Or. Admin. Code § 943-120-0112 - Scope and Sequence of Electronic Data Transmission Rules
(1) The Authority communicates with
and receives communications from its providers, CCOs, PHPs, and
allied agencies using a variety of methods appropriate to the
services being provided, the nature of the entity providing the
services, and constantly changing technology. These rules describe
some of the basic ways that the Authority will exchange data
electronically. Additional details may be provided in the Authority's
access control rules, provider-specific rules, or the applicable
contract documents.
(2)
Access to eligibility information about covered individuals may occur
using one or more of the following methods:
(a) Automated voice response, via a
telephone;
(b) Web portal
access;
(c) EDI submitter
access; or
(d) Point of
sale (POS) for pharmacy providers.
(3) Claims for which the Authority
is responsible for payment or encounter submissions made to the
Authority may occur using one or more of the following methods:
(a) Paper, using the form specified
in the provider specific rules and supplemental billing guidance.
Providers may submit paper claims, except that pharmacy providers are
required to use the POS process for claims submission, and CCOs and
PHPs must use the 837 electronic formats;
(b) Web portal access;
(c) EDI submitter access;
or
(d) POS for pharmacy
providers.
(4)
Authority informational updates, provider record updates, depository
for CCO or PHP reports, or EDT as specified by the Authority for
contract compliance.
(5)
Other Authority network and information system access is governed by
specific program requirements, which may include but is not limited
to IUP access. Affected providers, CCOs, PHPs, and allied agencies
shall be separately instructed about the access and requirements.
Incidents are subject to these rules.
(6) Providers and allied agencies
that continue to use only paper formats for claims transactions are
only subject to the confidentiality and security rule, OAR
943-120-0170.
Notes
Stat. Auth.: ORS 413.042 &414.065
Stats. Implemented: ORS 413.042 & 414.065
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