justicedao/ipfs_state_laws huggingface dataset:
333-010-0060 Cancer Reporting Regulations: Special Studies (1) From time to time, OSCaR may elect to conduct special studies of cancer mortality, morbidity, treatment options and cancer control. OSCaR is specifically authorized to obtain any information which may apply to a patient's reportable cancer or reportable non-malignant condition, and which may be found in the medical record of the patient under ORS 432.510 and 432.520. Upon request, the practitioner or health care facility must provide the requested information to OSCaR or provide OSCaR personnel access to the relevant portions of the medical records. Neither OSCaR nor the record holder shall bill the other for the cost of providing or obtaining this information. (2) If, in the conduct of a special study, OSCaR identifies a need for access to pathological specimens that have been collected in connection with a case, OSCaR must make a written request to the clinical laboratory or the health care facility with which the clinical laboratory is affiliated for the purpose of making arrangements for the procurement of such pathological specimens upon mutually agreeable terms. Statutory/Other Authority: ORS 432.510 & 432.520 Statutes/Other Implemented: ORS 432.510 & 432.520 History: PH 20-2017, amend filed 12/21/2017, effective 01/01/2018 PH 13-2011, f. 12-28-11, cert. ef. 1-1-12 HD 2-1996, f. & cert. ef. 2-29-96
333-010-0070 Cancer Reporting Regulations: Advisory Committee The Authority shall appoint an advisory committee to review the operations of the central registry and to make recommendations regarding registry policy, and to review research protocols for which confidential and privileged data are requested. The composition of the advisory committee must generally represent those with a professional or personal interest in cancer. Statutory/Other Authority: ORS 432.510 & 432.520 Statutes/Other Implemented: ORS 432.510 History: PH 13-2011, f. 12-28-11, cert. ef. 1-1-12 HD 2-1996, f. & cert. ef. 2-29-96
333-010-0080 Cancer Reporting Regulations: Training and Consultation The Authority shall provide annual continuing education for interested persons involved in cancer registry reporting. Continuing education content must include, but is not limited to, cancer diagnosis and management, epidemiology and statistics, and hardware and software registry applications. The central cancer registry staff must supplement the continuing education with one-on-one consultations to assist health care facilities and practitioners as needed in meeting the reporting requirements. Statutory/Other Authority: ORS 432.510 Statutes/Other Implemented: ORS 432.510 History: PH 20-2017, amend filed 12/21/2017, effective 01/01/2018 PH 13-2011, f. 12-28-11, cert. ef. 1-1-12 HD 2-1996, f. & cert. ef. 2-29-96
333-010-0090 Cancer Reporting Regulations: Fees This rule describes the process by which the Authority will calculate the cost of providing cancer reporting services to health care facilities, practitioners or clinical laboratories. For health care facilities, practitioners and clinical laboratories that are not in compliance with cancer reporting requirements, the Authority may elect to provide reporting services at cost. The Authority may also provide reporting services at the option of a health care facility, practitioner or clinical laboratory. (1) The Authority may charge a fee reasonably calculated to reimburse the Authority for the cost of providing cancer reporting services to health care facilities: (a) Costs include but are not limited to the services, supplies and time spent in: (A) Entering the health care facility, including transportation costs; (B) Obtaining the information, including costs associated with the electronic retrieval of records; (C) Reporting in conformance with the appropriate format and standards, including costs associated with the retrieval of paper or electronic records; (D) Computer programming necessary for reporting services; (E) Consultation with the health care facility on reporting in conformance with the appropriate format and standards; (b) Staff time will be calculated based on but not limited to hourly rate of pay, fringe benefits, office costs, insurance and information technology support for the position of the person performing the work. (2) The Authority shall notify the health care facility of the estimated costs for providing cancer case reporting services. Statutory/Other Authority: ORS 432.520 Statutes/Other Implemented: ORS 432.500 - 432.990 History: PH 20-2017, amend filed 12/21/2017, effective 01/01/2018 OHD 11-1999, f. & cert. ef. 12-8-99
