review contractor; or
(D) Federal or state oversight
authority.
(c) Payment
may be denied or subject to recovery if the review or audit determines the
care, service, or item was not provided in accordance with provider rules or
does not meet the criteria for quality or medical appropriateness of the care,
service, or item or payment. Related provider and hospital billings shall also
be denied or subject to recovery.
(d) If the Department determines that an
overpayment has been made to a provider, the amount of overpayment is subject
to recovery.
(e) The Department may
communicate with and coordinate any program integrity actions with the MFCU,
DHHS, and other federal and state oversight authorities.
Notes
Publications: Publications referenced are available from the agency.
Stat. Auth.: ORS 409.050, 411.060
Stats. Implemented: ORS 414.115, 414.125, 414.135, 414.1455
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