Or. Admin. Code § 410-120-1285 - Recoupment and Data Sharing with Third-Party Insurers

(1) The Oregon Health Authority (Authority) delegates to the Department of Human Services (Department), Office of Payment Accuracy and Recovery (OPAR) authority to administer Third-Party Liability programs required by federal law to reduce medical expenditures. This includes the following programs:

(a) The Data Match Unit;

(b) The Health Insurance Group;

(c) The Medical Payment Recovery Unit; and

(d) The Personal Injury Liens Unit.

(2) For this rule, an "insurer" means an employee benefit plan, self-insured plan, managed care organization or group health plan, a third-party administrator, fiscal intermediary or pharmacy benefit manager of the plan or organization, or other party that is by statute, contract, or agreement legally responsible for payment of a claim for a health care item or service.

(3) "OPAR" means the Office of Payment Accuracy and Recovery, Department of Human Services, and subunits.

(4) For this rule "subscriber" means an individual who is eligible for coverage on their behalf and not because of dependent status.

(5) An insurer shall provide to OPAR, a CCO, or a Managed Care Organization, upon request, within 30 calendar days, the following information:

(a) The period during which a recipient, a spouse, partner or dependents are covered by the insurer;

(b) The nature of coverage that is provided by the insurer; for example, medical, prescription drug, dental, vision, motor vehicle personal injury protection, or workers compensation;

(c) The name, claim submission address, and identifying numbers of the plan; for example, group and policy numbers;

(d) The name of the subscriber, if any, and the date of birth and social security number;

(e) The amount of any copay, coinsurance, or deductible required by the insurer.

(6) An insurer may not deny a claim submitted by OPAR, a managed care organization, or a CCO, based on the date of submission of the claim, the type or format of the claim form, or a failure to present proper documentation at the point of sale that is the basis of the claim if:

(a) The claim is submitted within the three-year period beginning on the date on which the health care item or service was furnished; and

(b) Any action to enforce the claim is commenced within six years of submission of the claim.

(7) If an insurer denies a claim or does not pay the claim in full, the insurer shall provide a detailed explanation for its action, including citation to applicable contractual or statutory authority for the action. If the insurer cites a contractual provision, the insurer shall provide a copy of the applicable contractual provision on request.

(8) An insurer, when requested by OPAR, shall provide OPAR an electronic file of all insured or subscribed individuals residing in Oregon to assist OPAR to do a data match with recipient records to determine if any Medicaid recipient has coverage through the insurer. The electronic file shall be delivered to OPAR every 30 days, unless otherwise agreed. The Authority may enter into a trading partner agreement with the insurer to permit the exchange of information via "ASC X 12N 270/271 Health Benefit Inquiry and Response" transactions or other HIPAA compliant secure transaction methods in the event 270/271 transactions are not available. The insurer shall include the following information in the electronic file:

(a) The period during which a subscriber or insured, the spouse, partner or dependents are covered by the plan;

(b) The nature of coverage that is provided by the plan; for example, medical, prescription, dental, vision, or automotive personal injury protection, and workers compensation;

(c) The name, claim submission address, and identifying numbers of the plan; for example, group and policy numbers;

(d) The name of the subscriber, if any, and date of birth and social security number;

(e) The amount of any copay, coinsurance, or deductible required by the insurer.

(9) An insurer may not charge a fee for sharing data with the Authority, OPAR, a managed care organization, or CCO or for processing claims submitted by OPAR, a managed care organization, or a CCO.

(10) In the event a claim submitted to an insurer by OPAR, a managed care organization, or a CCO is paid all or in part to a third party, the insurer shall within 14 calendar days give the name and address of the payee, the check number, date and amount of the check or electronic payment, and a copy of the check or electronic payment to the claimant on request.

Notes

Or. Admin. Code § 410-120-1285

DMAP 48-2019, adopt filed 11/25/2019, effective 1/1/2020; DMAP 22-2023, minor correction filed 03/31/2023, effective 3/31/2023; DMAP 131-2024, amend filed 10/30/2024, effective 11/10/2024

Statutory/Other Authority: ORS 413.042, 413.085, 414.685, 42 USC § 1396a(a)(25) & (45), 42 USC § 1396k, 42 CFR §§ 433.135 to 433.139, 42 CFR §§ 433.145 to 433.146 & Oregon Medicaid State Plan Attachment 4.22-A(3) & (7)

Statutes/Other Implemented: ORS 414.685, 659.830 & 743B.470