333-010-0100 ScreenWise Breast and Cervical Cancer Program: Description of the ScreenWise Breast and Cervical Cancer Program The mission of the Oregon ScreenWise Program is to reduce breast cancer, cervical cancer, cardiovascular disease and other diseases by promoting early detection through screening, risk reduction counseling, behavior modification support, and referral to medical treatment. ScreenWise includes the Breast and Cervical Cancer Program (ScreenWise BCC), a federal screening and early detection program administered by the Oregon Health Authority to provide screening and diagnostic services to eligible Oregonians statewide. ScreenWise BCC provides coverage for screening and diagnostic services to Oregonians with family incomes up to 250 percent of the Federal Poverty Level through a contract network of qualified providers. OAR 333-010-0100 through 333-010-0197 apply only to providers who have an approved medical services agreement to provide screening and diagnostic services through this program. The program is limited to a finite source of funds which may restrict availability of services on an annual basis. Statutory/Other Authority: ORS 413.042 Statutes/Other Implemented: ORS 413.042 History: PH 11-2016, f. & cert. ef. 4-1-16 PH 20-2015(Temp), f. & cert. ef. 10-12-15 thru 4-8-16 PH 28-2014, f. & cert. ef. 10-10-14 PH 1-2012, f. & cert. ef. 1-17-12 PH 9-2008, f. & cert. ef. 6-16-08
333-010-0110 Client Eligibility In order to be eligible for the ScreenWise BCC a client must meet the following eligibility criteria: (1) Have an income based on family size that is at or below 250 percent of the Federal Poverty Level at the time of enrollment; and (2) Reside or declare an intent to reside in Oregon; and (3) Have no health insurance or be underinsured; and (4) Meet one of the following criteria: (a) Be a woman age 21 or over for clinically recommended breast and cervical cancer screening and diagnostic services; or (b) Be a man of any age who is displaying signs or symptoms that may indicate breast cancer. Statutory/Other Authority: ORS 413.042 Statutes/Other Implemented: ORS 413.042 History: PH 11-2016, f. & cert. ef. 4-1-16 PH 20-2015(Temp), f. & cert. ef. 10-12-15 thru 4-8-16 PH 1-2012, f. & cert. ef. 1-17-12 PH 9-2008, f. & cert. ef. 6-16-08
333-010-0115 Client Enrollment (1)(a) Clients are determined eligible on a self-declared basis, when they submit a completed and signed ScreenWise BCC enrollment form at the clinic site at the time of service. (b) Prior to enrolling a client in ScreenWise BCC, providers with access to the Medicaid Management Information System (MMIS) shall check MMIS to verify that applicant is not currently receiving Medicaid. Clients enrolled in Medicaid are ineligible for ScreenWise BCC. (2) Eligibility is effective for one year unless a client justifiably needs to begin a second breast or cervical cycle, as defined in the program manual, before the end of one year. Justifications include: (a) The presence of new signs or symptoms; or (b) The necessity of short-term follow-up, as defined in the program manual. (3) If breast or cervical services are justifiably initiated again before the end of one year, then eligibility will automatically extend through the end of that cycle, even if the cycle lasts into a new year. (4) ScreenWise BCC providers must keep a signed enrollment form on file at the clinic for a minimum of four years. Clients enrolled into the program who are found ineligible will be disenrolled. Statutory/Other Authority: ORS 413.042 Statutes/Other Implemented: ORS 413.042 History: PH 11-2016, f. & cert. ef. 4-1-16 PH 20-2015(Temp), f. & cert. ef. 10-12-15 thru 4-8-16 PH 28-2014, f. & cert. ef. 10-10-14 PH 1-2012, f. & cert. ef. 1-17-12 PH 9-2008, f. & cert. ef. 6-16-08
333-010-0120 Covered Services (1) ScreenWise BCC covers screening and diagnostic services specific to breast and cervical cancer. Contracted providers will only be reimbursed for services related to breast and cervical cancer screening and diagnosis. (2) Screening and diagnostic services include, but are not limited to: (a) For breast cancer, both a clinical breast examination and a mammogram; (b) For cervical cancer, both a pelvic examination and a Pap smear; and (c) Laboratory tests and medical procedures necessary for detection and diagnosis of breast and cervical cancer. (3) Information regarding covered services and CPT code lists, including required notice to providers regarding revisions, may be found in the provider’s Medical Services Agreement. Statutory/Other Authority: ORS 413.042 Statutes/Other Implemented: ORS 413.042 History: PH 11-2016, f. & cert. ef. 4-1-16 PH 20-2015(Temp), f. & cert. ef. 10-12-15 thru 4-8-16 PH 9-2008, f. & cert. ef. 6-16-08
