Or. Admin. R. 410-123-1000 - Eligibility, Services Reviewed by the Division, Billing and the Dental Billing Invoice

Current through Register Vol. 60, No. 12, December 1, 2021

(1) Eligibility:

(a) Providers are responsible for verification of client eligibility and must do so before providing any service or billing the Oregon Health Authority, Health Systems Division (Division) or any Oregon Health Plan (OHP) Managed Care Entitiy (MCE);

(b) The Division may not pay for services provided to an ineligible client even if services were authorized. Refer to General Rules OAR 410-120-1140 (Verification of Eligibility) for details.

(2) Services Reviewed by the Health Services Division (Division):

(a) Services requiring prior authorization (PA): See OAR 410-123-1160 and 410-120-1320 for information about services that require PA or how to request PA.

(b) By Report Procedures:

(A) Request for payment for dental services listed as "by report" (BR) must be submitted with a full description of the procedure, including relevant operative or clinical history reports and/or radiographs. Payment for BR procedures will be approved in consultation with a Division dental consultant;

(B) Refer to the "Covered and Non-Covered Dental Services" data base, as referenced in OAR 410-123-1260, for a list of procedures noted as BR. See OAR 410-123-1220.

(3) Billing:

(a) Providers must follow the Division rules in effect on the date of service. All Division rules are intended to be used in conjunction with the Division's General Rules Program (chapter 410, division 120), the OHP Administrative Rules (chapter 410, division 141), Pharmaceutical Services Rules (chapter 410, division 121) and other relevant Division OARs applicable to the service provided, where the service is delivered, and the qualifications of the person providing the service including the requirement for a current signed provider enrollment agreement;

(b) Providers must comply with OAR 410-120-1280 Billing rules and OAR 410-120-1360 requirements to develop and maintain adequate financial and clinical records and other documentation that supports the specific care, items, or services for which payment has been requested;

(A) Authority will only pay for services that are adequately documented.

(B) Documentation must support the dates of service, the amounts billed, the specific services provided, who provided the services, and the medical necessity of those services.

(C) Financial records must indicate that the amount billed to the Authority was appropriate and that all other resources were pursued before billing the Authority.

(D) FFS providers must keep clinical information on file for seven years, and financial records five years. Providers contracted with an MCE must retain all clinical records for a minimum of ten (10) years after the date of services for which claims are made, OAR 410-141-3520. If an audit, litigation, research and evaluation, or other action involving the records is started before the end of the retention period, the clinical records must be retained until all issues arising out of the action are resolved.

(c) Third Party Resources: A third party resource (TPR) is an alternate insurance resource, other than the Division, available to pay for medical/dental services and items on behalf of OHP clients. Any alternate insurance resource must be billed before the Division or any OHP MCE can be billed. Indian Health Services or Tribal facilities are not considered to be a TPR pursuant to the Division's General Rules Program rule 410-120-1280;

(d) For Medicaid covered services, the provider must not:

(A) Bill the Authority more than the provider's usual charge (see definitions) or the reimbursement specified in the applicable Authority program rules;

(B) Bill the client for missed appointments. A missed appointment is not considered to be a distinct Medicaid service by the federal government and as such is not billable to the client or the Authority;

(C) Bill the client for services or treatments that have been denied due to provider error (e.g., required documentation not submitted, prior authorization not obtained, etc.);

(e) For Non-covered services: Before the provider provides the non-covered service, the client must sign the provider-completed Agreement to Pay (OHP 3165) in Table 3165 of OAR 410-120-1280 Billing rule. The completed OHP 3165 is valid only if dated and signed by the client prior to service(s) being delivered, the estimated fee does not change, and the service is scheduled within 30 days of the client's signature. Providers must make a copy of the completed OHP 3165 form available to the Authority or MCE upon request;

(f) Co-payments for OHP clients may be required for certain services. See General Rules OAR 410-120-1230 for specific information on co-pays;

(g) Refer to OAR 410-123-1160 for information regarding dental services requiring prior authorization (PA);

(h) The client's records must include documentation to support the appropriateness of the service and level of care rendered;

(i) The Division shall only reimburse for dental services that are dentally appropriate as defined in OAR 410-123-1060;

(j) Refer to OAR chapter 410, division 147 for information about reimbursement for dental services provided through a Federally Qualified Health Center (FQHC) or Rural Health Center (RHC);

(k) Treatment Plans: Being consistent with established dental office protocol and the standard of care within the community, scheduling of appointments is at the discretion of the dentist. The agreed upon treatment plan established by the dentist and patient shall establish appointment sequencing. Eligibility for medical assistance programs does not entitle a client to any services or consideration not provided to all clients.

(4) Billing Invoice:

(a) Providers: Refer to the Dental Services Provider Guide for information regarding claims submissions and billing information.

(b) Providers billing dental services on paper must use the 2019 version of the American Dental Association (ADA) claim form.

(c) Submission of electronic claims directly or through an agent must comply with the Electronic Data Interchange (EDI) rules. OAR 943-120-0100 et seq.

