reglab/statecodes huggingface dataset:
Oregon Administrative Rules › Chapter 407 - DEPARTMENT OF HUMAN SERVICES › Division 50 - MEDICARE PART D AUTHORIZED DECISION MAKERS › Section 407-050-0010 - Authorized Decision Makers

Current through Register Vol. 63, No. 7, July 1, 2024
(1)
			 These rules only pertain to those Part D-eligible Individuals who receive
			 benefits or services, which are provided by, operated by, authorized or funded
			 by the Department. Those acting under the authority of this rule must do so
			 with the express purpose of assisting the Part D-eligible Individual to obtain
			 the Part C or D drug benefit that will appropriately meet their pharmaceutical
			 needs and protect their health and safety.
(2) These rules only apply to those persons
			 who can make decisions and take action on behalf of Part D-eligible Individuals
			 for Medicare Part D Decisions.
(3)
			 A Capable Part D-eligible Individual or their Individual Designee must be
			 allowed to make all Medicare Part D Decisions.
(4) If the Part D-eligible Individual is
			 incapable and has a Personal Representative, the Personal Representative must
			 be allowed to make all Medicare Part D Decisions.
(5) If the Part D-eligible Individual is
			 incapable and has an Individual Designee, the Individual Designee must be
			 allowed to make Part D Decisions within the scope of their authority as a
			 designee of the Part D-eligible Individual.
(6) If the Part D-eligible Individual is
			 incapable and does not have an Individual Designee or Personal Representative,
			 these rules authorize the first available person from the following list to be
			 an Authorized Representative for the Part D-eligible Individual solely for the
			 purpose of making Medicare Part D Decision, in order of priority:
(a) Closest Available Relative;
(b) Friend or Advocate;
(c) Department Case Manager/ Eligibility
			 Specialist or Department Social Worker or designee named by the Department
			 office responsible for enrollment;
(d) Owner, operator, or employee of a
			 Department licensed or certified residential service, nursing home, foster
			 home, or a Brokerage funded by the Department to provide Developmental
			 Disability Support Services.
Oregon Administrative Rules › Chapter 407 - DEPARTMENT OF HUMAN SERVICES › Division 70 - DEMOGRAPHICS › Section 407-070-0000 - Race, Ethnicity, Language, and Disability Demographic Data Collection Standards

Current through Register Vol. 63, No. 7, July 1, 2024
(1)
			 Pursuant to ORS 413.161, the Oregon Health
			 Authority, in collaboration with the Oregon Department of Human Services,
			 established uniform standards, based on local, statewide and national best
			 practices, for the collection of data on race, ethnicity, preferred spoken and
			 written languages and disability status. These standards are set forth in OAR
			 950-030-0000  to 950-030-0200  and 950-038-0010.
(2) The Oregon Department of Human Services
			 adopts and incorporates by reference the rules established in OAR 950-030-0000  to 950-030-0200  and 950-038-0010  for those matters related to data collection
			 standards.
Statutory/Other Authority: ORS
				  409.050 &
				  413.161
Statutes/Other Implemented: ORS
				  413.161
Oregon Administrative Rules › Chapter 407 - DEPARTMENT OF HUMAN SERVICES › Division 100 - RESILIENCE HUBS AND NETWORKS GRANT › Section 407-100-0010 - Purpose and Scope

Current through Register Vol. 63, No. 7, July 1, 2024
(1) OAR 407-100
			 establishes the Resilience Hubs and Networks Grant Program within the Oregon
			 Department of Human Services (ODHS) Office of Resilience and Emergency
			 Management (OREM). The Program offers grants to organizations or individuals
			 who wish to develop, expand, or strengthen a Resilience Hub or Network in their
			 community.
(2) The purpose of the
			 Resilience Hubs and Networks Grant Program is to empower communities to become
			 more resilient.
Statutory/Other Authority: HB 3409 Section 86 (2023) &
				  ORS 409.050
Statutes/Other Implemented: HB 3409 Section 86
				  (2023)
Oregon Administrative Rules › Chapter 407 - DEPARTMENT OF HUMAN SERVICES › Division 100 - RESILIENCE HUBS AND NETWORKS GRANT › Section 407-100-0020 - Definitions