333-010-0125 Excluded Services (1) Services and laboratory tests not directly related to breast and cervical cancer screening and diagnosis are not covered by ScreenWise BCC for any eligible client. If the client accepts financial responsibility for a non-covered service that is received during a visit, payment arrangements are between the provider and the client, per OAR 333-010-0140(5)(a). (2) No payment will be made for any expense incurred for any of the following services or items: (a) Treatment for cancer or pre-cancerous conditions; or (b) Any medical service or laboratory tests whose primary purpose is for a reason other than breast or cervical cancer screening or diagnostic testing. Statutory/Other Authority: ORS 413.042 Statutes/Other Implemented: ORS 413.042 History: PH 11-2016, f. & cert. ef. 4-1-16 PH 9-2008, f. & cert. ef. 6-16-08
333-010-0145 Claims and Data Submission (1) In addition to submitting standard claims information, enrolling providers are required to submit client data in order to receive payment for the claim. The data is used to collect information pertaining to breast and cervical cancer prevention, diagnosis, and treatment and is used by the National Breast and Cervical Cancer Early Detection Program and the ScreenWise BCC primarily to monitor the delivery of services and clinical outcomes of the program. (2) Although data requirements may require more information than necessary for payment of a specific claim, all related fields must be completed and submitted. (3) Data requirements for enrolling providers and ancillary providers are as follows: (a) Enrolling providers must provide required information on client data forms, as defined by the program and posted on the Program website: www.healthoregon.org/screenwise. (b) Ancillary providers must provide results of services to enrolling providers. Ancillary providers are not required to provide data to the ScreenWise BCC directly. (4) If a provider terminates the medical services agreement all data must be submitted through the completion of each client’s cycle. Statutory/Other Authority: ORS 413.042 Statutes/Other Implemented: ORS 413.042 History: PH 11-2016, f. & cert. ef. 4-1-16 PH 20-2015(Temp), f. & cert. ef. 10-12-15 thru 4-8-16 PH 9-2008, f. & cert. ef. 6-16-08
333-010-0150 Timely Submission of Claims and Data (1) All claims for services must be submitted within 120 days of the date of service. Claims older than 120 days from the date of service will not be paid, except as provided for in section (2) and (3) of this rule. (2) If a claim is denied, the claim must be resolved within 120 days of the date of the denial. Claims older than 120 days from the date of denial will not be paid, except as provided for in section (3) of this rule. (3) When the Center has made an error that caused the provider not to be able to bill within 120 days of the date of service, then the claim may be submitted to the Center. The error must be confirmed by the Center. (4) Client data not related to payment of the claim may be updated or corrected at any time after the date of service. (5) Ancillary providers must provide results of services to enrolling providers within 14 calendar days from the date of service. (6) Enrolling providers must provide the ScreenWise BCC with enrollment and eligibility information immediately or within five calendar days from the date of enrollment. All other data must be submitted within 90 days from the date of enrollment. In the event that a case requires additional diagnostic procedures that exceed 90 days from the date of enrollment, the data must be submitted immediately upon receipt. Statutory/Other Authority: ORS 413.042 Statutes/Other Implemented: ORS 413.042 History: PH 11-2016, f. & cert. ef. 4-1-16 PH 28-2014, f. & cert. ef. 10-10-14 PH 9-2008, f. & cert. ef. 6-16-08
333-010-0155 Payment (1) The Center will make payment only to providers that have a medical services agreement with the ScreenWise BCC and are billing for an eligible client. (2) The ScreenWise BCC reimbursement amount will be up to the Medicare reimbursement rate for the Portland metropolitan area for ScreenWise BCC approved CPT codes, on a fee-for-service basis. (3) Federally qualified health centers or rural health centers are not paid at their Prospective Payment System (PPS) rate; they will receive up to the Medicare reimbursement rate for ScreenWise BCC approved CPT codes, on a fee-for-service basis. (4) Center payments for ScreenWise BCC provider services, unless in error, constitute payment in full. (5) The Center will not make payment on claims that have been assigned, sold, or otherwise transferred, or on which a provider of billing services receives a percentage of the amount billed or payment authorized. This includes, but is not limited to, transfer to a collection agency or individual who advances money to a provider for accounts receivable. Statutory/Other Authority: ORS 413.042 Statutes/Other Implemented: ORS 413.042 History: PH 11-2016, f. & cert. ef. 4-1-16 PH 28-2014, f. & cert. ef. 10-10-14 PH 13-2014(Temp), f. & cert. ef. 4-22-14 thru 10-19-14 PH 9-2008, f. & cert. ef. 6-16-08
