justicedao/ipfs_state_laws huggingface dataset:
943-120-0180 Record Retention and Audit (1) Records Retention. A provider, CCO, PHP, web portal submitter, trading partner, and EDI submitter shall maintain, for a period of no less than seven years from the date of service, complete, accurate, and unaltered copies of all source documents associated with all data transmissions. (2) EDI Trade Data Log. An EDI submitter must establish and maintain a trade data log that must record all data transmissions taking place between an EDI submitter and the Authority during the term of a TPA. A trading partner and EDI submitter must take necessary and reasonable steps to ensure that the trade data log constitutes a current, truthful, accurate, complete, and unaltered record of all data transmissions between the parties and must be retained by each party for no less than 24 months following the date of the data transmission. The trade data log may be maintained on electronic media or other suitable means provided that, if necessary, the information may be timely retrieved and presented in readable form. (3) Right to Audit. A provider, CCO or PHP must allow and require any web portal submitter to allow, and a trading partner must allow and require an EDI submitter or other agent to allow access to the Authority, the Oregon Secretary of State, the Oregon Department of Justice Medicaid Fraud Unit, or its designees, and DHHS or its designees to audit relevant business records, source documents, data, data transmissions, trade data logs, or information systems of a provider and its web portal submitter, and a trading partner, and its agents, as necessary, to ensure compliance with these rules. A provider must allow and require its web portal submitter to allow, and a trading partner must allow and require an EDI submitter or other agent to allow the Authority, or its designee, access to ensure that adequate security precautions have been made and are implemented to prevent unauthorized disclosure of any data, data transmissions, or other information. Statutory/Other Authority: ORS 413.042 & 414.065 Statutes/Other Implemented: ORS 413.042 & 414.065 History: OHA 7-2012, f. 10-9-12, cert. ef. 10-10-12 OHA 4-2012(Temp), f. & cert. ef. 7-12-12 thru 1-6-13 OHA 26-2011, f. 10-31-11, cert. ef. 11-1-11 OHA 13-2011(Temp), f. & cert. ef. 7-1-11 thru 12-27-11
943-120-0190 Material Changes (1) Changes in Any Material Information — EDT Process. A trading partner must submit an updated TPA, application for authorization, or EDI registration form to the Authority within ten business days of any material change in information. A material change includes but is not limited to mailing or email address change, contract number or contract status (termination, expiration, extension), identification of authorized individuals of a trading partner or EDI submitter, the addition or deletion of authorized transactions, or any other change that may affect the accuracy of or authority for an EDI transaction. The Authority may act on data transmissions submitted by a trading partner and its EDI submitter based on information on file in the application for authorization and EDI registration forms until an updated form has been received and approved by the Authority. A trading partner's signature or the signature of an authorized EDI submitter is required to ensure that an updated TPA, authorization, or EDI registration form is valid and authorized. (2) Changes in Any Material Information — Web Portal Access. Providers must submit an updated web portal registration form to the Authority within ten business days of any material changes in information. A material change includes but is not limited to mailing or email address change, contract number or contract status (termination, suspension, expiration), identification of web portal submitter contact information, or any other change that may affect the accuracy of or authority for a DDE transaction. The Authority is authorized to act on data transmissions submitted by a provider and its web portal submitter based on information on file in the web portal registration form until an updated form has been received and approved by the Authority. A provider's signature or the signature of an authorized business representative is required to ensure that an updated web portal registration form is valid and authorized. (3) Failure to submit a timely updated form may impact the ability of a data transaction to be processed without errors. Failure to submit a signed, updated form may result in the rejection of a data transmission. Statutory/Other Authority: ORS 413.042 & 414.065 Statutes/Other Implemented: ORS 413.042 & 414.065 History: OHA 26-2011, f. 10-31-11, cert. ef. 11-1-11 OHA 13-2011(Temp), f. & cert. ef. 7-1-11 thru 12-27-11
