justicedao/ipfs_state_laws huggingface dataset:
333-010-0220 Provider Enrollment (1) An individual or organization that wishes to be an enrolling provider or an ancillary provider with the WW Program shall apply to the Center on a form prescribed by the Center. (2) In order to be eligible for enrollment, an individual or organization shall: (a) Have a valid Oregon business license if such a license is a requirement of the state, federal, county or city government to operate a business or to provide services; and (b) Meet applicable licensing or regulatory requirements set forth by federal and state statutes, regulations, and rules to be enrolled and to bill as a health care provider. (3) A laboratory or any other entity that does laboratory tests must provide evidence that it is CLIA certified in order to be a provider or an ancillary provider. (4) An individual or organization that is currently subject to sanctions by the Authority or the federal government is not eligible for enrollment. (5) Upon receipt of an application the Center shall verify the information and determine if the individual or organization is eligible to be an enrolling or ancillary provider. (6) If the Center approves an application, an individual or organization shall: (a) Sign a medical services agreement that requires the provider to comply with these rules; and (b) Be issued a BCCP/WW Program agency number. (7) An enrolling or ancillary provider may not offer services to a client prior to receiving information from a Center WW Program representative about administering the WW Program. (8) An enrolling provider or ancillary provider shall notify the Center in writing within 30 days of the change if it changes its address, business affiliation, licensure, ownership, certification, billing agents, registered name, or Federal Tax Identification Number (TIN). Changes in business affiliation, ownership, registered name, and TIN may require the submission of a new application. Payments made to an enrolling provider or an ancillary provider who has not furnished such notification may be recovered by the Center. (9) An enrolling provider or an ancillary provider shall notify the Center in writing of a bankruptcy proceedings within 15 days. (10) An individual or organization outside the state of Oregon may be eligible for enrollment if the individual or organization: (a) Is appropriately licensed or certified in its state; and (b) Is located in a state contiguous to Oregon, and is within 75 miles of the Oregon border. (11) An enrolling provider or an ancillary provider may terminate enrollment at any time by sending a written termination notice to the Center, via certified mail, return receipt requested. The notice shall specify the agency number to be terminated and the effective date of termination. Termination of a provider enrollment does not terminate any obligations of the provider for services provided to a client prior to the effective date of the termination. 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
333-010-0230 Submission of Information by Ancillary Providers Ancillary providers shall provide results of services to enrolled providers within 14 calendar days from the date of service. Statutory/Other Authority: ORS 413.042 Statutes/Other Implemented: ORS 413.042 & 431.150 History: PH 1-2009, f. & cert. ef. 2-13-09
333-010-0235 Covered Services The WW Program Manual, October 2014, incorporated by reference, includes a complete list of covered services. [Publications: Publications referenced are available from the Oregon WW 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 12-2014(Temp), f. & cert. ef. 4-18-14 thru 10-15-14 PH 1-2009, f. & cert. ef. 2-13-09
333-010-0240 Excluded Services (1) Services and laboratory tests not directly related to heart disease, stroke and diabetes, or not included in the ICD-10 and CPT code lists provided in the WW Program Manual are not covered by the WW Program. (2) No payment will be made for any expense incurred for any other medical service or laboratory tests whose primary purpose is for a reason other than heart disease, stroke, or diabetes screening and prevention. Statutory/Other Authority: ORS 413.042 Statutes/Other Implemented: ORS 413.042 & 431.250 History: PH 17-2015, f. 9-30-15, cert. ef. 10-1-15 PH 1-2009, f. & cert. ef. 2-13-09
333-010-0250 Payment (1) The Center shall only pay claims submitted by an enrolling or ancillary provider for a client. (2) The Center shall reimburse an enrolling or ancillary provider an amount up to the Medicare reimbursement rate for the Portland metropolitan area for WW Program approved CPT codes, on a fee-for-service basis. (3) A federally qualified health center or rural health center shall not be paid at their Prospective Payment System (PPS) rate, but will be paid at the reimbursement rate described in section (2) of this rule. (4) The Center payments for WW Program provider services, unless in error, constitute payment in full. (5) The Center may 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, including claims that have been transferred 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 & 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
333-010-0255 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 WW Program’s rules or the generally accepted standards of a provider’s scope of practice or specialty. (2) Payment may be denied or subject to recovery if a review or audit determines the service was not provided in accordance with the WW Program’s rules or the generally accepted standards of a provider’s scope of practice or specialty. Statutory/Other Authority: ORS 413.042 Statutes/Other Implemented: ORS 413.042 & 431.250 History: PH 1-2009, f. & cert. ef. 2-13-09
