Oregon Administrative Rules › Chapter 407 - DEPARTMENT OF HUMAN SERVICES › Division 120 - PROVIDER RULES › Section 407-120-0100 - Definitions

Current through Register Vol. 63, No. 7, July 1, 2024
The following definitions apply to OAR 407-120-0100  through
				407-120-0200:
(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, 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 Department to
			 provide for the delivery of services to covered individuals and that request to
			 conduct electronic data transactions in relation to the contract.
(4) "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 Department, 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.
(5) "Confidential Information" means
			 information relating to covered individuals which is exchanged by and between
			 the Department, a provider, 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
			 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."
(6) "Contract" means
			 a specific written agreement between the Department and a provider, PHP,
			 clinic, or allied agency that provides or manages the provision of services,
			 goods, or supplies to covered individuals and where the Department and a
			 provider, PHP, clinic, or allied agency may exchange data. A contract
			 specifically includes, without limitation, a Department 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, a county financial assistance
			 agreement, or any other applicable written agreement, interagency agreement,
			 intergovernmental agreement, or grant agreement between the Department and a
			 provider, PHP, clinic, or allied agency.
(7) "Covered Entity" means a health plan,
			 health care clearing house, health care provider, 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.
(8) "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, PHP, clinic, or allied
			 agency under the terms of a contract applicable to a governmental program for
			 which the Department processes or administers data transmissions.
(9) "Data" means a formalized representation
			 of specific facts or concepts suitable for communication, interpretation, or
			 processing by individuals or by automatic means.
(10) Data Transmission" means the transfer or
			 exchange of data between the Department 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.
(11) "Department"
			 means the Department of Human Services.
(12) "Department Network and Information
			 Systems" means the Department'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
			 Department.
(13) "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.
(14) "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 Department
			 designates for EDI transactions. For purposes of these rules (OAR 407-120-0100  through 407-120-0200), EDI does not include electronic transmission by web
			 portal.
(15) "Electronic Data
			 Interchange Submitter" means an individual or entity authorized to establish
			 the electronic media connection with the Department to conduct an EDI
			 transaction. An EDI submitter may be a trading partner or an agent of a trading
			 partner.
(16) "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.
(17) "Electronic
			 Media Claims (EMC)" means an electronic media means of submitting claims or
			 encounters for payment of services or supplies provided by a provider, PHP,
			 clinic, or allied agency to a covered individual.
(18) "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 Department 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 PHPs, the remittance
			 advice file contains information on the adjudication status of encounter claims
			 submitted.
(19) "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.
(20)
			 "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 Department.
(21) "HIPAA Transaction Rule" means the
			 standards for electronic transactions at  45 CFR Part 160 and 162  (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.
(22) "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 Department information assets or
			 confidential information.
(23)
			 "Individual User Profile (IUP)" means Department forms used to authorize a
			 user, identify their job assignment, and the required access to the
			 Department's network and information system. It generates a unique security
			 access code used to access the Department's network and information
			 system.
(24) "Information Asset"
			 means all information, also known as data, provided through the Department,
			 regardless of the source, which requires measures for security and privacy of
			 the information.
(25) "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.
(26) "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.
(27)
			 "Mailbox" means the term used by the Department to indicate trading
			 partner-specific locations on the Department's secure file transfer protocol
			 (SFTP) server to deposit and retrieve electronic data identified by a unique
			 Department assigned trading partner number.
(28) "Password" means the alpha-numeric codes
			 assigned to an EDI submitter by the Department for the purpose of allowing
			 access to the Department'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.
(29)
			 "Personal Identification Number (PIN)" means the alpha-numeric codes assigned
			 to web portal submitters by the Department for the purpose of allowing access
			 to the Department'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.
(30) "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
			 Department on a case managed, prepaid, capitated basis under the Oregon Health
			 Plan (OHP).
(31) "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 Department. A provider does not include
			 billing providers as used in the Division of Medical Assistance (DMAP) general
			 rules. DMAP billing providers are defined in these rules as agents, except for
			 DMAP billing providers that are clinics.
(32) "Provider Enrollment Agreement" means an
			 agreement between the Department and a provider for payment for the provision
			 of covered services to covered individuals.
(33) "Registered Transaction" means each type
			 of EDI transaction applicable to a trading partner that must be registered with
			 the Department before it can be tested or approved for EDI
			 transmission.
(34) "Security Access
			 Codes" means the alpha-numeric codes assigned by the Department to the web
			 portal submitter or EDI submitter for the purpose of allowing access to the
			 Department'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.
(35) "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, PHP's, clinic's, or allied agency's name,
			 identification number, and signature.
(36) "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.