Current through Register Vol. 63, No. 7, July 1, 2024
(1) "Awardee" means
			 a Resilience Hubs and Networks grant applicant that is selected for a grant
			 award.
(2) "Grant Agreement" means
			 the document agreed to and signed by Awardee and ODHS that describes the terms
			 and conditions required by ODHS to issue the grant award.
(3) "Grant Applicant" means an organization
			 or individual who submits an application to the Resilience Hubs and Networks
			 grant.
(4) "Oregon Buys" means a
			 web-based eProcurement system that automates the state of Oregon's procurement
			 process.
(5) "Resilience Hub" means
			 a physical facility that is operated, managed, or supported by one or more
			 local residents, local governments, tribal governments, public schools,
			 community-based organizations, faith-based organizations, nonprofit
			 organizations, or nongovernmental organizations and that:
(a) Supports the needs of community members
			 or tribal communities, facilitates gathering and communication, distributes
			 resources and otherwise enhances quality of life within a community;
(b) Serves as a central point for gathering,
			 information sharing, and coordination in response to a disruption in the
			 community;
(c) Enhances the ability
			 of a community to respond to and recover from a disruption in a
			 community;
(d) Is positioned,
			 operated and resourced on a day-to-day basis to provide community resources,
			 including but not limited to food, water, information exchange, electronic
			 charging stations, basic medical supplies and equipment proportionate to the
			 size of the community's population and needs;
(e) Supports community cache sites and other
			 support for community members who shelter in place;
(f) Can provide child care, training, food
			 distribution and other services that can help a community respond to unmet
			 social needs to prepare for, respond to and recover from disasters;
(g) Can provide, or can be retrofitted to
			 provide, heating, cooling, air filtration and weather protection,
			 and;
(h) Accommodates individuals
			 with accessibility needs.
Oregon Administrative Rules › Chapter 407 - DEPARTMENT OF HUMAN SERVICES › Division 100 - RESILIENCE HUBS AND NETWORKS GRANT › Section 407-100-0030 - Eligibility

Current through Register Vol. 63, No. 7, July 1, 2024
Individuals or organizations in Oregon are eligible to apply
				for the Resilience Hubs and Networks grant. In accordance with Oregon House
				Bill 3409 Section 86 (2023), the Office of Resilience and Emergency Management
				encourages grant applications that describes activities that:
(1) Supports the needs of community members
			 or tribal communities, facilitates gathering and communication, distributes
			 resources and otherwise enhances quality of life within a community;
(2) Serves as a central point for gathering,
			 information sharing, and coordination in response to a disruption in the
			 community;
(3) Enhances the ability
			 of a community to respond to and recover from a disruption in a
			 community;
(4) Support a Resilience
			 Hub that is positioned, operated and resourced on a day-to-day basis to provide
			 community resources, including but not limited to food, water, information
			 exchange, electronic charging stations, basic medical supplies and equipment
			 proportionate to the size of the community's population and needs;
(5) Supports community cache sites and other
			 support for community members who shelter in place;
(6) Can provide child care, training, food
			 distribution and other services that can help a community respond to unmet
			 social needs to prepare for, respond to and recover from disasters;
(7) Can provide, or can be retrofitted to
			 provide, heating, cooling, air filtration and weather protection,
			 and;
(8) Accommodates individuals
			 with accessibility needs.
Statutory/Other Authority: HB 3409 Section 86 (2023) &
				  ORS 409.050
Statutes/Other Implemented: HB 3409 Section 86
				  (2023)
Oregon Administrative Rules › Chapter 407 - DEPARTMENT OF HUMAN SERVICES › Division 100 - RESILIENCE HUBS AND NETWORKS GRANT › Section 407-100-0040 - Evaluation Criteria

Current through Register Vol. 63, No. 7, July 1, 2024
Individuals or organizations may apply for grants by submitting
				an application that must include:
(1)
			 A description of the purposes for which grant moneys will be
			 expended;
(2) A plan for
			 implementing specific strategies to build resilience in a community;
(3) A description of additional resources
			 available for purposes of the Resilience Hub or Network;
(4) A description of the project's ability to
			 serve vulnerable populations and communities traditionally underrepresented in
			 the public process, including communities of color, communities experiencing
			 lower incomes, tribal communities, rural communities, coastal communities,
			 communities with limited infrastructure, seniors, youth, and persons with
			 disabilities; and any other information required by the department.
Statutory/Other Authority: HB 3409 Section 86 (2023) &
				  ORS 409.050
Statutes/Other Implemented: HB 3409 Section 86
				  (2023)
Oregon Administrative Rules › Chapter 407 - DEPARTMENT OF HUMAN SERVICES › Division 100 - RESILIENCE HUBS AND NETWORKS GRANT › Section 407-100-0050 - Technical Review Process

