Oregon Administrative Rules › Chapter 943 - OREGON HEALTH AUTHORITY › Division 120 - PROVIDER RULES › Section 943-120-0100 - Definitions

Current through Register Vol. 63, No. 7, July 1, 2024
The following definitions apply to OAR 943-120-0100 through 943-120-0200:
(1)
			 "Access" means the ability or means necessary to read, write, modify,
			 or communicate data or information or otherwise use any information
			 system resource.
(2)
			 "Agent" means a third party or organization that contracts with a
			 provider, allied agency, coordinated care organization (CCO) or
			 prepaid health plan (PHP), to perform designated services in order to
			 facilitate a transaction or conduct other business functions on its
			 behalf. Agents include billing agents, claims clearinghouses,
			 vendors, billing services, service bureaus, and accounts receivable
			 management firms. Agents may also be clinics, group practices, and
			 facilities that submit billings on behalf of providers but the
			 payment is made to a provider, including the following: an employer
			 of a provider, if a provider is required as a condition of employment
			 to turn over his fees to the employer; the facility in which the
			 service is provided, if a provider has a contract under which the
			 facility submits the claim; or a foundation, plan, or similar
			 organization operating an organized health care delivery system, if a
			 provider has a contract under which the organization submits the
			 claim. Agents may also include electronic data transmission
			 submitters.
(3) "Allied
			 Agency" means local and regional allied agencies and includes local
			 mental health authority, community mental health programs, Oregon
			 Youth Authority, Department of Corrections, local health departments,
			 schools, education service districts, developmental disability
			 service programs, area agencies on aging, federally recognized
			 American Indian tribes, and other governmental agencies or regional
			 authorities that have a contract (including an interagency,
			 intergovernmental, or grant agreement, or an agreement with an
			 American Indian tribe pursuant to ORS
			 190.110) with the
			 Oregon Health Authority to provide for the delivery of services to
			 covered individuals and that request to conduct electronic data
			 transactions in relation to the contract.
(4) "Authority" or "Oregon Health
			 Authority" means the agency established in ORS Chapter 413 that
			 administers the funds for Titles XIX and XXI of the Social Security
			 Act. It is the single state agency for the administration of the
			 medical assistance program under ORS chapter 414. For purposes of
			 these rules, the agencies under the authority of the Authority are
			 the Public Health Division, the Addictions and Mental Health
			 Division, and the Division of Medical Assistance Programs..
(5) "Authority Network and
			 Information Systems" means the Authority's computer infrastructure
			 that provides personal communications, confidential information,
			 regional, wide area and local networks, and the internetworking of
			 various types of networks on behalf of the Authority.
(6) "Clinic" means a group
			 practice, facility, or organization that is an employer of a
			 provider, if a provider is required as a condition of employment to
			 turn over his fees to the employer; the facility in which the service
			 is provided, if a provider has a contract under which the facility
			 submits the claim; or a foundation, plan, or similar organization
			 operating an organized health care delivery system, if a provider has
			 a contract under which the organization submits the claim; and the
			 group practice, facility, or organization is enrolled with the
			 Authority, and payments are made to the group practice, facility, or
			 organization. If the entity solely submits billings on behalf of
			 providers and payments are made to each provider, then the entity is
			 an agent.
(7)
			 "Confidential Information" means information relating to covered
			 individuals which is exchanged by and between the Authority, a
			 provider, CCO, PHP, clinic, allied agency, or agents for various
			 business purposes, but which is protected from disclosure to
			 unauthorized individuals or entities by applicable state and federal
			 statutes such as ORS
			 414.679,
			 344.600,
			 410.150,
			 411.320,
			 418.130, or the Health
			 Insurance Portability and Accountability Act of 1996,
			 Public Law
			 104-191 and its implementing
			 regulations. These statutes and regulations are collectively referred
			 to as "Privacy Statutes and Regulations."
(8) "Contract" means a specific
			 written agreement between the Authority and a provider, CCO, PHP,
			 clinic, or allied agency that provides or manages the provision of
			 services, goods, or supplies to covered individuals and where the
			 Authority and a provider, CCO, PHP, clinic, or allied agency may
			 exchange data. A contract specifically includes, without limitation,
			 an Authority provider enrollment agreement, fully capitated heath
			 plan managed care contract, dental care organization managed care
			 contract, mental health organization managed care contract, chemical
			 dependency organization managed care contract, physician care
			 organization managed care contract, coordinated care organization
			 contract, a county financial assistance agreement, or any other
			 applicable written agreement, interagency agreement,
			 intergovernmental agreement, or grant agreement between the Authority
			 and a provider, CCO, PHP, clinic, or allied agency.