333-010-0165 Compliance with Federal and State Statutes (1) Submission of a claim for medical services or supplies provided to a ScreenWise BCC client shall be deemed a representation by the medical provider to the Center of the medical provider’s compliance with the applicable sections of the federal and state statutes referenced in this rule: (a) 45 CFR Part 84 which implements Title V, Section 504 of the Rehabilitation Act of 1973; (b) Title II and Title III of the Americans with Disabilities Act of 1991; (c) Title VI of the Civil Rights Act of 1964; (d) 42 CFR Part 493 Laboratory Requirements and ORS chapter 438 (Clinical Laboratories). (2) Providers are required to comply with HIPAA regarding the confidentiality of client records. (3) CLIA requires all entities that perform even one laboratory test, including waived tests on, "materials derived from the human body for the purpose of providing information for the diagnosis, prevention or treatment of any disease or impairment of, or the assessment of the health of, human beings" to meet certain federal requirements. If an entity performs tests for these purposes, it is considered under CLIA to be a laboratory. Statutory/Other Authority: ORS 413.042 Statutes/Other Implemented: ORS 413.042 History: PH 11-2016, f. & cert. ef. 4-1-16 PH 9-2008, f. & cert. ef. 6-16-08
333-010-0170 Denial or Recovery of Reimbursement Resulting from Review or Audit (1) The Center’s staff, contractor or auditor may review a claim for assurance that the specific medical service was provided in accordance with the program’s policies and rules and the generally accepted standards of a provider’s scope of practice or specialty. (2) Payment may be denied or subject to recovery if review or audit determines the service does not meet the program’s policies, rules or the Standards of Care for Breast and Cervical Cancer Screening and Diagnostic Services set forth in OAR 333-010-0130. Statutory/Other Authority: ORS 413.042 Statutes/Other Implemented: ORS 413.042 History: PH 9-2008, f. & cert. ef. 6-16-08
333-010-0185 Provider Appeals A provider may appeal certain decisions affecting the provider made by the Center. There are two levels of appeal. Level 1 is a reconsideration on a claim. Level 2 is a contested case hearing. Statutory/Other Authority: ORS 413.042 Statutes/Other Implemented: ORS 413.042 History: PH 9-2008, f. & cert. ef. 6-16-08
333-010-0190 Provider Appeals (Level 1) — Claims Reconsideration A provider disputing the Center’s claim decision may request reconsideration. The provider must submit the request in writing to the Center. The request must include the reason for the dispute, and any information pertinent to the outcome of the dispute. The Center will complete an additional review and respond back to the provider in writing. If the provider is not satisfied with the review, the provider may request a contested case hearing. Statutory/Other Authority: ORS 413.042 Statutes/Other Implemented: ORS 413.042 History: PH 9-2008, f. & cert. ef. 6-16-08
333-010-0195 Provider Appeals (Level 2) — Contested Case Hearing Contested case hearings will be held in accordance with ORS 183. Statutory/Other Authority: ORS 413.042 Statutes/Other Implemented: ORS 413.042 History: PH 9-2008, f. & cert. ef. 6-16-08
333-010-0197 Presumptive Eligibility for BCCTP (1) Any licensed health care provider who can diagnose breast or cervical cancer may presumptively enroll a client into BCCTP and refer the client to the Oregon Health Plan if she meets the presumptive eligibility criteria as described in section (2) of this rule. (2) In order to be presumptively enrolled into BCCTP a client must meet the eligibility criteria in OAR 333-010-0110 and 410-200-0400. Statutory/Other Authority: ORS 413.042 & 414.540 Statutes/Other Implemented: ORS 414.534 & 414.536 History: PH 11-2016, f. & cert. ef. 4-1-16 PH 20-2015(Temp), f. & cert. ef. 10-12-15 thru 4-8-16 PH 1-2012, f. & cert. ef. 1-17-12