Current through Register Vol. 63, No. 7, July 1, 2024
(1) Applications
			 will be scored on objective criterion and subjective essay questions, which
			 will be combined to calculate a combined total score. The applications combined
			 total score will be used to determine funding decisions.
(2) Objective score rubric: The objective
			 score will be based upon the physical address submitted in the application.
			 That score will be derived from that physical address' location within the
			 Center for Disease Control (CDC) Social Vulnerability Index Map (SVI), and the
			 Environmental Protection Agencies' (EPA) Environmental Justice (EJ) Screen map.
			 Based on the CDC's SVI map, an application will receive a score commensurate
			 with that location's SVI rating; if a location has the highest SVI rating, then
			 that application will receive the highest score in that category.
(3) The physical address entered in an
			 application will be used to determine 13 scores as derived from different
			 values within the various layers of the EPA's EJ Screen map. The physical
			 address entered into an application will determine and render the following
			 scores based on the following CDC SVI and EJ Screen layers: (See attached Rubic
			 below.)
(4) Subjective essay
			 scoring rubric: Applicants will be required to answer the following six essay
			 questions. A review panel will read the applicants' essays and apply scores to
			 each answer based on the following rubric. The total of the six essays' score
			 will be added to the total objective score to produce an application's final
			 total score: (See attached Rubic below.)
To view attachments referenced in rule text,
click here to view
				  rule
.
Statutory/Other Authority: HB 3409 Section 86 (2023); &
				  ORS 409.050
Statutes/Other Implemented: HB 3409 Section 86
				  (2023)
Oregon Administrative Rules › Chapter 407 - DEPARTMENT OF HUMAN SERVICES › Division 100 - RESILIENCE HUBS AND NETWORKS GRANT › Section 407-100-0060 - Funding Decision

Current through Register Vol. 63, No. 7, July 1, 2024
Awards may be funded in-whole or in-part.
Statutory/Other Authority: HB 3409 Section 86 (2023) &
				  ORS 409.050
Statutes/Other Implemented: HB 3409 Section 86
				  (2023)
Oregon Administrative Rules › Chapter 407 - DEPARTMENT OF HUMAN SERVICES › Division 100 - RESILIENCE HUBS AND NETWORKS GRANT › Section 407-100-0070 - Grant Agreement Conditions

Current through Register Vol. 63, No. 7, July 1, 2024
(1) Awards may not
			 be used as pass-through funds; grant awards will be issued directly to the
			 individual or organization that will be using the awarded resources.
(2) Awardees will be required to register in
			 Oregon Buys to establish and store the Grant Agreement and to receive their
			 funding award.
(3) Awardees will be
			 required to submit a report within 360 days after grant agreement is signed by
			 all parties and entered into Oregon Buys, which describes:
(a) How funds were allocated;
(b) How the resource impacted the
			 community;
(c) How the existence of
			 the new resource was communicated to the community; and
(d) Submission of photographs of the new
			 resource(s).
Oregon Administrative Rules › Chapter 407 - DEPARTMENT OF HUMAN SERVICES › Division 100 - RESILIENCE HUBS AND NETWORKS GRANT › Section 407-100-0080 - Waiver and Periodic Review of Rules

Current through Register Vol. 63, No. 7, July 1, 2024
The Office of Resilience and Emergency Management may waive the
				requirements of these rules for individual grant applications unless required
				by statute, when doing so will result in more efficient or effective
				implementation of the Resilience Hubs and Networks grant program. Any waiver
				must be in writing and included in the grant file to which the waiver applies.
				The administrative rules for monitoring grants may be periodically reviewed by
				the OREM staff and revised as necessary and appropriate.
Statutory/Other Authority: HB 3409 Section 86 (2023) &
				  ORS 409.050
Statutes/Other Implemented: HB 3409 Section 86
				  (2023)
Oregon Administrative Rules › Chapter 407 - DEPARTMENT OF HUMAN SERVICES › Division 120 - PROVIDER RULES › Section 407-120-0110 - Purpose

Current through Register Vol. 63, No. 7, July 1, 2024
(1) These rules
			 establish requirements applicable to providers, PHPs, and allied agencies that
			 want to conduct electronic data transactions with the Department. These rules
			 govern the conduct of all web portal or EDI transactions with the Department.
			 These rules only apply to services or items that are paid for by the
			 Department. If the service or item is paid for by a plan or an allied agency,
			 these rules do not apply.
(2) These
			 rules establish the Department's electronic data transaction requirements for
			 purposes of the Health Insurance Portability and Accountability Act of 1996,
			 42 USC
			 1320 d -- 1320d-8,
			 Public Law
			 104-191,
			 sec.
			 262and sec. 264, and the implementing
			 standards for electronic transactions rules. Where a federal HIPAA standard has
			 been adopted for an electronic data transaction, this rule implements and does
			 not alter the federal standard.
(3)
			 These rules establish procedures that must be followed by any provider, PHP, or
			 allied agency in the event of a security or privacy incident, regardless of
			 whether the incident is related to the use of an electronic data
			 transaction.
Stat. Auth.: ORS
				  409.050,
				  414.065
Stats. Implemented: ORS
				  414.065
Oregon Administrative Rules › Chapter 407 - DEPARTMENT OF HUMAN SERVICES › Division 120 - PROVIDER RULES › Section 407-120-0112 - Scope and Sequence of Electronic Data Transmission Rules