943-120-0310 Provider Requirements (1) All providers seeking reimbursement from the Authority, a PHP, CCO, or a county pursuant to a county agreement with the Authority for the provision of covered services or items to eligible recipients, must comply with: (a) These rules, OAR 943-120-0300 to 943-120-0350: and (b) The applicable rules or contracts of the specific programs described below: (A) Programs administered by the Division of Medical Assistance Programs (Division) including the OHP medical assistance program and the CHIP program that reimburse providers for services or items provided to eligible recipients, subject to OAR chapter 410 divisions 120 and 141 and provider rules in chapter 410 applicable to the provider’s service category; (B) Programs administered by the Addictions and Mental Health Division (AMH) that reimburse providers for services or items provided to eligible AMH recipients (OAR chapters 309 and 415); or (C) Programs administered by Aging and People with Disabilities (APD) that reimburse providers for services or items provided to eligible APD recipients (OAR chapter 411). (2) Providers must submit visit data pursuant to program-specific rules or contract. Authority programs use visit data to monitor service delivery, planning, and quality improvement activities. Visit data is not a HIPAA transaction and is not a claim for reimbursement. [Publications: Publications referenced are available from the agency.] Statutory/Other Authority: ORS 413.042 Statutes/Other Implemented: ORS 414.065, 414.115; 414.125; 414.135; & 414.145 History: OHA 8-2012, f. 10-30-12, cert. ef. 11-1-12 OHA 20-2011, f. 8-30-11, cert. ef. 9-1-11 OHA 14-2011(Temp), f. & cert. ef. 7-1-11 thru 12-27-11
943-120-0320 Provider Enrollment (1) In some Authority program areas, being an enrolled Authority provider is a condition of eligibility for an Authority contract for certain services or activities. Billing providers must be enrolled with the Authority as providers consistent with the provider enrollment processes set forth in OAR 410-120-0310 through 0350 and 410-120-1260. If reimbursement for covered services is made under a contract with the Authority, the provider must also meet the Authority's contract requirements. Contract requirements are separate from the requirements of these rules. Enrollment as a provider with the Authority is not a promise that the enrolled provider shall receive any amount of work from the Authority, a CCO, PHP, or a county. (2) Provider enrollment establishes essential Authority provider participation requirements for becoming an enrolled Authority provider. The details of provider qualification requirements, client eligibility, covered services, how to obtain prior authorization or review, if required, documentation requirements, claims submission, and available electronic access instructions, and other instructions and requirements are contained in Authority program-specific rules in chapter 410 or contract. (3) Prior to enrollment, providers must: (a) Meet all program-specific or contract requirements identified in program-specific rules or contracts and the requirements set forth in these rules and OAR 410-120-1260; (b) Meet Authority contracting requirements, as specified by the Authority's Office of Contracts and Procurement (OC&P); (c) Meet Authority and federal licensing and certification requirements for the type of service for which the provider is enrolling; and (d) Obtain a provider number from the Authority subject to OAR 410-120-1260. (4) A provider may request to conduct electronic transactions with the Authority by enrolling and completing the appropriate authorization forms pursuant to the electronic data transaction rules (OAR 943-120-0100 to 943-120-0200). [Publications: Publications referenced are available from the agency.] Statutory/Other Authority: ORS 413.042 Statutes/Other Implemented: ORS 414.065 History: OHA 8-2012, f. 10-30-12, cert. ef. 11-1-12 OHA 20-2011, f. 8-30-11, cert. ef. 9-1-11 OHA 14-2011(Temp), f. & cert. ef. 7-1-11 thru 12-27-11