(9) "Coordinated Care Organization"
			 (CCO) means an entity that has been certified by the Authority to
			 provide coordinated and integrated health services.
(10) "Covered Entity" means a
			 health plan, health care clearing house, health care provider who
			 transmits any health information in electronic form in connection
			 with a transaction covered by
			 45 CFR
			 162.100 through
			 162.1902,
			 or allied agency that transmits any health information in electronic
			 form in connection with a transaction, including direct data entry
			 (DDE), and who must comply with the National Provider Identifier
			 (NPI) requirements of
			 45 CFR 162.402
			 through
			 162.414.
(11) "Covered Individual" means
			 individuals who are eligible for payment of certain services or
			 supplies provided to them or their eligible dependents by or through
			 a provider, CCO, PHP, clinic, or allied agency under the terms of a
			 contract applicable to a governmental program for which the Authority
			 processes or administers data transmissions.
(12) "Data" means a formalized
			 representation of specific facts or concepts suitable for
			 communication, interpretation, or processing by individuals or by
			 automatic means.
(13)
			 "Data Transmission" means the transfer or exchange of data between
			 the Authority and a web portal or electronic data interchange (EDI)
			 submitter by means of an information system which is compatible for
			 that purpose and includes without limitation, web portal, EDI,
			 electronic remittance advice (ERA), or electronic media claims (EMC)
			 transmissions.
(14)
			 "Department" means the Department of Human Services.
(15) "Direct Data Entry (DDE)"
			 means the process using dumb terminals or computer browser screens
			 where data is directly keyed into a health plan's computer by a
			 provider or its agent, such as through the use of a web
			 portal.
(16) "Electronic
			 Data Interchange (EDI)" means the exchange of business documents from
			 application to application in a federally mandated format or, if no
			 federal standard has been promulgated, using bulk transmission
			 processes and other formats as the Authority designates for EDI
			 transactions. For purposes of these rules (OAR 943-120-0100  through
			 943-120-0200), EDI does not include electronic transmission by web
			 portal.
(17) "Electronic
			 Data Interchange Submitter" means an individual or entity authorized
			 to establish the electronic media connection with the Authority to
			 conduct an EDI transaction. An EDI submitter may be a trading partner
			 or an agent of a trading partner.
(18) "Electronic Media" means
			 electronic storage media including memory devices in computers or
			 computer hard drives; any removable or transportable digital memory
			 medium such as magnetic tape or disk, optical disk, or digital memory
			 card; or transmission media used to exchange information already in
			 electronic storage media. Transmission media includes but is not
			 limited to the internet (wide-open), extranet (using internet
			 technology to link a business with information accessible only to
			 collaborating parties), leased lines, dial-up lines, private
			 networks, and the physical movement of removable or transportable
			 electronic storage media. Certain transmissions, including paper via
			 facsimile and voice via telephone, are not considered transmissions
			 by electronic media because the information being exchanged did not
			 exist in electronic form before transmission.
(19) "Electronic Media Claims
			 (EMC)" means an electronic media means of submitting claims or
			 encounters for payment of services or supplies provided by a
			 provider, CCO, PHP, clinic, or allied agency to a covered
			 individual.
(20)
			 "Electronic Remittance Advice (ERA)" means an electronic file in X12
			 format containing information pertaining to the disposition of a
			 specific claim for payment of services or supplies rendered to
			 covered individuals which are filed with the Authority on behalf of
			 covered individuals by providers, clinics, or allied agencies. The
			 documents include, without limitation, the provider name and address,
			 individual name, date of service, amount billed, amount paid, whether
			 the claim was approved or denied, and if denied, the specific reason
			 for the denial. For CCOs or PHPs, the remittance advice file contains
			 information on the adjudication status of encounter claims
			 submitted.
(21)
			 "Electronic Data Transaction (EDT)" means a transaction governed by
			 the Health Insurance Portability and Accountability Act (HIPAA)
			 transaction rule, conducted by either web portal or EDI.
(22) "Envelope" means a control
			 structure in a mutually agreed upon format for the electronic
			 interchange of one or more encoded data transmissions either sent or
			 received by an EDI submitter or the Authority.
(23) "HIPAA Transaction Rule" means
			 the standards for electronic transactions at  45 CFR Part 160 and 162
			  as revised effective January 16, 2009 (from version in effect on
			 January 1, 2008) adopted by the Department of Health and Human
			 Services (DHHS) to implement the Health Insurance Portability and
			 Accountability Act of 1996,
			 42 USC
			 1320 d et. seq.
