Oregon Administrative Rules › Chapter 407 - DEPARTMENT OF HUMAN SERVICES › Division 120 - PROVIDER RULES › Section 407-120-0300 - Definitions

Current through Register Vol. 63, No. 7, July 1, 2024
The following definitions apply to OAR 407-120-0300  to
				407-120-0400:
(1) "Abuse" means
			 provider practices that are inconsistent with sound fiscal, business, or
			 medical practices resulting in an unnecessary cost to the Department, or in
			 reimbursement for services that are not medically necessary or that fail to
			 meet professionally recognized standards for health care. It also includes
			 actions by clients or recipients that result in unnecessary cost to the
			 Department.
(2) "Advance Directive"
			 means a form that allows an individual to have another individual make health
			 care decisions when he or she cannot make decisions and informs a doctor if the
			 individual does not want any life sustaining help if he or she is near
			 death.
(3) "Benefit Package" means
			 the package of covered health care services for which the client is
			 eligible.
(4) "Billing Agent or
			 Billing Service" means a third party or organization that contracts with a
			 provider to perform designated services in order to facilitate claim submission
			 or electronic transactions on behalf of the provider.
(5) "Billing Provider" means an individual,
			 agent, business, corporation, clinic, group, institution, or other entity who,
			 in connection with submission of claims to the Department, receives or directs
			 payment from the Department on behalf of a performing provider and has been
			 delegated the authority to obligate or act on behalf of the performing
			 provider.
(6) "Children's Health
			 Insurance Program (CHIP)" means a federal and state funded portion of the
			 Oregon Health Plan (OHP) established by Title XXI of the Social Security Act
			 and administered by the Division of Medical Assistance Programs
			 (DMAP).
(7) "Claim" means a bill
			 for services, a line item of a service, or all services for one client within a
			 bill. Claim includes a bill or an encounter associated with requesting
			 reimbursement, whether submitted on paper or electronically. Claim also
			 includes any other methodology for requesting reimbursement that may be
			 established in contract or program-specific rules.
(8) "Client or Recipient" means an individual
			 found eligible by the Department to receive services under the OHP
			 demonstration, medical assistance program, or other public assistance programs
			 administered by the Department. The following OHP categories are eligible for
			 enrollment:
(a) Temporary Assistance to Needy
			 Families (TANF) are categorically eligible families with income levels under
			 current TANF eligibility rules;
(b)
			 CHIP children under one year of age whose household has income under 185%
			 Federal Poverty Level (FPL) and do not meet one of the other eligibility
			 classifications;
(c) Poverty Level
			 Medical (PLM) adults under 100% of the FPL are clients who are pregnant women
			 with income under 100% of FPL;
(d)
			 PLM adults over 100% of the FPL are clients who are pregnant women with income
			 between 100% and 185% of the FPL;
(e) PLM children under one year of age who
			 have family income under 133% of the FPL or were born to mothers who were
			 eligible as PLM adults at the time of the child's birth;
(f) PLM or CHIP children one through five
			 years of age who have family income under 185% of the FPL and do not meet one
			 of the other eligibility classifications;
(g) PLM or CHIP children six through 18 years
			 of age who have family income under 185% of the FPL and do not meet one of the
			 other eligibility classifications;
(h) OHP adults and couples are clients age 19
			 or over and not Medicare eligible, with income below 100% of the FPL who do not
			 meet one of the other eligibility classifications, and do not have an unborn
			 child or a child under age 19 in the household;
(i) OHP families are clients, age 19 or over
			 and not Medicare eligible, with income below 100% of the FPL who do not meet
			 one of the other eligibility classifications, and have an unborn child or a
			 child under the age of 19 in the household;
(j) General Assistance (GA) recipients are
			 clients who are eligible by virtue of their eligibility under the GA program,
			 ORS 411.710 et seq.;
(k) Assistance to Blind and Disabled (AB/AD)
			 with Medicare eligibles are clients with concurrent Medicare eligibility with
			 income levels under current eligibility rules;
(l) AB/AD without Medicare eligibles are
			 clients without Medicare with income levels under current eligibility
			 rules;
(m) Old Age Assistance (OAA)
			 with Medicare eligibles are clients with concurrent Medicare Part A or Medicare
			 Parts A and B eligibility with income levels under current eligibility
			 rules;
(n) OAA with Medicare Part B
			 only are OAA eligibles with concurrent Medicare Part B only income under
			 current eligibility rules;
(o) OAA
			 without Medicare eligibles are clients without Medicare with income levels
			 under current eligibility rules; or
(p) Children, Adults and Families (CAF)
			 children are clients with medical eligibility determined by CAF or Oregon Youth
			 Authority (OYA) receiving OHP under ORS
			 414.025,
			 418.034, and
			 418.187 to
			 418.970. These individuals are
			 generally in placement outside of their homes and in the care or custody of CAF
			 or OYA.