reglab/statecodes huggingface dataset:
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 115 - OHP Bridge › Section 410-115-0030 - OHP Bridge Covered Services

Current through Register Vol. 63, No. 7, July 1, 2024
(1) OHP Bridge
			 members shall be eligible for the Oregon Health Plan (OHP) Bridge benefit
			 package.
(a) Benefit Package identifier:
			 BRG
(b) Coverage for the OHP Bridge
			 benefit package includes:
(A) Coverage of the
			 ten (10) essential health benefits described in section 1302(b) of the
			 Affordable Care Act as adopted under
			 42 CFR
			 600.405;
(B) Covered Services set forth for the Oregon
			 Health Plan and defined in OAR 410-141-3820; and,
(C) All other services described in the
			 applicable CCO Contracts.
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 115 - OHP Bridge › Section 410-115-0035 - No Premiums or Copayments

Current through Register Vol. 63, No. 7, July 1, 2024
OHP Bridge members are not and shall not be required to pay any
				premiums, copayments and they do not and shall not have to pay any provider to
				receive covered services.
Statutory/Other Authority: ORS
				  413.042,
				  414.065,
				  414.241,
				  42 CFR
				  600.505,
				  600.510,
				  600.515,
				  600.520 & 600.525
Statutes/Other Implemented: ORS
				  413.042 &
				  414.241
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 115 - OHP Bridge › Section 410-115-0040 - Service Authorization

Current through Register Vol. 63, No. 7, July 1, 2024
The service authorization provisions for OHP Bridge are
				described in OAR 410-141-3835.
Statutory/Other Authority: ORS
				  413.042,
				  414.065,
				  414.241,
				  414.615,
				  414.625,
				  414.635,
				  414.651 &  42 CFR 600
Statutes/Other Implemented: ORS
				  413.042,
				  414.065,
				  414.241 & ORS
				  414.610-414.685
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 115 - OHP Bridge › Section 410-115-0045 - CCO Administration of OHP Bridge - Basic Health Program; OHP Bridge Enrollment and Choice of CCO

Current through Register Vol. 63, No. 7, July 1, 2024
(1) OHP Bridge -
			 Basic Health Program shall be administered by Coordinated Care Organizations
			 (CCOs) pursuant to an OHP Bridge - Basic Health Program CCO Contract entered
			 into by each CCO and the state acting by and through the Authority.
(2) The terms and conditions included in the
			 OHP Bridge - Basic Health Program CCO Contract shall comply with all applicable
			 state and federal laws, including, without limitation
			 42 USC
			 18051,  42 CFR Part 660, ORS
			 414.241 and
			 414.245, and OAR Chapter 410,
			 Division 141. The rules set forth in this Division 115, OAR Chapter 410,
			 Division 141, and the federal regulations set forth in  42 CFR Part 600.
(3) Applicants determined by the
			 Authority to be eligible for OHP Bridge - Basic Health Program shall be
			 enrolled in a CCO. Enrollment and disenrollment from a CCO, including choice of
			 CCO, shall be made in accordance with OAR 410-141-3805  and OAR 410-141-3810,
			 except that:
(a) Exceptions to mandatory
			 managed care enrollment described in OAR 410-141-3805  (4 - 16) do not apply to
			 OHP Bridge - Basic Health Program; and
(b) OHP Bridge Basic Health Program members
			 cannot be disenrolled from the OHP Bridge - Basic Health Program and be covered
			 under the fee-for-service (FFS) delivery system under OAR
			 410-141-3810.
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 115 - OHP Bridge › Section 410-115-0050 - OHP Bridge - BHP Trust Fund

Current through Register Vol. 63, No. 7, July 1, 2024
The Authority shall maintain an OHP Bridge - BHP Trust Fund for
				the receipt of the federal funds and other non-federal funds the Authority is
				required to use to pay for the Basic Health Program. Pursuant to
				42 CFR
				600.705, the Authority does not have the
				right to use the funds maintained in the BHP Trust for any purpose other than
				the following:
(1) Paying contracted
			 rates to the CCOs for providing OHP Bridge - Basic Health Program covered
			 services to OHP Bridge - Basic Health Program members (including ancillary
			 payments related to CCO or provider (or both) performance incentives, risk
			 management, and similar purposes as set forth in the OHP Bridge - Basic Health
			 Program CCO Contract);
(2) Paying
			 the CCOs to provide additional covered services or benefits to OHP Bridge -
			 Basic Health Program members, which may be delivered through a network managed
			 by the Authority or its administrator;
(3) Paying health care providers directly for
			 covered services that are not included in the OHP Bridge - Basic Health Program
			 CCO contract(s), but are included in the BRG Benefit Package defined in OAR
			 410-115-0030; and,
(4) Paying
			 health care providers directly to augment amounts paid by CCOs for services
			 delivered to OHP Bridge - Basic Health Program members.
Statutory/Other Authority: ORS
				  413.042,
				  414.241,
				  414.245,  42 CFR 600, 600.700,
				  600.705,
				  600.710 & 600.715
Statutes/Other Implemented: ORS
				  413.042,
				  414.241,
				  414.245 & ORS
				  414.065
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 120 - MEDICAL ASSISTANCE PROGRAMS › Section 410-120-0001 - Interpreter Services