Current through Register Vol. 63, No. 7, July 1, 2024
(1) The Department
			 communicates with and receives communications from its providers, PHPs, and
			 allied agencies using a variety of methods appropriate to the services being
			 provided, the nature of the entity providing the services, and constantly
			 changing technology. These rules describe some of the basic ways that the
			 Department will exchange data electronically. Additional details may be
			 provided in the Department's access control rules, provider-specific rules, or
			 the applicable contract documents.
(2) Access to eligibility information about
			 covered individuals may occur using one or more of the following methods:
(a) Automated voice response, via a
			 telephone;
(b) Web portal
			 access;
(c) EDI submitter access;
			 or
(d) Point of sale (POS) for
			 pharmacy providers.
Oregon Administrative Rules › Chapter 407 - DEPARTMENT OF HUMAN SERVICES › Division 120 - PROVIDER RULES › Section 407-120-0114 - Provider Enrollment Agreement

Current through Register Vol. 63, No. 7, July 1, 2024
(1)
			 When a provider applies to enroll, the application form will include
			 information about how to participate in the web portal for use of DDE and
			 automated voice response (AVR) inquiries. The enrollment agreement will include
			 a section describing the process that will permit the provider, once enrolled,
			 to participate in DDE over the Internet using the secure Department web portal.
			 This does not include providers enrolled through the use of the DMAP 3108
			 Managed Care Plan and FFS Non Paid Provider Application.
(2) When the provider number is issued by the
			 Department, the provider will also receive two PINs: one that may be used to
			 access the web portal and one that may be used for AVR.
(a) If the PINs are not activated within 60
			 days of issuance, the Department will initiate a process to inactivate the PIN.
			 If the provider wants to use PIN-based access to the web portal or AVR after
			 deactivation, the provider must submit an update form to obtain another
			 PIN.
(b) Activating the PIN will
			 require Internet access and the provider must supply security data that will be
			 associated with the use of the PIN.
(c) Providers using the PIN are responsible
			 for protecting the confidentiality and security of the PIN pursuant to OAR
			 407-120-0170.
Oregon Administrative Rules › Chapter 407 - DEPARTMENT OF HUMAN SERVICES › Division 120 - PROVIDER RULES › Section 407-120-0116 - Web Portal Submitter

Current through Register Vol. 63, No. 7, July 1, 2024
(1) Any
			 provider activating their web portal access for web portal submission may be a
			 web portal submitter. The provider will be referred to as the web portal
			 submitter when functioning in that capacity, and shall be required to comply
			 with these rules governing web portal submitters.
(2) The authorized signer of the provider
			 enrollment agreement shall be the individual who is responsible for the
			 provider's DDE claims submission process.
(a)
			 If a provider submits their own claims directly, the provider will be referred
			 to as the web portal submitter when functioning in that capacity and shall be
			 required to comply with these rules governing web portal submitters.
(b) If a provider uses an agent or clinic to
			 submit DDE claims using the Department's web portal, the agent or clinic will
			 be referred to as the web portal submitter when functioning in that capacity
			 and shall be required to comply with these rules governing web portal
			 submitters.
Oregon Administrative Rules › Chapter 407 - DEPARTMENT OF HUMAN SERVICES › Division 120 - PROVIDER RULES › Section 407-120-0118 - Conduct of Direct Data Entry Using Web Portal

Current through Register Vol. 63, No. 7, July 1, 2024
(1) The web portal submitter is responsible
			 for the conduct of the DDE transactions submitted on behalf of the provider, as
			 follows:
(a) Accuracy of Web Portal
			 Submissions. The web portal submitter must take reasonable care to ensure that
			 data and DDE transmissions are timely, complete, accurate, and secure, and must
			 take reasonable precautions to prevent unauthorized access to the information
			 system or the DDE transmission. The Department will not correct or modify an
			 incorrect DDE transaction prior to processing. The transactions may be rejected
			 and the web portal submitter will be notified of the rejection.
(b) Cost of Equipment. The web portal
			 submitter and the Department must bear their own information system costs. The
			 web portal submitter must, at their own expense, obtain access to Internet
			 service that is compatible with and has the capacity for secure access to the
			 Department's web portal. Web portal submitters must pay their own costs for all
			 charges, including but not limited to charges for equipment, software and
			 services, Internet connection and use time, terminals, connections, telephones,
			 and modems. The Department is not responsible for providing technical
			 assistance for access to or use of Internet web portal services or the
			 processing of a DDE transaction.
(c) Format of DDE Transactions. The web
			 portal submitter must send and receive all data transactions in the
			 Department's approved format. Any attempt to modify or alter the DDE
			 transaction format may result in denial of web portal access.
(d) Re-submissions. The web portal submitter
			 must maintain source documents and back-up files or other means sufficient to
			 re-create a data transmission in the event that re-creation becomes necessary
			 for any purpose, within timeframes required by federal or state law, or by
			 contractual agreement. Back ups, archives, or related files are subject to the
			 terms of these rules to the same extent as the original data
			 transmission.
Oregon Administrative Rules › Chapter 407 - DEPARTMENT OF HUMAN SERVICES › Division 120 - PROVIDER RULES › Section 407-120-0120 - Registration Process - EDI Transactions