943-120-0330 Billing Procedures (1) These rules only apply to covered services and items provided to clients that are paid for by the Authority based on an Authority fee schedule or other reimbursement method (often referred to as fee-for-service), or for services that are paid for by the Authority at the request of a county for county-authorized services. (a) If a client's service or item is paid for by a PHP or CCO, the provider must comply with the billing and procedures related to claim submission established under contract with that PHP, CCO, or the rules applicable to non-participating providers if the provider is not under contract with that PHP or CCO. (b) If the client is enrolled in a PHP or CCO, but the client is permitted by a contract or program-specific rules to obtain covered services reimbursed by the Authority (such as family planning services that may be obtained from any provider). In addition to this rule, the provider must comply with the billing and claim procedures established in OAR chapter 410 division 120. (2) All Authority-assigned provider numbers are issued at enrollment and are directly associated with the provider as defined in OAR 410-120-1260 and have the following uses: (a) Log-on identification for the Authority web portal; (b) Claim submission in the approved paper formats; and (c) For electronic claims submission including the web portal for atypical providers pursuant to 45 CFR 160 and 162 where an NPI is not mandated. Use of the Authority-assigned provider number shall be considered the providers authorization and the provider shall be accountable for its use. (d) Providers may not bill clients or the Authority for services or items provided free of charge. This limitation does not apply to established sliding fee schedules where the client is subject to the same standards as other members of the public or clients of the provider. (e) Providers shall pay for costs incurred for failing to confirm eligibility or that services are covered. Statutory/Other Authority: ORS 413.042 Statutes/Other Implemented: ORS 414.065 History: OHA 8-2012, f. 10-30-12, cert. ef. 11-1-12 OHA 20-2011, f. 8-30-11, cert. ef. 9-1-11 OHA 14-2011(Temp), f. & cert. ef. 7-1-11 thru 12-27-11
943-120-0350 Payments and Overpayments (1) When an individual’s health care services or item is reimbursed by the Medical Assistance Program, either through a CCO, MCO or the Authority, the provider shall comply with the payment requirements pursuant to OAR chapter 410 or established under contract with that CCO or MCO. (2) All other covered services and items provided to eligible individuals not part of the Medical Assistance Program shall be: (a) Within the program-specific contract in effect on the date of service; (b) Based on program-specific or contract fee schedules or other reimbursement methods; or (c) For services that are paid for by the Authority, on behalf of a county, authorized by and at the request of a county, provider reimbursement shall include county service authorization information. (3) The Authority shall pay for services or items for hospitals and ambulatory surgical center services using: (a) The most recent Medicare payment methodologies established by the Centers for Medicare and Medicaid Services, or similar payment methodologies; or (b) An alternative payment methodology. (4) For purposes of this rule, “Alternative payment methodology” means a payment other than a fee-for-services payment, used by health plans as compensation for the provision of integrated and coordinated health care and services. “Alternative payment methodology” includes, but is not limited to: (a) Shared savings arrangements; (b) Bundled payments; (c) Payments based on episodes; (d) Pay for performance; or (e) Capitation. (5) The reimbursement methods in these rules are described in greater detail for the Medical Assistance Program in chapter 410 Division 125, the Public Employees’ Benefit Board, chapter 101 and the Oregon Educators Benefits Board, chapter 111 program rules. Statutory/Other Authority: ORS 413.042 Statutes/Other Implemented: ORS 414.065 History: OHA 1-2016, f. 9-30-16, cert. ef. 10-1-16 OHA 8-2012, f. 10-30-12, cert. ef. 11-1-12 OHA 20-2011, f. 8-30-11, cert. ef. 9-1-11 OHA 14-2011(Temp), f. & cert. ef. 7-1-11 thru 12-27-11
943-120-1505 Audits and Overpayment Recovery Providers or contractors receiving payments from or through the Oregon Health Authority are subject to audit or other post payment review procedures for all payments applicable to items or services furnished or supplied by the provider or contractor to or on behalf of the Authority or to its clients. (1) The Authority adopts and incorporates by reference the rules established in OAR 407-120-1505, for those matters that involve providers or contractors of the Authority, except as otherwise provided in this rule. Audit rules and procedures from OAR 407-120-1505 as incorporated into this rule ensure proper payments were made by the Authority based on requirements applicable to covered services and promote program integrity. (2) Any