Current through Register Vol. 63, No. 7, July 1, 2024
(1) Health care
			 providers are required to provide health care language interpreter services for
			 Medicaid members with Limited English Proficiency (LEP) and communication
			 services for people who are deaf and hard of hearing pursuant to Title VI of
			 the Civil Rights Act, The Americans with Disabilities Act (ADA), ORS
			 413.550 to
			 413.558, and subject to the
			 requirements in OAR Chapter 950 Division 50. These services must be provided at
			 no cost to the member. This rule applies to Fee-For-Service providers; for
			 those contracting with a Coordinated Care Organization, refer to OAR
			 410-141-3515(12)  or contact your contracted CCO for requirements.
(2) Enrolled OHP providers who wish to bill
			 the Authority for Interpreter services when communicating with a patient who
			 prefers to communicate in a language other than English, including signed
			 languages:
(a) Shall work with a qualified or
			 certified health care interpreter from the health care interpreter central
			 registry administered by the Authority;
(b) Exceptions to working with the central
			 registry interpreters are specified in OAR 950-050-0160;
(c) The Health Care Interpreter Registry can
			 be searched online at
https://hciregistry.dhsoha.state.or.us/
.
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 120 - MEDICAL ASSISTANCE PROGRAMS › Section 410-120-0003 - OHP Standard Benefit Package

Current through Register Vol. 63, No. 7, July 1, 2024
The OHP Standard benefit package is eliminated effective
				January 1, 2014. Although references to OHP Standard exist elsewhere in rule,
				the benefit package currently is not funded and is not offered as a benefit.
				Those enrolled in OHP Standard are enrolled in other existing benefit
				packages.
Stat. Auth.: ORS
				  413.042
Stats. Implemented: ORS
				  414.706
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 120 - MEDICAL ASSISTANCE PROGRAMS › Section 410-120-0006 - Medical Eligibility Standards

Current through Register Vol. 63, No. 7, July 1, 2024
As the state Medicaid and CHIP agency, the Oregon Health
				Authority (Authority) is responsible for establishing and implementing
				eligibility policies and procedures consistent with applicable law. As outlined
				in OAR 943-001-0020, the Authority and the Department of Human Services
				(Department) work together to adopt rules to assure that medical assistance
				eligibility procedures and determinations are consistent across both
				agencies.
(1) The Authority adopts and
			 incorporates by reference the rules established in OAR Chapter 461 for all
			 overpayment, personal injury liens, and estates administration for Authority
			 programs covered under OAR chapter 410, division 200.
(2) Any reference to OAR chapter 461 in
			 contracts of the Authority are deemed to be references to the requirements of
			 this rule and shall be construed to apply to all eligibility policies,
			 procedures, and determinations by or through the Authority.
(3) For purposes of this rule, references in
			 OAR chapter 461 to the Department or to the Authority shall be construed to be
			 references to both agencies.
Statutory/Other Authority: ORS
				  413.042
Statutes/Other Implemented: ORS
				  413.042 &
				  414.065
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 120 - MEDICAL ASSISTANCE PROGRAMS › Section 410-120-0011

Current through Register Vol. 63, No. 7, July 1, 2024
Statutory/Other Authority: ORS
				  409.050
Statutes/Other Implemented: ORS
				  414.065
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 120 - MEDICAL ASSISTANCE PROGRAMS › Section 410-120-0030 - Children's Health Insurance Program

Current through Register Vol. 63, No. 7, July 1, 2024
(1) The Children's Health Insurance Program
			 (CHIP) is a federal non-entitlement program. The Oregon Health Authority
			 (Authority), Division of Medical Assistance Program (Division) administers two
			 programs funded under CHIP in accordance with the Oregon Health Plan (OHP)
			 waiver and the CHIP state plan:
(a) CHIP:
			 Provides health coverage for uninsured, low-income children who are ineligible
			 for Medicaid;
(b) CHIP Pre-natal
			 care expansion program.
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 120 - MEDICAL ASSISTANCE PROGRAMS › Section 410-120-0035 - Public Entity

Current through Register Vol. 63, No. 7, July 1, 2024
(1) This rule
			 pertains to Centers for Medicare and Medicaid (CMS) regulations for payments to
			 and from the Oregon Health Authority (Authority) and public entities.
(2) Effective July 1, 2008, unit of
			 government providers responsible by rule or contract for the local match share
			 portion for claims eligible for Federal Financial Participation (FFP) submitted
			 to Medicaid for reimbursement must submit the local match payment prior to the
			 Authority claiming the federal share from CMS:
(a) Before the provider submits its claims to
			 the Authority, the provider must transfer funds from allowable sources to the
			 Authority representing the local match share of the total allowable cost for
			 claimed services;
(b) Upon receipt
			 of provider's transfer of the local match share and the Authority's receipt of
			 claims in the Medical Management Information System (MMIS) that are
			 reimbursable to the extent of the transferred local match share amount, the
			 Authority will claim FFP from CMS and reimburse the provider for the total
			 reimbursable allowable claimed amount for the services;
(c) Transfer of the local match share to the
			 Authority means that the provider certifies that for the purposes of
			 42 CFR
			 433.51, the funds it transfers to the
			 Authority for the local match share are public funds that are not federal
			 funds, or are federal funds authorized by federal law to be used to match other
			 federal funds; and that all sources of funds are allowable under  42 CFR 433
			  Subpart B.
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 120 - MEDICAL ASSISTANCE PROGRAMS › Section 410-120-0045 - Applications for Medical Assistance at Provider Locations