333-010-0200 ScreenWise WISEWOMAN Program: Description of the WISEWOMAN Program The WISEWOMAN (WW) Program is a federal program, administered by the Oregon Health Authority, that provides heart disease, stroke and diabetes screening support to develop and maintain healthy behaviors, and referral services in an effort to prevent cardiovascular disease to eligible women statewide. The WW Program provides these services through a contract network of qualified providers. These rules (OAR 333-010-0200 through 333-010-0290) apply only to providers who have an approved medical services agreement to provide screening and services through this program. The program is limited to a finite source of funds, which may restrict availability of services on an annual basis. Statutory/Other Authority: ORS 413.042 Statutes/Other Implemented: ORS 413.042 & 431.250 History: PH 27-2014, f. & cert. ef. 10-10-14 PH 1-2009, f. & cert. ef. 2-13-09
333-010-0205 Definitions (1) "Agency number" means the administrative number assigned to the service provider by the Center for Prevention and Health Promotion (Center) for identification as a BCCP/WW provider. (2) "Ancillary provider" means an individual or entity that has met the eligibility requirements for enrollment in the WW Program, has executed a medical services agreement with the Center, has been assigned a BCCP/WW Program agency number, and performs services beyond the scope of an enrolling provider, such as laboratory, imaging, or surgical services. (3) "Approved medical services agreement" means the completed WW Program agreement, submitted to and approved by the Center for Prevention and Health Promotion. (4) "Authority" means the Oregon Health Authority. (5) "BCCP" means the Oregon Breast and Cervical Cancer Program. (6) "Care coordination" or "case management" means that a client is provided with services, results, follow-up recommendations, and active tracking of progress towards follow-up recommendations. (7) "Center" means the Center for Prevention and Health Promotion, within the Oregon Health Authority, Public Health Division. (8) "CLIA" means the federal Clinical Laboratory Improvement Amendments of 1988 (P.L. 100-578, 42 U.S.C. 201 and 263a) (9) "Client" means a woman 40 to 64 years of age who is enrolled in and receives screening or services from the WW Program. (10) "Enrolling provider" means an individual or entity that has met the eligibility requirements for enrollment in the WW Program, has executed a medical services agreement with the Center, has been assigned a BCCP/WW Program agency number, and provides screening, services, or care coordination for WW Program clients. (11) "FPL" means the federal poverty level guidelines established each year by the United States Department of Health and Human Services, used to determine eligibility for the WW Program and other federally funded programs. (12) "HIPAA" means the Health Insurance Portability and Accountability Act. (13) "Site number" means the administrative number assigned to the family planning service provider by the Center for identification of the geographic location of each WW provider. (14) "WISEWOMAN Program" or "WW Program" means the program that provides statewide heart disease, stroke and diabetes screening and services to eligible clients, that is administered by the Center. (15) "WW Program provider network" means the combination of all contracted WW Program providers, including enrolling and ancillary providers. Statutory/Other Authority: ORS 413.042 Statutes/Other Implemented: ORS 413.042 & 431.250 History: PH 27-2014, f. & cert. ef. 10-10-14 PH 12-2014(Temp), f. & cert. ef. 4-18-14 thru 10-15-14 PH 11-2011, f. & cert. ef. 10-27-11 PH 5-2011(Temp), f. & cert. ef. 7-1-11 thru 12-27-11 PH 1-2009, f. & cert. ef. 2-13-09
333-010-0210 Client Eligibility A person must meet the following WW Program eligibility criteria in order to be enrolled in the WW Program: (1) Be a woman 40 to 64 years of age; and (2) Be enrolled in the BCCP program. Statutory/Other Authority: ORS 413.042 Statutes/Other Implemented: ORS 413.042 & 431.250 History: PH 27-2014, f. & cert. ef. 10-10-14 PH 1-2009, f. & cert. ef. 2-13-09
333-010-0215 Client Enrollment (1) A person is determined eligible for the WW Program after submitting a completed and signed BCCP/WW Program enrollment form. (2) Eligibility is effective for one year. (3) A person who enrolled in the WW Program but who is later found to be ineligible shall be notified by the Center or her enrolling provider in writing of such disenrollment and may be responsible for the payment of services received from her provider. Statutory/Other Authority: ORS 413.042 Statutes/Other Implemented: ORS 413.042 & 431.250 History: PH 27-2014, f. & cert. ef. 10-10-14 PH 12-2014(Temp), f. & cert. ef. 4-18-14 thru 10-15-14 PH 1-2009, f. & cert. ef. 2-13-09