Current through Register Vol. 63, No. 7, July 1, 2024
(1) The EDI transaction process is preferred
			 by providers, PHPs, and allied agencies for conducting batch or real time
			 transactions, rather than the individual data entry process used for DDE. EDI
			 registration is an administrative process governed by these rules. The EDI
			 registration process begins with the submission of a TPA by a provider, PHP,
			 clinic, or allied agency, including all requirements and documentation required
			 by these rules.
(2) Trading
			 partners must be Department providers, PHPs, clinics, or allied agencies with a
			 current Department contract. The Department will not accept a TPA from
			 individuals or entities who do not have a current contract with the Department.
(a) The Department may receive and hold the
			 TPA for individuals or entities that have submitted a provider enrollment
			 agreement or other pending contract, subject to the satisfactory execution of
			 the pending document.
(b)
			 Termination, revocation, suspension, or expiration of the contract will result
			 in the concurrent termination, revocation, suspension, or expiration of the TPA
			 without any additional notice; except that the TPA will remain in effect to the
			 extent necessary for a trading partner or the Department to complete
			 obligations involving EDI under the contract for dates of service when the
			 contract was in effect. Contracts that are periodically renewed or extended do
			 not require renewal or extension of the TPA unless there is a lapse of time
			 between contracts.
(c) Failure to
			 identify a current Department contract during the registration process will
			 result in a rejection of the TPA. The Department will verify that the contract
			 numbers identified by a provider, PHP, clinic, or allied agency are current
			 contracts.
(d) If contract number
			 or contract status changes, the trading partner must provide the Department
			 with updated information within five business days of the change in contract
			 status. If the Department determines that a valid contract no longer exists,
			 the Department shall discontinue EDI transactions applicable for any time
			 period in which the contract no longer exists; except that the TPA will remain
			 in effect to the extent necessary for the trading partner or the Department to
			 complete obligations involving EDI under the contract for dates of service when
			 the contract was in effect.
Oregon Administrative Rules › Chapter 407 - DEPARTMENT OF HUMAN SERVICES › Division 120 - PROVIDER RULES › Section 407-120-0130 - Trading Partner as EDI Submitter - EDI Transactions

Current through Register Vol. 63, No. 7, July 1, 2024
(1) A trading partner may be an EDI
			 submitter. Registered trading partners that also qualify as an EDI submitter
			 may submit their own EDI transactions directly to the Department. A trading
			 partner will be referred to as an EDI submitter when functioning in that
			 capacity and will be required to comply with applicable EDI submitter rules,
			 except as provided in section (3) of this rule.
(2) Authorization and Registration
			 Designating Trading Partner as EDI Submitter. Before acting as an EDI
			 submitter, a trading partner must designate in the application for application
			 that they are an EDI submitter who is authorized to send and receive data
			 transmissions in the performance of EDI transactions. A trading partner must
			 complete the "Trading Partner Application for Authorization to Submit EDI
			 Transactions" and the "EDI Submitter Information" required in the application.
			 A trading partner must also submit the EDI registration form identifying them
			 as an EDI submitter. A trading partner must notify the Department of any
			 material changes in the information no less than ten days prior to the
			 effective date of the change.
(3)
			 EDI Submitter Certification Conditions. Where a trading partner is acting as
			 its own EDI submitter, the trading partner is not required to submit the EDI
			 submitter certification conditions in the application for authorization
			 applicable to agents.
Stat. Auth.: ORS
				  409.050,
				  414.065
Stats. Implemented: ORS
				  414.065
Oregon Administrative Rules › Chapter 407 - DEPARTMENT OF HUMAN SERVICES › Division 120 - PROVIDER RULES › Section 407-120-0150 - Testing - EDI Transactions