Current through Register Vol. 63, No. 7, July 1, 2024
(1)
			 The Oregon Health Authority (Authority) allows Division enrolled providers the
			 opportunity to assist patients applying for public and private health coverage
			 offered through the Authority and the Oregon Health Insurance Exchange (OHIX,
			 as defined in ORS 741.300(6)). To
			 apply for this opportunity, providers fill out and submit form OHA 3128,
			 Application Assistance by Provider Staff; this is an addendum to the provider's
			 agreement to provide Medicaid reimbursed services. Once the provider is
			 determined certified by the Authority to provide application assistance,
			 providers shall receive an approval letter, requirements for assister
			 certification, training requirements, and other information.
(2) For purposes of this rule, the provider's
			 practice shall be referred to as a site. Sites can be, but are not limited to,
			 the following:
(a) Hospitals;
(b) Federally qualified health centers/rural
			 health clinics (FQHC/RHCs);
(c)
			 County health departments;
(d)
			 Substance Use Disorder adult and adolescent treatment and recovery
			 centers;
(e) Tribal health
			 clinics;
(f) Family Planning
			 clinics;
(g) Other primary care
			 clinics as approved by the Authority.
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 120 - MEDICAL ASSISTANCE PROGRAMS › Section 410-120-0250 - Managed Care Entity

Current through Register Vol. 63, No. 7, July 1, 2024
(1) The
			 Authority provides clients with health services through contracts with a
			 Managed Care Entity (MCE).
(2) The
			 MCE is responsible for providing, arranging, and making reimbursement
			 arrangements for covered services as governed by state and federal law, or
			 MCE's contract with the Authority, and the OHP administrative rules governing
			 MCEs (OAR chapter 410, division 141).
(3) All MCEs are required to provide benefit
			 coverage pursuant to OAR 410-120-1210  and 410-141-0480  through 410-141-0520;
			 however, authorization criteria may vary between MCEs. It is the providers'
			 responsibility to comply with the MCE's Prior Authorization requirements or
			 other policies necessary for reimbursement from the MCE before providing
			 services to any OHP client enrolled in an MCE.
Statutory/Other Authority: ORS
				  413.042
Statutes/Other Implemented: ORS
				  414.025,
				  414.065,
				  414.631  & 414.651
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 120 - MEDICAL ASSISTANCE PROGRAMS › Section 410-120-1140 - Verification of Eligibility and Coverage

Current through Register Vol. 63, No. 7, July 1, 2024
(1) To ensure Division reimbursement of
			 services, providers are responsible to verify the following before rendering
			 services:
(a) Client eligibility: That the
			 person is an eligible Oregon Health Plan (OHP) client on the date(s) services
			 are rendered; and
(b) Benefit
			 coverage: That the person is enrolled in an OHP benefit package that covers the
			 services they plan to render. See OAR 410-120-1210  for services covered under
			 each Division benefit package.
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 120 - MEDICAL ASSISTANCE PROGRAMS › Section 410-120-1180 - Medical Assistance Benefits: Out-of-State Services

Current through Register Vol. 63, No. 7, July 1, 2024
(1) A provider located in a state other than
			 Oregon whose services are rendered in that state shall be licensed and
			 otherwise certified by the proper agencies in the state of residence as
			 qualified to render the services. Certain cities within 75 miles of the Oregon
			 border may be closer for Oregon residents than major cities in Oregon, and
			 therefore, these areas are considered contiguous areas, and providers are
			 treated as providing in-state services.
(2) Out-of-state providers must enroll with
			 the Authority as described in OARs 943-120-0320  and 410-120-1260, Provider
			 Enrollment. Out-of-state providers must provide services and bill in compliance
			 with these rules and the OARs for the appropriate type of services
			 provided.
(3) Payment rates for
			 out-of-state providers are established in the individual provider rules through
			 contracts or service agreements and in accordance with OAR chapter 943,
			 division 120 and OAR 410-120-1340, Payment.
(4) For enrolled non-contiguous, out-of-state
			 providers, the Division reimburses for covered services under any of the
			 following conditions:
(a) For clients enrolled
			 in an MCE:
(A) The service is authorized by an
			 MCE, and payment to the out-of-state provider is the responsibility of the
			 MCE;
(B) If a client has coverage
			 through an MCE, the request for non-emergency services must be referred to the
			 MCE. Payment for these services is the responsibility of the MCE;
(C) The service or item is not available in
			 the State of Oregon or provision of the service or item by an out-of-state
			 provider is cost effective, as determined by the MCE.
(D) MCE must provide all Members with the
			 option to utilize mail order pharmacy services. MCE may use an out-of-state
			 mail order provider when necessary to meet the needs of the Member, as long as
			 the pharmacy has signed a participating provider agreement or subcontract with
			 the MCE, is licensed to operate in state they reside, and adheres to
			 out-of-state services and other applicable Division rules.
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 120 - MEDICAL ASSISTANCE PROGRAMS › Section 410-120-1190 - Medically Needy Benefit Program