reference to OAR 407-120-1505 in rules or contracts of the Authority are deemed to be references to the requirements of this rule, and shall be construed to apply to providers or contractors receiving payments from or through the Authority. (3) The Authority authorizes the Department to act on its behalf in carrying out audits and establishing overpayment amounts associated with the administration of programs or activities administered by the Authority. (4) Provider appeals for the Authority shall be handled by the Authority under the procedures set forth in OAR 407-120-1505. References to “the OPAR Administrator” or “the Administrator” are hereby incorporated as references to “the Authority Director.” [Publication: Publications referenced are available from the agency.] Statutory/Other Authority: ORS 413.042 Statutes/Other Implemented: ORS 411.010, 413.032, 414.065 & 414.715 History: OHA 21-2011, f. 8-31-11, cert. ef. 9-1-11 OHA 15-2011(Temp), f. & cert. ef. 7-1-11 thru 12-27-11
944-001-0000 Purpose (1) These rules prescribe general minimum operational standards including services and supports provided by the Behavioral Health Resource Networks (BHRN). (2) These rules prescribe the formation, implementation, and operation of Behavioral Health Resource Networks. (3) These rules specify general criteria used to distribute grants and funding required to establish the Behavioral Health Resource Networks and to increase access to community care as described in SB 755 (2021). (4) These rules specify reporting requirements used to satisfy the Secretary of State to conduct financial and performance audits. Statutory/Other Authority: Ballot Measure 110 (2020) & SB 755 (2021) Statutes/Other Implemented: Ballot Measure 110 (2020) & SB 755 (2021) History: OAAC 1-2022, adopt filed 02/24/2022, effective 02/26/2022 OAAC 1-2021, temporary adopt filed 08/30/2021, effective 09/01/2021 through 02/27/2022
944-001-0040 Data collecting and reporting requirements for Behavioral Health Resource Networks and recipients of grants or funds (1) Financial recordkeeping and reporting is required as follows: (a) BHRNs and Access to Care grants and funding recipients must keep accurate books, records and accounts that are subject to inspection and audit by the Secretary of State Audits Division upon request. (b) Additional financial reporting must be followed as outlined in each grant agreement or contract. (2) Client demographics and client service and support reporting is required as follows: (a) Each network and recipient must, at a minimum, collect and report on the following: (A) Number of clients with substance use disorder receiving services from each network or recipient; (B) Average duration of client participation and client outcomes; (C) The number of individuals seeking assistance from the network or recipients who are denied or not connected to substance use disorder treatment and other services, and the reasons for the denials; (D) The average time it takes for clients to access services and fulfill their individual intervention plan and the reason for any delays, such as waiting lists at referred services; (E) Whether the average time to access services to which clients are referred, such as housing or medication assisted treatment, has increased or decreased since network or recipient received funding; and (F) Demographic data on clients served, including self-reported demographic data on race, ethnicity, gender, and age. Each network or funding recipient must collect data in accordance with OAR 950-030. (b) Each BHRN and Access to Care grant or funding recipient will submit a summary of how demographics are collected, including any tools used and the staff person or network entity who will collect the data. The summary must include justification for the approach. (c) Additional client, client service, and client outcome reporting requirements must be followed as outlined in each grant or funding agreement or contract. (d) Licensed or certified behavioral health treatment providers that are part of a network or a recipient of grants or funds, must report the entry of all clients on the mandated state data system. Statutory/Other Authority: Ballot Measure 110 (2020) & SB 755 (2021) Statutes/Other Implemented: Ballot Measure 110 (2020) & SB 755 (2021) History: OAAC 2-2023, minor correction filed 05/24/2023, effective 05/24/2023 OAAC 1-2022, adopt filed 02/24/2022, effective 02/26/2022 OAAC 1-2021, temporary adopt filed 08/30/2021, effective 09/01/2021 through 02/27/2022