333-010-0265 Client Data Submission (1) In addition to submitting the claim information required in OAR 333-010-0225, in order to receive payment an enrolling provider shall submit client data to the Center. The data shall be used by the WW Program to monitor the delivery of services and clinical outcomes of the program. (2) An enrolling provider shall submit client data to the Center, in a manner specified by the Center, on the Enrollment Form, Assessment Form and the Screening Form, included in the WW Program Manual within 90 days from the date of enrollment. In the event that a client requires additional diagnostic procedures and the information is not available within 90 days from the date of enrollment, the data shall be submitted to the Center immediately once it is received by the provider. (3) An ancillary provider shall report data to an enrolling provider and is not required to provide data to the Center directly. (4) An enrolling provider may update or correct client data not related to payment of the claim at any time after the date of service. (5) If an enrolling provider or the Center terminates the medical services agreement, data are still required to be submitted for each client that was provided services while the agreement was in effect. [Publications: Publications referenced are available from the agency] 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
333-010-0270 Requirements for Financial, Clinical and Other Records (1) An enrolling provider shall: (a) Develop and maintain adequate financial and clinical records and other documentation that supports the services for which payment has been requested; (b) Ensure that all medical records document the service provided, primary diagnosis code for the services, the date on which the service was provided, and the individual who provided the services; (c) Ensure that patient account and financial records include documentation of charges, identify other payment resources pursued, indicate the date and amount of all debit or credit billing actions, and support the appropriateness of the amount billed and paid in accurate and sufficient detail to substantiate the data reported; (d) Ensure that clinical records sufficiently document that the client’s services were primarily for heart disease, stroke and diabetes; (e) Ensure that each time a service is provided to a client, the client’s record is signed or initialed by the individual who provided the service or otherwise clearly indicates who provided the service; (f) Ensure that the information contained in the record reflects that the standard of care for heart disease, stroke and diabetes screening and services were met; (g) Have policies and procedures to ensure the confidentiality of medical records and that address the circumstances under which information may be released in accordance with federal and state law; and (h) Retain client enrollment forms, clinical, financial and other records described in this rule for at least four years from the date of last activity. (2) The Center, the Authority, the Oregon Department of Justice Medicaid Fraud Unit, the Oregon Secretary of State, or their authorized representatives (requestor) may request, in writing, any records related to an enrolling or ancillary provider’s participation in the WW Program, including client medical records. An enrolling or ancillary provider shall furnish requested records, without charge, immediately or within the time frame specified in the written request. Copies of the documents may be furnished unless the originals are requested. At the requestor’s discretion, representatives of the requestor may review and copy the original documentation in the provider’s place of business. Upon the written request of the provider, the requestor may, at its sole discretion, modify or extend the time for provision of such records for good cause shown. (3) Failure to comply with requests for documents within the specified time frames means that the records subject to the request may be deemed by the Authority not to exist for purposes of verifying appropriateness of payment, medical appropriateness, the quality of care, and the access to care in an audit or overpayment determination, and accordingly subjects the provider to possible denial or recovery of payments made by the Authority, or to sanctions. 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
333-010-0275 Compliance with Federal and State Statutes (1) Submission of a claim for medical services or supplies provided to a client shall be deemed a representation by the enrolling or ancillary provider to the Center of the provider’s compliance with the applicable sections of the following federal and state statutes: (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; and (d) 42 CFR Part 493 Laboratory Requirements and ORS Chapter 438 (Clinical Laboratories). (2) Enrolling and ancillary providers are required to comply with HIPAA regarding the confidentiality of client records. (3) A provider that performs 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" is considered a laboratory under CLIA and therefore CLIA certification may be required. 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