Current through Register Vol. 63, No. 7, July 1, 2024
The Medically Needy Program is eliminated effective February 1,
				2003. Although references to this benefit exist elsewhere in rule, the program
				currently is not funded and is not offered as a benefit.
Stat. Auth.: ORS
				  413.042
Stats. Implemented: ORS
				  414.025 &
				  414.065
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 120 - MEDICAL ASSISTANCE PROGRAMS › Section 410-120-1195

Current through Register Vol. 63, No. 7, July 1, 2024
Statutory/Other Authority: ORS
				  413.042
Statutes/Other Implemented: ORS
				  414.025 &
				  414.065
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 120 - MEDICAL ASSISTANCE PROGRAMS › Section 410-120-1200 - Excluded Services and Limitations

Current through Register Vol. 63, No. 7, July 1, 2024
(1) Certain services or items are not covered
			 under any program or for any group of eligible clients. Service limitations are
			 subject to either:
(a) the Health Evidence
			 Review Commission (HERC) Prioritized List of Health Services as referenced in
			 Oregon Administrative Rule (OAR) 410-141-3830  and the individual program
			 chapter 410 OARs; or
(b) Early and
			 Periodic Screening, Diagnostic and Treatment (EPSDT) as set forth in chapter
			 410 Division 151.
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 120 - MEDICAL ASSISTANCE PROGRAMS › Section 410-120-1210 - Medical Assistance Benefit Packages and Delivery System

Current through Register Vol. 63, No. 7, July 1, 2024
(1) The services
			 clients are eligible to receive are based on their benefit package. Not all
			 packages receive the same benefits.
(2) The Health Systems Division (Division),
			 Medical Assistance Programs benefit package description, codes, eligibility
			 criteria, coverage, limitations, and exclusions are identified in these
			 rules.
(3) The limitations and
			 exclusions listed here are in addition to those described in OAR 410-120-1200  and in any chapter 410 OARs.
(4)
			 Benefit package descriptions:
(a) Oregon
			 Health Plan (OHP) Plus:
(A) Benefit package
			 identifier: BMH;
(B) Eligibility
			 criteria: As defined in federal regulations and in the 1115 OHP waiver
			 demonstration, a client is categorically eligible for medical assistance if
			 they are eligible under a federally defined mandatory, selected, optional
			 Medicaid program or the Children's Health Insurance Program (CHIP) and also
			 meets Oregon Health Authority (Authority) adopted income and other eligibility
			 criteria;
(C) Coverage includes:
(i) Services above the funding line on the
			 Health Evidence Review Commission (HERC) Prioritized List of Health Services
			 (Prioritized List), (OAR 410-141-3820  through 410-141-3830);
(ii) Ancillary services, (OAR
			 410-141-3820);
(iii) Substance use
			 disorder treatment and recovery services provided through local substance use
			 disorder treatment and recovery providers;
(iv) Mental health services based on the
			 Prioritized List to be provided by Board licensed, certified, or credentialed
			 providers or through Community Mental Health Programs certified and
			 credentialed providers;
(v)
			 Hospice;
(vi) Post-hospital
			 extended care benefit up to a 20-day stay in a nursing facility for
			 non-Medicare Division clients who meet Medicare criteria for a post-hospital
			 skilled nursing placement. This benefit requires prior authorization by
			 pre-admission screening (OAR 411-070-0043) or by the Coordinated Care
			 Organization (CCO) for clients enrolled in a CCO; and
(vii) HRSN Services (OAR
			 410-120-2000).
(D)
			 Limitations: The following services have limited coverage for non-pregnant
			 adults age 21 and older, who are outside of the protected postpartum
			 eligibility period (see OAR 410-200-0135). (Refer to the cited OAR chapters and
			 divisions for details):
(i) Selected dental
			 (OAR chapter 410, division 123 and 200);
(ii) Vision services such as frames, lenses,
			 contacts corrective devices and eye exams for the purpose of prescribing
			 glasses or contacts (OAR chapter 410, division 140 and 200).
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 120 - MEDICAL ASSISTANCE PROGRAMS › Section 410-120-1230 - Client Co-payment

Current through Register Vol. 63, No. 7, July 1, 2024
(1)
			 Effective January 1, 2017, Oregon Health Plan (OHP) Plus clients are not
			 responsible for paying an OHP Plus copayment.
(2) For dates of service prior to January 1,
			 2017, OHP Plus clients are responsible for paying a co-payment for some
			 services. This co-payment shall be paid directly to the provider. A co-payment
			 applies regardless of location of services rendered, i.e., provider's office or
			 client's residence.
(3) The
			 following services are exempt from co-payment:
(a) Emergency medical services as defined in
			 OAR 410-120-0000;
(b) Family
			 planning services and supplies;
(c)
			 Prescription drug products for nicotine replacement therapy (NRT);
(d) Prescription drugs ordered through the
			 Division's Mail Order (a.k.a., Home-Delivery) Pharmacy program;
(e) Services to treat "health care-acquired
			 conditions" (HCAC) and "other provider preventable conditions" (OPPC) services
			 as defined in OAR 410-125-0450.
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 120 - MEDICAL ASSISTANCE PROGRAMS › Section 410-120-1260 - Provider Enrollment