944-010-0000 Behavioral Health Resource Networks (1) These rules prescribe general criteria and requirements for each Behavioral Health Resource Network (BHRN), individually and jointly, including the requirements to collect and report information necessary for the Secretary of State to conduct financial and performance audits required by ORS 430.392. (2) These rules 944-010-0000 through 944-010-0090 apply to a BHRN and/or funded entities authorized to provide services on and after July 1, 2025. Statutory/Other Authority: ORS 430.389(2)(a), 430.390, 413.042 & SB 610 (2025) Statutes/Other Implemented: ORS 430.389(2)(a) & 430.390 History: DTRS 1-2025, amend filed 12/25/2025, effective 01/01/2026 DTRS 3-2024, adopt filed 10/22/2024, effective 11/01/2024 DTRS 1-2024, temporary adopt filed 05/30/2024, effective 06/01/2024 through 11/27/2024
944-010-0030 Screenings (1) Screening services provided by an entity funded under ORS 430.389(2) must be provided by a Peer Support Specialist, Certified Recovery Mentor, Peer Wellness Specialist, or other addiction professional acting within their scope of practice to determine whether an individual needs a comprehensive behavioral health needs assessment or referrals to additional services and supports. A screening must at a minimum cover the following: (a) Acute care needs; (b) Treatment for substance use disorders and co-existing health problems; (c) Personal safety; (d) Harm reduction; (e) Addiction Peer supports; (f) Housing; (g) Employment and training; (h) Childcare; (i) Food and other basic living needs; and (j) The need for, and provision of, mobile or virtual outreach services. (2) Screening services must be provided with 48 hours of initial client contact. (3) Once screening is completed, an individual must be provided, at a minimum, with: (a) Referrals to all requested and appropriate services. (b) Supportive services if the individual is waiting for services that are not readily available. (4) If, after the completion of a screening, an individual indicates a desire to address some or all of the identified needs, a case manager must work with the individual to design an individual intervention plan. The plan must address all of the individual’s needs identified in the screening. Statutory/Other Authority: ORS 430.389, 430.390, ORS 430.383 & SB 610 (2025) Statutes/Other Implemented: ORS 430.383, 430.389, 430.390 & 430.392 History: DTRS 1-2025, amend filed 12/25/2025, effective 01/01/2026 DTRS 3-2024, adopt filed 10/22/2024, effective 11/01/2024 DTRS 1-2024, temporary adopt filed 05/30/2024, effective 06/01/2024 through 11/27/2024
944-010-0040 Comprehensive Behavioral Health Needs Assessments (1) Comprehensive behavioral health needs assessment services provided by an entity funded under ORS 430.389(2) must include a substance use disorder screening to determine if an individual has been appropriately diagnosed with a substance use disorder or other co-occurring disorders including but not limited to gambling disorders and mental health disorders, to create a self-identified individual intervention plan. (2) Assessments and/or diagnoses provided by a funded entity must be conducted by a certified alcohol and drug counselor or other credentialed addiction treatment professional acting within their scope of practice. (3) An assessment must prioritize the self-identified needs of an individual and must: (a) Be provided within 72 hours of an individual's request for an assessment or from a referral. (b) For substance use disorder services, be consistent with the dimensions described in the ASAM and document a diagnosis and level of care determination consistent with the DSM and ASAM. (c) Include an assessment of the need for, and provision of, mobile or virtual outreach services. (4) When an assessment provided by a funded entity identifies a co-occurring gambling disorder, mental health disorders, or any risk to health and safety the entity must document the finding and provide appropriate referrals for further assessment, planning, and intervention by an appropriate professional. (5) Case Management services must also be provided by a funded entity to assist individuals to connect to and gain access to needed services and supports outlined in an individual intervention plan; substance use disorder treatment, health care, housing, employment and training, childcare and other applicable services and supports. Statutory/Other Authority: ORS 430.389, 430.390, 430.391 & SB 610 (2025) Statutes/Other Implemented: ORS 430.383 & 430.392 History: DTRS 1-2025, amend filed 12/25/2025, effective 01/01/2026 DTRS 3-2024, adopt filed 10/22/2024, effective 11/01/2024 DTRS 1-2024, temporary adopt filed 05/30/2024, effective 06/01/2024 through 11/27/2024