(24) "Incident" means the attempted
			 or successful unauthorized access, use, disclosure, modification, or
			 destruction of an information system or information asset including
			 but not limited to unauthorized disclosure of information, failure to
			 protect user IDs, and theft of computer equipment using or storing
			 Authority information assets or confidential information.
(25) "Individual User Profile
			 (IUP)" means Authority forms used to authorize a user, identify their
			 job assignment, and the required access to the Authority's network
			 and information system. It generates a unique security access code
			 used to access the Authority's network and information
			 system.
(26) "Information
			 Asset" means all information, also known as data, provided through
			 the Authority, regardless of the source, which requires measures for
			 security and privacy of the information.
(27) "Information System" means an
			 interconnected set of information resources under the same direct
			 management control that shares common functionality. A system
			 normally includes hardware, software, information, data,
			 applications, communications, and trained personnel necessary for
			 successful data transmission.
(28) "Lost or Indecipherable
			 Transmission" means a data transmission which is never received by or
			 cannot be processed to completion by the receiving party in the
			 format or composition received because it is garbled or incomplete,
			 regardless of how or why the message was rendered garbled or
			 incomplete.
(29)
			 "Mailbox" means the term used by the Authority to indicate trading
			 partner-specific locations on the Authority's secure file transfer
			 protocol (SFTP) server to deposit and retrieve electronic data
			 identified by a unique Authority assigned trading partner
			 number.
(30) "Password"
			 means the alpha-numeric codes and special characters assigned to an
			 EDI submitter by the Authority for the purpose of allowing access to
			 the Authority's information system, including the web portal, for the
			 purpose of successfully executing data transmissions or otherwise
			 carrying out the express terms of a trading partner agreement or
			 provider enrollment agreement and these rules.
(31) "Personal Identification
			 Number (PIN)" means the alpha-numeric codes assigned to web portal
			 submitters by the Authority for the purpose of allowing access to the
			 Authority's information system, including the web portal, for the
			 purpose of successfully executing DDE, data transmissions, or
			 otherwise carrying out the express terms of a trading partner
			 agreement, provider enrollment agreement, and these rules.
(32) "Prepaid Health Plan (PHP) or
			 Plan" means a managed health care, dental care, chemical dependency,
			 physician care organization, or mental health care organization that
			 contracts with the Authority on a case managed, prepaid, capitated
			 basis under the Oregon Health Plan (OHP).
(33) "Provider" means an
			 individual, facility, institution, corporate entity, or other
			 organization which supplies or provides for the supply of services,
			 goods or supplies to covered individuals pursuant to a contract,
			 including but not limited to a provider enrollment agreement with the
			 Authority. A provider does not include billing providers as used in
			 the Division of Medical Assistance (DMAP) general rules but does
			 include non -healthcare providers such as foster care homes. DMAP
			 billing providers are defined in these rules as agents, except for
			 DMAP billing providers that are clinics.
(34) "Provider Enrollment
			 Agreement" means an agreement between the Authority and a provider
			 for payment for the provision of covered services to covered
			 individuals.
(35)
			 "Registered Transaction" means each type of EDI transaction
			 applicable to a trading partner that must be registered with the
			 Authority before it can be tested or approved for EDI
			 transmission.
(36)
			 "Security Access Codes" means the access code assigned by the
			 Authority to the web portal submitter or EDI submitter for the
			 purpose of allowing access to the Authority's information system,
			 including the web portal, to execute data transmissions or otherwise
			 carry out the express terms of a trading partner agreement, provider
			 enrollment agreement, and these rules. Security access codes may
			 include passwords, PINs, or other codes. For password standards,
			 refer to the Authority's ISPO best practice:
			 http://www.dhs.state.or.us/policy/admin/security/090_002.htm [File
			 Link Not Available].
(37)
			 "Source Documents" means documents or electronic files containing
			 underlying data which is or may be required as part of a data
			 transmission with respect to a claim for payment of charges for
			 medical services or supplies provided to a covered individual, or
			 with respect to any other transaction. Examples of data contained
			 within a specific source document include but are not limited to an
			 individual's name and identification number, claim number, diagnosis
			 code for the services provided, dates of service, service procedure
			 description, applicable charges for the services provided, and a
			 provider's, CCOs, PHP's, clinic's, or allied agency's name,
			 identification number, and signature.
(38) "Standard" means a rule,
			 condition, or requirement describing the following information for
			 products, systems, or practices:
(a) Classification of components;
(b) Specification of
			 materials, performance, or operations; or
(c) Delineation of
			 procedures.