Current through Register Vol. 63, No. 7, July 1, 2024
(1) This
			 rule applies to providers requesting enrollment, currently enrolled, and
			 previously enrolled with the Oregon Health Authority (Authority), Health
			 Systems Division (Division).
(2)
			 Providers signing the Provider Enrollment Agreement constitute agreement to
			 comply with all applicable Authority provider rules, Oregon Department of Human
			 Services (ODHS) provider rules, and federal and state laws and regulations
			 applicable to Medicaid payments.
(3) Authority review of a provider
			 application for enrollment, material change in a provider's enrollment
			 information, and any documentation received in response to an Authority
			 re-validation request is based on a categorical risk level of limited,
			 moderate, or high. If a provider falls within more than one risk level
			 described in 42 CFR
			 455.450, the highest level of review is
			 conducted by Authority. Authority will assign a risk level which meets or
			 exceeds federal requirement and reserves the right to adjust provider risk
			 level at any time when:
(a) Authority imposes
			 a payment suspension, in accordance with OAR 410-120-1400, on a provider based
			 on credible allegation of fraud, waste or abuse;
(b) The provider has an existing Medicaid
			 overpayment which, including all outstanding depts and interest, is $1,500 or
			 greater and all of the following:
(A) Is more
			 than 30 calendar days old;
(B) Has
			 not been repaid at the time the application for enrollment is filed;
(C) Is not currently being appealed;
			 and
(D) Is not part of an Authority
			 approved extended repayment schedule for the entire outstanding
			 overpayment.
(c) The
			 provider has been excluded by the Office of Inspector General (OIG) or another
			 state's Medicaid program within the previous 10 years; or
(d) Authority or CMS in the previous six (6)
			 months lifted a temporary moratorium for the particular provider type, in
			 compliance with 42 CFR
			 455.470 and
			 42 CFR
			 424.570, and a provider that was prevented
			 from enrolling based on the moratorium applies for enrollment as a provider at
			 any time within six (6) months from the date the moratorium was
			 lifted.
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 120 - MEDICAL ASSISTANCE PROGRAMS › Section 410-120-1280 - Billing

Current through Register Vol. 63, No. 7, July 1, 2024
(1) A provider enrolled with the Authority or
			 providing services to a client in a Managed Care Entity (MCE) under the Oregon
			 Health Plan (OHP) may not seek payment from the client for any services covered
			 by Medicaid fee-for-service or through contracted health care plans, except as
			 authorized by the Authority under this rule.
(2) Identification of eligibility and
			 third-party liability (TPL). The provider must:
(a) Verify the client's eligibility for
			 medical assistance and benefit package prior to rendering service pursuant to
			 OAR 410-120-1140;
(b) Make
			 "reasonable efforts" to identify third-party resources as described in section
			 (10)(b) of this rule; and
(c) Ask
			 the client at the point of service and verify prior to billing if the client
			 has medical assistance, is applying for medical assistance, enrolled with an
			 MCE or has other third-party liability.
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 120 - MEDICAL ASSISTANCE PROGRAMS › Section 410-120-1285 - Recoupment and Data Sharing with Third-Party Insurers

Current through Register Vol. 63, No. 7, July 1, 2024
(1) The Oregon Health Authority (Authority)
			 delegates to the Department of Human Services (Department), Office of Payment
			 Accuracy and Recovery (OPAR) authority to administer Third-Party Liability
			 programs required by federal law to reduce medical expenditures. This includes
			 the following programs:
(a) The Data Match
			 Unit;
(b) The Health Insurance
			 Group;
(c) The Medical Payment
			 Recovery Unit; and
(d) The Personal
			 Injury Liens Unit.
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 120 - MEDICAL ASSISTANCE PROGRAMS › Section 410-120-1300 - Timely Submission of Claims

Current through Register Vol. 63, No. 7, July 1, 2024
(1)
			 In order to be reimbursed for services rendered, providers must comply with the
			 following:
(a) Medicaid fee-for-service only
			 claims must be filed within 12 months of the date of service. The date of
			 service for an inpatient hospital stay is considered the date of
			 discharge;
(b) Claims for
			 recipients that have Medicare and Medicaid coverage must be filed with the
			 Medicare fiscal intermediary within 12 months of the date of service to meet
			 the Division's timely filing rule;
(c) Claims that fail to cross over
			 electronically from Medicare must be submitted hard copy to the Division within
			 six months from the date on the Medicare Explanation of Medicare Benefits
			 (EOMB), provided they are filed with Medicare within one year from the date of
			 service;
(d) Claims for CCO
			 enrolled members must comply with Oregon Administrative Rule
			 410-141-3565.
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 120 - MEDICAL ASSISTANCE PROGRAMS › Section 410-120-1320 - Authorization of Payment