Current through Register Vol. 63, No. 7, July 1, 2024
(1)
			 When a trading partner or authorized EDI submitter registers an EDI transaction
			 with the Department, the Department may require testing before authorizing the
			 transaction. Testing may include third party and business-to-business testing.
			 An EDI submitter must be able to demonstrate its capacity to send and receive
			 each transaction type for which it has registered. The Department will reject
			 any EDI transaction if an EDI submitter either refuses or fails to comply with
			 the Department testing requirements.
(2) The Department may require EDI submitters
			 to complete compliance testing at an EDI submitter's expense for each
			 transaction type if either the Department or an EDI submitter has experienced a
			 change to hardware or software applications by entering into
			 business-to-business testing.
(3)
			 When third party or business-to-business testing is completed to the
			 Department's satisfaction, the Department will notify an EDI submitter that it
			 will register and accept the transactions in the production environment. This
			 notification authorizes an EDI submitter to submit the registered EDI
			 transactions to the Department for processing and response, as applicable. If
			 there are any changes in the trading partner or EDI submitter authorization,
			 profile data or EDI registration information on file with the Department,
			 updated information must be submitted to the Department as required in OAR
			 407-120-0190.
(4) Testing will be
			 conducted using secure electronic media communications methods.
(5) An EDI submitter may be required to
			 re-test with the Department if the Department format changes or if the EDI
			 submitter format changes.
Stat. Auth.: ORS
				  409.050 &
				  414.065
Stats. Implemented: ORS
				  414.065
Oregon Administrative Rules › Chapter 407 - DEPARTMENT OF HUMAN SERVICES › Division 120 - PROVIDER RULES › Section 407-120-0160 - Conduct of Transactions - EDI Transactions

Current through Register Vol. 63, No. 7, July 1, 2024
(1) EDI Submitter Obligations. An EDI
			 submitter is responsible for the conduct of the EDI transactions registered on
			 behalf of a trading partner, including the following:
(a) EDI Transmission Accuracy. An EDI
			 submitter shall take reasonable care to ensure that data and data transmissions
			 are timely, complete, accurate, and secure; and shall take reasonable
			 precautions to prevent unauthorized access to the information system, the data
			 transmission, or the contents of an envelope which is transmitted either to or
			 from the Department. The Department will not correct or modify an incorrect
			 transaction prior to processing. The transaction may be rejected and an EDI
			 submitter notified of the rejection.
(b) Re-transmission of Indecipherable
			 Transmissions. Where there is evidence that a data transmission is lost or
			 indecipherable, the sending party must make best efforts to trace and
			 re-transmit the original data transmission in a manner which allows it to be
			 processed by the receiving party as soon as practicable.
(c) Cost of Equipment. An EDI submitter and
			 the Department will pay for their own information system costs. An EDI
			 submitter shall, at its own expense, obtain and maintain its own information
			 system. An EDI submitter shall pay its own costs for all charges related to
			 data transmission including, without limitation, charges for information system
			 equipment, software and services, electronic mailbox maintenance, connect time,
			 terminals, connections, telephones, modems, any applicable minimum use charges,
			 and for translating, formatting, sending, and receiving communications over the
			 electronic network to the electronic mailbox, if any, of the Department. The
			 Department is not responsible for providing technical assistance in the
			 processing of an EDI transaction.
(d) Back-up Files. EDI submitters must
			 maintain adequate data archives and back-up files or other means sufficient to
			 re-create a data transmission in the event that re-creation becomes necessary
			 for any purpose, within timeframes required by state and federal law, or by
			 contractual agreement. Data archives or back-up files shall be subject to these
			 rules to the same extent as the original data transmission.
(e) Transmissions Format. Except as otherwise
			 provided herein, EDI submitters must send and receive all data transmissions in
			 the federally mandated format, or (if no federal standard has been promulgated)
			 other formats as the Department designates.
(f) Testing. EDI submitters must, prior to
			 the initial data transmission and throughout the term of a TPA, test and
			 cooperate with the Department in the testing of information systems as the
			 Department considers reasonably necessary to ensure the accuracy, timeliness,
			 completeness, and confidentiality of each data transmission.
Oregon Administrative Rules › Chapter 407 - DEPARTMENT OF HUMAN SERVICES › Division 120 - PROVIDER RULES › Section 407-120-0165 - Pharmacy Point of Sale Access

Current through Register Vol. 63, No. 7, July 1, 2024
Pharmacy providers who electronically bill pharmaceutical
				claims must participate in and submit claims using the POS system, except as
				provided in OAR 410-121-0150.
Stat. Auth.: ORS
				  409.050,
				  414.065
Stats. Implemented: ORS
				  414.065
Oregon Administrative Rules › Chapter 407 - DEPARTMENT OF HUMAN SERVICES › Division 120 - PROVIDER RULES › Section 407-120-0180 - Record Retention and Audit