(d) Specific information regarding Health Insurance Portability and Accountability Act (HIPAA) requirements can be found on the Division Web site.

(e) Providers will not include any client co-payments on the claim when billing for dental services.

(f) Upon submission of a claim to the Authority for payment, the provider agrees that it has complied with all Authority program rules and understands that payment of the claim will be from federal and state funds, and that any falsification, or concealment of material fact, may be prosecuted under federal and state laws. Submission of a claim or encounter does not relieve the provider from the requirement of a signed provider enrollment agreement.

(5) A provider enrolled with the Authority must bill using the Authority assigned provider number, or the National Provider Identification (NPI) number, pursuant to OAR 410-120-1260;

(6) Unless otherwise specified, claims must be submitted after:

(a) Delivery of service; or

(b) Dispensing, shipment or mailing of the item.

(7) The provider must submit true, accurate and complete information when billing the Division. Use of a billing provider does not abrogate the performing provider's responsibility for the truth and accuracy of submitted information;

(a) A claim is considered a valid claim only if it contains all data required for processing. See the appropriate provider rules and supplemental information for specific instructions and requirements;

(b) A provider or its contracted agency, including billing providers, may not submit or cause to be submitted:

(A) Any false claim for payment;

(B) Any claim altered in such a way as to result in a payment for a service that has already been paid;

(C) Any claim upon which payment has been made or is expected to be made by another source until after the other source has been billed, with the exception of OAR 410-120-1280(10)(c)(A-D). If the other source denies the claim or pays less than the Medicaid allowable amount, a claim may be submitted to the Authority. Any amount paid by the other source must be clearly entered on the claim form and must include the appropriate TPR Explanation Code in box 9 of the appropriate claim form or in the appropriate field if electronically submitted in a manner authorized;

(D) Any claim for furnishing specific care, items, or services that has not been provided;

(E) Any claim for specific care, items or services that is not supported by the documentation, the member's treatment or care plan, as applicable, and compliant with program specific rules. All documentation must be complete and signed by the rendering provider prior to submitting a claim the Authority or MCE for payment.

(c) If an overpayment has been made by the Authority, the provider is required to do one of the following within 30 calendar days of the date on which the overpayment was identified:

(A) Adjust the original claim to show the overpayment as a credit in the appropriate field; or

(B) Submit an Individual Adjustment Request (OHP 1036); or

(C) Adjust the claim on the Provider Web Portal available online at all times at: https://www.or-medicaid.gov; or

(D) Refund the amount of the overpayment on any claim; or

(E) Void the claim via the Provider Web Portal if the Authority overpaid due to erroneous billing;

(F) If the overpayment occurred because of a payment from a third party payer refer to OAR 410-120-1280(10)(f) Billing rule.

(8) Procedure code requirement:

(a) For claims requiring a procedure code the provider must bill as instructed in the appropriate Authority program rules and must use the appropriate HIPAA procedure code set such as CPT, HCPCS, ICD-10-PCS, ADA CDT, NDC, established according to 45 CFR 162.1000 to 162.1011, which best describes the specific service or item provided;

(b) For claims that require the listing of a procedure code as a condition of payment, the reported procedure code must be supported by the client's medical record and the codes that most accurately describes the services provided. All providers, including Hospitals, billing the Authority must follow national coding guidelines;

(c) When there is no appropriate descriptive procedure code to bill the Authority, the provider must use the code for "unlisted services." A complete and accurate description of the specific care, item, or service must be documented on the claim;

(d) Where there is one CPT, CDT, or HCPCS code that according to CPT, CDT, and HCPCS coding guidelines or standards describes an array of services, the provider must bill the Authority using that code rather than itemizing the services under multiple codes. Providers may not "unbundle" services.

Notes

Or. Admin. R. 410-123-1000

HR 3-1994, f. & cert. ef. 2-1-94; HR 20-1995, f. 9-29-95, cert. ef. 10-1-95; OMAP 13-1998(Temp), f. & cert. ef. 5-1-98 thru 9-1-98; OMAP 28-1998, f. & cert. ef. 9-1-98; OMAP 23-1999, f. & cert. ef. 4-30-99; OMAP 17-2000, f. 9-28-00, cert. ef. 10-1-00; OMAP 48-2002, f. & cert. ef. 10-1-02; OMAP 65-2003, f. 9-10-03 cert. ef. 10-1-03; DMAP 25-2007, f. 12-11-07, cert, ef. 1-1-08; DMAP 18-2008, f. 6-13-08, cert. ef. 7-1-08; DMAP 41-2009, f. 12-15-09, cert. ef. 1-1-10; DMAP 14-2010, f. 6-10-10, cert. ef. 7-1-10; DMAP 31-2010, f. 12-15-10, cert. ef. 1-1-11; DMAP 45-2011, f. 12-21-11, cert. ef. 12-23-11; DMAP 46-2011, f. 12-23-11, cert. ef. 1-1-12; DMAP 61-2020, amend filed 12/11/2020, effective 1/1/2021

Statutory/Other Authority: ORS 413.042 & ORS 414.065

Statutes/Other Implemented: ORS 414.065