Current through Register Vol. 63, No. 7, July 1, 2024
(1) Some
			 services or items covered by the Division require authorization before the
			 service can be provided. See the appropriate Division rules for information on
			 services requiring authorization and the process to be followed to obtain
			 authorization.
(2) Documentation
			 submitted when requesting authorization must support the medical justification
			 for the service. A complete request is one that contains all necessary
			 documentation and meets any other requirements as described in the appropriate
			 Division rules.
(3) The Division
			 will authorize for the level of care or type of service that meets the client's
			 medical need. Only services which are medically appropriate and for which the
			 required documentation has been supplied may be authorized. The authorizing
			 agency may request additional information from the provider to determine
			 medical appropriateness or appropriateness of the service.
(4) The Division will not make payment for
			 authorized services under the following circumstances:
(a) The client was not eligible at the time
			 services were provided. The provider is responsible for checking the client's
			 eligibility each time services are provided;
(b) The provider cannot produce appropriate
			 documentation to support medical appropriateness, or the appropriate
			 documentation was not submitted to the authorizing agency;
(c) The service has not been adequately
			 documented (see OAR 410-120-1360, Requirements for
			 Financial, Clinical and Other Records); that is, the documentation in the
			 provider's files is not adequate to determine the type, medical
			 appropriateness, or quantity of services provided and required documentation is
			 not in the provider's files;
(d)
			 The services billed or provided are not consistent with the information
			 submitted when authorization was requested or the services provided are
			 determined retrospectively not to be medically appropriate;
(e) The services billed are not consistent
			 with those provided;
(f) The
			 services were not provided within the timeframe specified on the authorization
			 of payment document;
(g) The
			 services were not authorized or provided in compliance with the rules in these
			 General Rules and in the appropriate provider rules.
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 120 - MEDICAL ASSISTANCE PROGRAMS › Section 410-120-1340 - Payment

Current through Register Vol. 63, No. 7, July 1, 2024
(1) The Division shall make payment only to
			 the enrolled provider (see OAR 410-120-1260) who actually performs the service
			 or to the provider's enrolled billing provider for covered services rendered to
			 eligible clients.
(2) Division
			 reimbursement for services may be subject to review prior to
			 reimbursement.
(3) The Division
			 sets Fee-For-Service (FFS) payment rates for the billed services or items. The
			 FFS payment rates are the Division's maximum allowable rates for billed
			 services or items.
(4) The Division
			 reimburses providers for billed services or items at the lesser of:
(a) The amount billed;
(b) The Division's FFS payment rate in effect
			 on the date of service; or
(c) The
			 rate specified in the individual program provider rules.
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 120 - MEDICAL ASSISTANCE PROGRAMS › Section 410-120-1350 - Buying-Up

Current through Register Vol. 63, No. 7, July 1, 2024
(1) Providers are
			 not permitted to bill and accept payment from the Division or a managed care
			 plan for a covered service:
(a) When a
			 non-covered service has been provided; and
(b) Additional payment is sought or accepted
			 from the Division client.
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 120 - MEDICAL ASSISTANCE PROGRAMS › Section 410-120-1385 - Compliance with Public Meetings Law

Current through Register Vol. 63, No. 7, July 1, 2024
(1) Advisory committees with the authority to
			 make decisions for, conduct policy research for, or make recommendations on
			 administration or policy related to the medical assistance programs operated by
			 the Authority pursuant to ORS Chapter 414 must comply with provisions of ORS
			 192.610 to
			 192.690 - Public Meetings
			 Law.
(2) This rule applies to those
			 advisory committees of the medical assistance programs operated under ORS
			 Chapter 414 that are both:
(a) Created by
			 state constitution, statutes, administrative rule, order, intergovernmental
			 agreement, or other official act, including direct or delegated authority from
			 the Director of the Authority; and
(b) Comprised of at least two committee
			 members who are not employed by a public body.
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 120 - MEDICAL ASSISTANCE PROGRAMS › Section 410-120-1395 - Program Integrity

Current through Register Vol. 63, No. 7, July 1, 2024
(1) The Oregon
			 Health Authority (Authority) uses several approaches to promote program
			 integrity. These rules describe program integrity actions related to provider
			 payments. Our program integrity goal is to pay the correct amount to a properly
			 enrolled provider for covered, medically appropriate services provided to an
			 eligible client according to the client's benefit package of health care
			 services in effect on the date of service. Types of program integrity
			 activities include but are not limited to the following activities:
(a) Medical review and prior authorization
			 processes, including all actions taken to determine the medical appropriateness
			 of services or items;
(b) Provider
			 obligations to submit correct claims;
(c) Onsite visits to verify compliance with
			 standards;
(d) Implementation of
			 Health Insurance Portability and Accountability Act (HIPAA) electronic
			 transaction standards to improve accuracy and timeliness of claims processing
			 and encounter reporting;
(e)
			 Provider credentialing activities;
(f) Accessing federal Department of Health
			 and Human Services database (exclusions);
(g) Quality improvement activities;
(h) Cost report settlement
			 processes;
(i) Audits;
(j) Investigation of fraud or prohibited
			 kickback relationships;
(k)
			 Coordination with the Department of Justice Medicaid Fraud Control Unit (MFCU)
			 and other health oversight authorities.
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 120 - MEDICAL ASSISTANCE PROGRAMS › Section 410-120-1396 - Provider and Contractor Audits