Current through Register Vol. 63, No. 7, July 1, 2024
(1)
			 Records Retention. A provider, web portal submitter, trading partner, and EDI
			 submitter shall maintain, for a period of no less than seven years from the
			 date of service, complete, accurate, and unaltered copies of all source
			 documents associated with all data transmissions.
(2) EDI Trade Data Log. An EDI submitter must
			 establish and maintain a trade data log that must record all data transmissions
			 taking place between an EDI submitter and the Department during the term of a
			 TPA. A trading partner and EDI submitter must take necessary and reasonable
			 steps to ensure that the trade data log constitutes a current, truthful,
			 accurate, complete, and unaltered record of all data transmissions between the
			 parties and must be retained by each party for no less than 24 months following
			 the date of the data transmission. The trade data log may be maintained on
			 electronic media or other suitable means provided that, if necessary, the
			 information may be timely retrieved and presented in readable form.
(3) Right to Audit. A provider must allow and
			 require any web portal submitter to allow, and a trading partner must allow and
			 require an EDI submitter or other agent to allow access to the Department, the
			 Oregon Secretary of State, the Oregon Department of Justice Medicaid Fraud
			 Unit, or its designees, and DHHS or its designees to audit relevant business
			 records, source documents, data, data transmissions, trade data logs, or
			 information systems of a provider and its web portal submitter, and a trading
			 partner, and its agents, as necessary, to ensure compliance with these rules. A
			 provider must allow and require its web portal submitter to allow, and a
			 trading partner must allow and require an EDI submitter or other agent to allow
			 the Department, or its designee, access to ensure that adequate security
			 precautions have been made and are implemented to prevent unauthorized
			 disclosure of any data, data transmissions, or other information.
Stat. Auth.: ORS
				  409.050,
				  414.065
Stats. Implemented: ORS
				  414.065
Oregon Administrative Rules › Chapter 407 - DEPARTMENT OF HUMAN SERVICES › Division 120 - PROVIDER RULES › Section 407-120-0190 - Material Changes

Current through Register Vol. 63, No. 7, July 1, 2024
(1) Changes in
			 Any Material Information - EDT Process. A trading partner must submit an
			 updated TPA, application for authorization, or EDI registration form to the
			 Department within ten business days of any material change in information. A
			 material change includes but is not limited to mailing or email address change,
			 contract number or contract status (termination, expiration, extension),
			 identification of authorized individuals of a trading partner or EDI submitter,
			 the addition or deletion of authorized transactions, or any other change that
			 may affect the accuracy of or authority for an EDI transaction. The Department
			 may act on data transmissions submitted by a trading partner and its EDI
			 submitter based on information on file in the application for authorization and
			 EDI registration forms until an updated form has been received and approved by
			 the Department. A trading partner's signature or the signature of an authorized
			 EDI submitter is required to ensure that an updated TPA, authorization, or EDI
			 registration form is valid and authorized.
(2) Changes in Any Material Information - Web
			 Portal Access. Providers must submit an updated web portal registration form to
			 the Department within ten business days of any material changes in information.
			 A material change includes but is not limited to mailing or email address
			 change, contract number or contract status (termination, suspension,
			 expiration), identification of web portal submitter contact information, or any
			 other change that may affect the accuracy of or authority for a DDE
			 transaction. The Department is authorized to act on data transmissions
			 submitted by a provider and its web portal submitter based on information on
			 file in the web portal registration form until an updated form has been
			 received and approved by the Department. A provider's signature or the
			 signature of an authorized business representative is required to ensure that
			 an updated web portal registration form is valid and authorized.
(3) Failure to submit a timely updated form
			 may impact the ability of a data transaction to be processed without errors.
			 Failure to submit a signed, updated form may result in the rejection of a data
			 transmission.
Stat. Auth.: ORS
				  409.050,
				  414.065
Stats. Implemented: ORS
				  414.065
Oregon Administrative Rules › Chapter 407 - DEPARTMENT OF HUMAN SERVICES › Division 120 - PROVIDER RULES › Section 407-120-0200 - Department System Administration

Current through Register Vol. 63, No. 7, July 1, 2024
(1) No individual or entity shall be
			 registered to conduct a web portal or an EDI transaction with the Department
			 except as authorized under these the rules. Eligibility and continued
			 participation as a provider, PHP, allied agency, or web portal submitter in the
			 conduct of DDE transactions, or as a trading partner or EDI submitter in the
			 conduct of registered transactions, is conditioned on the execution and
			 delivery of the documents required in these rules, the continued accuracy of
			 that information consistent with OAR 407-120-0190, and compliance with a
			 requirements of these rules. Data, including confidential information, governed
			 by these rules may be used for purposes related to treatment, payment, and
			 health care operations and for the administration of programs or services by
			 the Department.
(2) In addition to
			 the requirements of section (1) of this rule, in order to qualify as a trading
			 partner:
(a) An individual or entity must be a
			 Department provider, PHP, clinic, or allied agency pursuant to a current valid
			 contract; and
(b) A provider, PHP,
			 clinic, or allied agency must have submitted an executed TPA and all related
			 documentation, including the application for authorization, that identifies and
			 authorizes an EDI submitter.
Oregon Administrative Rules › Chapter 407 - DEPARTMENT OF HUMAN SERVICES › Division 120 - PROVIDER RULES › Section 407-120-0310 - Provider Requirements

