Or. Admin. Code § 410-147-0080 - Prepaid Health Plans (PHPs)
(1)
Most Oregon Health Plan (OHP) clients have prepaid health services, contracted
for by the Oregon Health Authority (Authority) through enrollment in a Prepaid
Health Plan (PHP). Clinics serving eligible OHP clients who are enrolled in a
PHP must secure authorization from the PHP prior to providing PHP-covered
services or case management services. Federally Qualified Health Centers (FQHC)
and Rural Health Clinics (RHC) must request an authorization or referral from
the PHP before providing any services to clients enrolled in a PHP unless the
FQHC or RHC have contracted with the PHP to provide PHP-covered services. If an
FQHC or RHC has an arrangement or contract with a PHP, the clinic is
responsible to follow PHP rules and prior authorization requirements. See OAR
410 division 141 for OHP Program Rules and;
410-147-0060, Prior
Authorization.
(2) The Division of
Medical Assistance Programs (DMAP) encourages FQHCs and RHCs to contact each
PHP in their local service area for the purpose of requesting inclusion in
their panel of providers.
(3) PHPs
contracting with FQHCs or RHCs, for the provision of providing services to
their members, are required by
42 USC
1396 b(m)(2)(A)(ix) to provide payment to the
FQHC or RHC that is not less than the level and amount of payment which the PHP
would make for services furnished by a non-FQHC/RHC provider.
(4) Payment for services provided to
PHP-enrolled clients (PHP members) is a matter between the FQHC or RHC and the
PHP authorizing the services except as otherwise provided in OAR
410-141-0410, OHP Primary Care
Managers. If a PHP denies payment to an FQHC or RHC because arrangements were
not made with the PHP prior to providing the service, the Division will not
reimburse the FQHC or RHC under the encounter rate, except as outlined in
Section (5) of this rule (see OAR
410-141-0120, OHP PHP Provision
of Health Care Services).
(5) FQHCs
and RHCs can provide family planning services or HIV/AIDS prevention services
to eligible PHP members without authorization or a referral from the PHP. The
FQHC and RHC must bill the PHP first. If the PHP will not reimburse for the
service, then the clinic may bill DMAP. Refer to ORS
414.153, Authorization for
payment for certain point of contact services.
(6) PHPs will execute agreements with
publicly funded providers, unless cause can be demonstrated to DMAP's
satisfaction why such an agreement is not feasible for authorization of payment
for point of contact services in the following categories (refer to ORS
414.153):
(a) Immunizations;
(b) Sexually transmitted diseases;
and
(c) Other communicable
diseases.
(7) PHPs are
responsible to ensure the provision of qualified sign language and oral
interpreter services for covered medical, mental health or dental care visits,
for their enrolled PHP Members with a hearing impairment or who are non-English
speaking. Services must be sufficient for the FQHC or RHC provider to be able
to understand the PHP Member's complaint; to make a diagnosis; respond to the
PHP Member's questions and concerns; and to communicate instructions to the PHP
Member. See OAR 410-141-0220(7),
Oregon Health Plan Prepaid Health Plan Accessibility.
(8) The provider assumes full financial risk
in serving a person not confirmed by DMAP as eligible on the date(s) of
service. It is the responsibility of the provider to verify a client's
eligibility. Refer to OAR
410-120-1140 Verification of
Eligibility:
(a) That the individual
receiving medical services is eligible on the date of service for the service
provided;
(b) Whether an OHP client
receives services on a fee-for-service (open card) basis or is enrolled with a
PHP; and
(c) Whether the service is
covered by a third party resource (TPR), a PHP, or if DMAP reimburses on a
fee-for-service basis.
(9) DMAP requires the following of a FQHC or
RHC under contract with a PHP:
(a) Clinic
must maintain reimbursement and documentation records that will permit
calculation of supplemental payments according to OAR
410-147-0460. According to OAR
410-141-0180, Oregon Health Plan
Prepaid Health Plan Record Keeping, a PHP's participating providers shall
maintain a clinical record keeping system with sufficient detail and clarity to
permit internal and external clinical audit to validate encounter submissions
and to assure Medically Appropriate services are provided consistent with the
documented needs of the PHP Member. See also OAR
410-120-1360, Requirements for
Financial, Clinical and Other Records;
(b) Clinics are subject to ongoing
performance review by the PHP. According to OAR
410-141-0200, Oregon Health Plan
Prepaid Health Plan Quality Improvement (QI) System, PHPs must maintain an
effective process for monitoring, evaluating, and improving the access, quality
and appropriateness of services provided to DMAP Members. The QI program must
include QI projects that are designed to improve the access, quality and
utilization of services;
(c)
Clinics are subject to program review by the Division, the Authority's Audit
Unit, and the Department of Justice Medicaid Fraud Unit for the purposes of
assuring program integrity and:
(A)
Compliance with Oregon Revised Statutes, Oregon Administrative Rules and
Federal laws and regulations;
(B)
Use of accurate and complete encounter and fee-for-service claims data, and
supporting clinical documentation, for calculating PHP supplemental payments
and compensation for out-stationed outreach workers;
(C) Adequate records maintenance for cost
reimbursed services to thoroughly explain how the amounts reported on the cost
statement were determined. The records must be accurate and in sufficient
detail to substantiate the data reported.
Notes
Stat. Auth.: ORS 413.042 & 414.065
Stats. Implemented: ORS 414.065
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