Current through Register Vol. 63, No. 7, July 1, 2024
(1)
			 Individual providers or business entities (providers) enrolled with or under
			 contract with the Oregon Department of Human Services (ODHS) or the Oregon
			 Health Authority (Authority) (hereafter referred to as "provider") receiving
			 payments from the ODHS or Authority are subject to audit or other post payment
			 review procedures (hereafter referred to as "audit") for all payments
			 applicable to items or services furnished or supplied by the provider to or on
			 behalf of ODHS or Authority Medicaid members.
(a) Audit rules and procedures ensure proper
			 payments were made based on requirements applicable to covered services, ensure
			 program integrity of the Authority or ODHS programs and services as outlined in
			 Oregon Administrative Rules (OARs) 407-120-0310, 943-120-1505, 410-120-1160,
			 OAR Ch 410 sections applicable to specific services, and establish authority
			 for the Authority Office of Program Integrity (OPI) to recover overpayments and
			 discover possible instances of fraud, waste, and abuse in the Medicaid member
			 program.
(b) Audits are conducted
			 of providers paid under Oregon's Medicaid program who direct, furnish or supply
			 items or services as fee-for-service providers, as defined in OAR 410-120-0000,
			 or as participating providers, non-participating providers or subcontractors of
			 a Managed Care Entity (MCE), as defined in OAR 410-141-3500. This includes all
			 provider types enrolled by the Authority or ODHS under OAR 410-120-1260  or by
			 agreement or contract with the Authority or ODHS.
(c) The Authority and ODHS share duties and
			 functions related to audits and have the authority to determine which of the
			 two agencies is authorized to fulfill a particular function.
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 120 - MEDICAL ASSISTANCE PROGRAMS › Section 410-120-1397 - Recovery of Overpayments to Providers - Recoupments and Refunds

Current through Register Vol. 63, No. 7, July 1, 2024
(1) The Authority
			 requires Providers to submit true, accurate, and complete claims or encounters.
			 The Authority treats the submission of a claim or encounter, whether on paper
			 or electronically, as certification by the Provider of the following: "This is
			 to certify that the foregoing information is true, accurate, and complete. I
			 understand that payment of this claim or encounter will be from federal and
			 state funds, and that any falsification or concealment of a material fact maybe
			 prosecuted under federal and state laws."
(2) Authority staff or a designee may review
			 or audit a claim before or after payment for assurance that the specific care,
			 item or service was provided in accordance with the Authority rules and
			 policies, the terms applicable to the agreement or contract and the generally
			 accepted standards of a Provider's field of practice or specialty:
(a) "Designee" for the purposes of these
			 rules includes, but is not limited to, a medical, behavioral, drug or dental
			 utilization and review or a post-payment review contractor;
(b) "Claim" for the purposes of these rules
			 includes requests for payment under a Provider enrollment agreement or
			 contract, whether submitted as a claim or invoice or other method for
			 requesting payment authorized by administrative rule, and may include encounter
			 data.
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 120 - MEDICAL ASSISTANCE PROGRAMS › Section 410-120-1400 - Provider Sanctions

Current through Register Vol. 63, No. 7, July 1, 2024
(1) The
			 Authority recognizes two classes of Medicaid provider sanctions, mandatory and
			 discretionary, outlined in sections (4) and (5) of this rule.
(2) The Authority shall impose sanctions on
			 Medicaid providers at the discretion of the Authority Director or delegate.
			 Nothing in this rule limits the ability of Authority or the Oregon Department
			 of Human Services (ODHS) to also seek monetary recovery, or pursue remedies
			 specific to a contract with Authority or ODHS, or as otherwise permitted by
			 state or federal law. Authority sanctions of its contracted managed care
			 entities are governed by OAR 410-141-3530.
(3) Authority may sanction and suspend or
			 terminate a provider who:
(a) is applying for
			 enrollment, re-enrollment or revalidation as an Oregon Medicaid
			 provider;
(b) is enrolled as an
			 Oregon Medicaid provider; regardless of whether enrollment is continuous or
			 active; or
(c) was an enrolled
			 Oregon Medicaid provider at the time the sanctionable conduct, action,
			 conditions or activity occurred.
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 120 - MEDICAL ASSISTANCE PROGRAMS › Section 410-120-1460 - Type and Conditions of Sanction

Current through Register Vol. 63, No. 7, July 1, 2024
(1) The Health Systems Division (Division)
			 may impose mandatory Sanctions on a Provider pursuant to OAR 410-120-1400(4),
			 in which case:
(a) The Provider shall be
			 either Terminated or Suspended from participation in Oregon's medical
			 assistance programs;
(b) If
			 Suspended, the minimum duration of Suspension shall be determined by the
			 Secretary of the Department of Health and Human Services (DHHS), under the
			 provisions of 42 CFR Parts 420, 455, 1001, or 1002. The Authority may Suspend a
			 Provider from participation in Oregon's medical assistance programs longer than
			 the minimum Suspension determined by the DHHS Secretary.
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 120 - MEDICAL ASSISTANCE PROGRAMS › Section 410-120-1510 - Fraud and Abuse