333-010-0285 Provider Appeals (Level 1) — Claims Reconsideration An enrolling or ancillary provider disputing a claim or sanction decision by the Center may request reconsideration. The provider must submit the request for reconsideration 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 & 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
333-010-0290 Provider Appeals (Level 2) — Contested Case Hearing An enrolling or ancillary provider may request a contested case hearing within 30 calendar days of the date of a decision affecting the provider. Contested case hearings will be held in accordance with ORS Chapter 183 and the Attorney General’s model rules, OAR 137-003-0501 through 137-003-0700. 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
333-010-0310 Tobacco Prevention and Education Program: Purpose and Intent The purpose of this rule is to implement Chapter 2 of Oregon Laws of 1997, approved by the people as Ballot Measure 44, at the November 5, 1996 General Election, which: (1) Authorizes 5.77% of the money received by the Department of Revenue under the Tobacco Products Tax Act to be credited to the Tobacco Use Reduction Account; and (2) Requires the Public Health Division to adopt rules for awarding grants to programs for educating the public on the risk of tobacco use, including but not limited to, educating children on the health hazards and consequences of tobacco use, and promoting enrollment in smoking cessation programs. Statutory/Other Authority: ORS 431.834 Statutes/Other Implemented: ORS 431.831 - 431.836 History: HD 11-1997, f. & cert. ef. 9-12-97
333-010-0320 Tobacco Prevention and Education Program: Framework for Grant Awards (1) These rules describe provisions for awarding grants and contracts for local, regional, and statewide activities in four program areas. The program areas are: (a) Local Coalitions and Community-Based Programs; (b) School-Based Prevention Programs; (c) Statewide Public Awareness and Education Programs; and (d) Statewide and Regional Special Programs. (2) Proposals shall support the following goals of Oregon’s Statewide Tobacco Prevention Plan: (a) Decrease tobacco use by youth; (b) Treat tobacco dependence; (c) Protect children from exposure to tobacco; and (d) Protect workers and the public from second-hand smoke. (3) Proposals must contain a statement disclosing any and all direct and indirect organizational or business relationships between the applicant or its subcontractors, including its owners, parent company or subsidiaries, and companies involved in any way in the production, processing, distribution, promotion, sale or use of tobacco. Statutory/Other Authority: ORS 431.834 Statutes/Other Implemented: ORS 431.831 - 431.836 History: HD 11-1997, f. & cert. ef. 9-12-97
333-010-0370 Tobacco Prevention and Education Program: Reporting (1) During each biennium the Director shall prepare a report regarding the awarding of grants from the Tobacco Use Reduction Account and the formation of public-private partnerships in connection with the receipt of funds from the account. The report shall include an evaluation of the effectiveness of the program funded by the Tobacco Use Reduction Account. (2) The Public Health Division shall present the report to the Governor and to those committees of the Legislative Assembly to which matters of public health are assigned. Statutory/Other Authority: ORS 431.834 Statutes/Other Implemented: ORS 431.831 - 431.836 History: HD 11-1997, f. & cert. ef. 9-12-97
333-010-0600 Childhood Diabetes Database: Definitions (1) “Case” means a reportable case of type 1 or type 2 diabetes in an individual who is 18 years of age or younger, and a resident of Oregon. (2) “Diabetes Program” means the Oregon Diabetes Prevention and Control Program of Oregon Health Authority, Public Health Division, the program authorized to collect, receive, and maintain a childhood diabetes database under ORS 444.300. (3) “Date of diagnosis” means the date of initial diagnosis by a practitioner of a case of diabetes being reported to the Diabetes Program. (4) “Effective Date” means the date after which reporting by schools and physicians shall be required. (5) “Identifying information” includes, but is not limited to the student’s name, address, date of birth, and information that identifies the individual or could be used to identify the individual, and relates to the individual's past, present or future health, and the provision of healthcare to the individual. "Identifying information" also includes “Individually Identifiable Health Information” as that is defined in the 1996 Health Insurance Portability and Accountability Act and “Directory Information” as that is defined in the Federal Family Educational Right to Privacy Act (FERPA) (20 U.S.C. § 1232g; 34 CFR Part 99). (6) “Practitioner” means any person whose professional license allows him or her to diagnose or treat diabetes patients. (7) “Reportable childhood diabetes” means a medical condition, occurring in a person aged 18 years or younger, and meeting the criteria for diagnosis of diabetes in a child as outlined by the American Diabetes Association. (Reference: American Diabetes Association. Standards of Medical Care in Diabetes. Diabetes Care 2005; 28: S4-S36.) (8) “School” means any public, public charter, or registered private school in Oregon. [Publications: Publications referenced are available from the agency.] Statutory/Other Authority: ORS 444.300 Statutes/Other Implemented: ORS 444.300-444.330 History: PH 6-2007, f. & cert. ef. 4-13-07