Current through Register Vol. 63, No. 7, July 1, 2024
(1) This rule sets
			 forth requirements for reporting, detecting and investigating fraud and abuse.
			 The terms fraud and abuse are defined in OAR 410-120-0000. For the purpose of
			 these rules, the following definitions apply:
(a) "Credible allegation of fraud" means an
			 allegation of fraud, that has been verified by the state and has indicia of
			 reliability that comes from any source as defined in
			 42
			 CFR 455.2;
(b) "Conviction" or "convicted" means that a
			 judgment of conviction has been entered by a federal, state, or local court
			 regardless of whether an appeal from that judgment is pending;
(c) "Exclusion" means that the Authority or
			 the Department of Human Services (Department) shall not reimburse a specific
			 provider who has defrauded or abused the Authority or Department for items or
			 services which that provider furnished;
(d) "Prohibited kickback relationships" means
			 remuneration or payment practices that may result in federal civil penalties or
			 exclusion for violation of
			 42 CFR
			 1001.951;
(e) "Suspension" means the Authority or
			 Department shall not reimburse a specified provider who has been convicted of a
			 program-related offense in a federal, state, or local court for items or
			 services which that provider furnished.
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 120 - MEDICAL ASSISTANCE PROGRAMS › Section 410-120-1560 - Provider Appeals

Current through Register Vol. 63, No. 7, July 1, 2024
(1) For purposes
			 of Division provider appeal rules in chapter 410, division 120, the following
			 terms and definitions are used:
(a)
			 "Provider" means an individual or entity enrolled with the Division or under
			 contract with the Division that is subject to the Division rules and that has
			 requested an appeal in relation to health care, items, drugs, or services
			 provided or requested to be provided to a client on a fee-for-service basis or
			 under contract with the Division where that contract expressly incorporates
			 these rules;
(b) "Provider
			 Applicant" means an individual or entity that has submitted an application to
			 become an enrolled provider with the Division, but the application has not been
			 approved;
(c) "Prepaid Health Plan"
			 has the meaning set forth in OAR 410-141-3500, except to the extent that Mental
			 Health Organizations (MHO) have separate procedures applicable to provider
			 grievances and appeals;
(d)
			 "Prepaid Health Plan provider" means an individual or entity enrolled with the
			 Division but that provided health care services, supplies or items to a client
			 enrolled with a PHP, including both participating providers and
			 non-participating providers as those terms are defined in OAR 410-141-0000,
			 except that services provided to a client enrolled with an MHO shall be
			 governed by the provider grievance and appeal procedures administered by the
			 Authority's Addictions and Mental Health Division;
(e) The "Provider Appeal Rules" refers to the
			 rules in OAR 410-120-1560  to 410-120-1600, describing the availability of
			 appeal procedures and the procedures applicable to each;
(f) "Non-participating provider" has the
			 meaning set forth in OAR 410-141-3500;
(g) Coordinated Care Organization (CCO) has
			 the meaning set forth in OAR 410-141-3500.
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 120 - MEDICAL ASSISTANCE PROGRAMS › Section 410-120-1570 - Claim Re-Determinations

Current through Register Vol. 63, No. 7, July 1, 2024
(1)
			 If a provider disagrees with an initial claim determination made by the
			 Division of Medical Assistance Program (Division), the provider may request a
			 review for re-determination of the denied claim payment.
(2) This rule does not apply to
			 determinations that:
(a) Result in a "Notice
			 of Action" that must be provided to the OHP client. If the decision under
			 review requires any notice to the OHP client under applicable rules (OAR
			 410-120-1860, 410-141-3885), the procedures for notices and hearings must be
			 followed; or
(b) Are made by a CCO
			 or PHP regarding services to a CCO or PHP member. The provider must contact the
			 CCO or PHP in accordance with OAR 410-120-1560.
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 120 - MEDICAL ASSISTANCE PROGRAMS › Section 410-120-1580 - Provider Appeals- Administrative Review

Current through Register Vol. 63, No. 7, July 1, 2024
(1) An administrative review is a provider
			 appeal process that allows an opportunity for the Administrator of the Division
			 of Medical Assistance Programs (Division) or designee to review a Division
			 decision affecting the provider, provider applicant, Coordinated Care
			 Organization (CCO) or Prepaid Health Plan (PHP) provider, where administrative
			 review is appropriate and consistent with these provider appeal rules OAR
			 410-120-1560.
(2) Administrative
			 review is an appeal process under OAR 410-120-1560  that addresses primarily
			 legal or policy issues that may arise in the context of a Division decision
			 that adversely affects the Provider and that is not otherwise reviewed as a
			 claim re-determination, a contested case, or client appeal.
(a) If the Division finds that the appeal
			 should be handled as a different form of provider appeal or as a client appeal,
			 the Administrator or designee will notify the provider of this determination.
(b) Within the time limits
			 established by the Division in the administrative review, the provider,
			 provider applicant, CCO or PHP provider must provide Division (and CCO or PHP,
			 if applicable) with a copy of all relevant records, the Division, CCO or PHP
			 decisions, and other materials relevant to the appeal.