333-010-0610 Childhood Diabetes Database: General Authority and Purpose According to ORS 444.300(1), subject to available funding, including gifts, grants or donations, the Diabetes Program shall establish a uniform, statewide database for the collection of information on type 1 and type 2 diabetes occurring in children in Oregon. The purposes of the database shall be to collect and serve as a repository for data about the prevalence and incidence of diabetes occurring in the pediatric population of this state and to make the data available for scientific and medical research and for assistance in making decisions about the allocation of public resources. Statutory/Other Authority: ORS 444.300 Statutes/Other Implemented: ORS 444.300-444.330 History: PH 6-2007, f. & cert. ef. 4-13-07
333-010-0620 Childhood Diabetes Database: Reporting Requirements for Schools (1) The Diabetes Program shall conduct an annual survey to collect information about diabetes occurring in students age 18 years or younger. Preferably the survey will be completed and returned to the Diabetes Program within 30 days of the date the survey or electronic survey link is sent out, but in no event, later than June 15 of each year. (2) Each school surveyed, upon receipt of written consent of the parent, guardian (or of the student if age18 years) shall report to the Diabetes Program for each student enrolled at the school, during the academic year, who has type 1 or type 2 diabetes, the following information: (a) The name and address of the student; (b) The sex of the student; (c) The date of birth of the student; (d) The type of diabetes diagnosed (if known); (e) The date of diagnosis; (if known); and (f) The name of the child’s practitioner (if known). Statutory/Other Authority: ORS 444.300 Statutes/Other Implemented: ORS 444.300-444.330 History: PH 6-2007, f. & cert. ef. 4-13-07
333-010-0630 Childhood Diabetes Database: Reporting Requirements for Practitioners (1) Upon diagnosing or first treating a case of type 1 or type 2 diabetes in an Oregon child, a practitioner shall report the following information to the Diabetes Program: (a) The name and address of the child; (b) The sex of the child; (c) The date of birth of the child; (d) The type of diabetes diagnosed; (e) The date of diagnosis or first treatment by the reporting practitioner; and (f) The measured height and weight of the child. (2) The practitioner shall report the case to the Diabetes Program within 30 days of diagnosing or first treating the child. (a) The practitioner shall report the case using the Diabetes Program's Practitioner Childhood Diabetes Report Form. The report may be sent to the Diabetes Program by mail, electronically, or by fax. Copies of the form, and directions for submission may be obtained from the Diabetes Program, 800 NE Oregon Street, Portland, Oregon 97232; or may be downloaded through the Diabetes Program’s website. (b) The Diabetes Program may elect to supplement passive reporting from practitioners with active solicitation of reporting through periodic contacts with certain practitioners. Statutory/Other Authority: ORS 444.300 Statutes/Other Implemented: ORS 444.300-444.330 History: PH 6-2007, f. & cert. ef. 4-13-07
333-010-0640 Childhood Diabetes Database: Confidentiality and Access to Data (1) All identifying information regarding individual patients, reporting schools, and practitioners reported pursuant to OAR 333-010-0620 and 333-010-0630 shall be confidential and privileged. Except as required in connection with the administration or enforcement of public health laws or rules, no public health official, employee or agent shall be examined in an administrative or judicial proceeding as to the existence or contents of data collected under the childhood diabetes database. (2) The information collected and maintained by the diabetes database shall be stored in physically secure locations and in a technologically secure manner, and shall be used solely for the purposes stated in ORS 444.330 Statutory/Other Authority: ORS 444.300 Statutes/Other Implemented: ORS 444.300-444.330 History: PH 6-2007, f. & cert. ef. 4-13-07
333-010-0650 Childhood Diabetes Database: Research Studies (1) Prior to any confidential data from the database being released to a researcher, the researcher must: (a) Obtain approval from Oregon Health Authority, Public Health Division Institutional Review Board, established in accordance with 45 C.F.R. 46. (b) Obtain approval from the Diabetes Program. (2) In reviewing research proposals for approval under section (1)(b) of this rule, the Diabetes Program, with input from its advisory committee, shall consider whether the research will: (a) Further knowledge of the prevalence and incidence of diabetes occurring in the pediatric population; (b) Better define causes of and treatment for childhood diabetes; or (c) Inform decision-making about the allocation of public resources. (3) The Diabetes Program shall also ensure that the research proposal has been reviewed for scientific excellence by a nationally recognized peer review group. (4) Prior to confidential information being released to a researcher, the Diabetes Program will contact the family and offer the option to decline contact regarding research opportunities. Statutory/Other Authority: ORS 444.300 Statutes/Other Implemented: ORS 444.300-444.330 History: PH 6-2007, f. & cert. ef. 4-13-07