Current through Register Vol. 63, No. 7, July 1, 2024
(1) Scope
			 of Rule. All providers seeking reimbursement from the Department, a PHP, or a
			 county pursuant to a county agreement with the Department for the provision of
			 covered services or items to eligible recipients, must comply with these rules,
			 OAR 407-120-0300  to 407-120-0400, and the applicable rules or contracts of the
			 specific programs described below:
(a)
			 Programs administered by DMAP including the OHP and the medical assistance
			 program that reimburses providers for services or items provided to eligible
			 recipients, including but not limited to chapter 410, division 120; chapter
			 410, division 141; and provider rules in chapter 410 applicable to the
			 provider's service category;
(b)
			 Programs administered by AMH that reimburse providers for services or items
			 provided to eligible AMH recipients; or
(c) Programs administered by SPD that
			 reimburse providers for services or items provided to eligible SPD
			 recipients.
Oregon Administrative Rules › Chapter 407 - DEPARTMENT OF HUMAN SERVICES › Division 120 - PROVIDER RULES › Section 407-120-0320 - Provider Enrollment

Current through Register Vol. 63, No. 7, July 1, 2024
(1) In some Department program areas, being an enrolled Department provider is a condition of eligibility for a Department contract for certain services or activities. The Department requires billing providers to be enrolled as providers consistent with the provider enrollment processes set forth in this rule. If reimbursement for covered services will be made under a contract with the Department, the provider must also meet the Department's contract requirements. Contract requirements are separate from the requirements of these provider enrollment rules. Enrollment as a provider with the Department is not a promise that the enrolled provider will receive any amount of work from the Department, a PHP, or a county.
(2) Relation to Program-Specific or Contract Requirements. Provider enrollment establishes essential Department provider participation requirements for becoming an enrolled Department provider. The details of provider qualification requirements, client eligibility, covered services, how to obtain prior authorization or review (if required), documentation requirements, claims submission, and available electronic access instructions, and other pertinent instructions and requirements are contained in the program-specific rules or contract.
(3) Criteria for Enrollment. Prior to enrollment, providers must:
(a) Meet all program-specific or contract requirements identified in program-specific rules or contracts in addition to those requirements identified in these rules;
(b) Meet Department contracting requirements, as specified by the Department's Office of Contracts and Procurement (OC&P);
(c) Meet Department and federal licensing requirements for the type of service for which the provider is enrolling;
(d) Meet Department and federal certification requirements for the type of service for which the provider is enrolling; and
(e) Obtain a provider number from the Department for the specific service for which the provider is enrolling.
Oregon Administrative Rules › Chapter 407 - DEPARTMENT OF HUMAN SERVICES › Division 120 - PROVIDER RULES › Section 407-120-0330 - Billing Procedures

Current through Register Vol. 63, No. 7, July 1, 2024
(1) These
			 rules only apply to covered services and items provided to clients that are
			 paid for by the Department based on a Department fee schedule or other
			 reimbursement method (often referred to as fee-for-service), or for services
			 that are paid for by the Department at the request of a county for
			 county-authorized services, in accordance with program-specific rules or
			 contract.
(a) If a client's service or item
			 is paid for by a PHP, the provider must comply with the billing and procedures
			 related to claim submission established under contract with that PHP, or the
			 rules applicable to non-participating providers if the provider is not under
			 contract with that PHP.
(b) If the
			 client is enrolled in a PHP, but the client is permitted by a contract or
			 program-specific rules to obtain covered services reimbursed by the Department
			 (such as family planning services that may be obtained from any provider), the
			 provider must comply with the billing and claim procedures established under
			 these rules.
Oregon Administrative Rules › Chapter 407 - DEPARTMENT OF HUMAN SERVICES › Division 120 - PROVIDER RULES › Section 407-120-0340 - Claim and PHP Encounter Submission

Current through Register Vol. 63, No. 7, July 1, 2024
(1) Claim and PHP Encounter Submission. All
			 claims must be submitted using one of the following methods:
(a) Paper forms, using the appropriate form
			 as described in the program-specific rules or contract;
(b) Electronically using the web portal
			 accessed by provider-specific PIN and password. Initial activation by provider
			 of Department-assigned provider number and PIN for web portal access invokes
			 provider's agreement to meet all of the standards for HIPAA privacy, security,
			 and transactions and codes sets standards as defined in   45 CFR 162  ;
(c) Electronically in a manner authorized by
			 the Department's EDT rules (OAR 407-120-0100  to 407-120-0200); or
(d) Electronically, for PHP encounters, in
			 the manner required by the PHP contract with the Department and authorized by
			 the Department's EDT rules.
Oregon Administrative Rules › Chapter 407 - DEPARTMENT OF HUMAN SERVICES › Division 120 - PROVIDER RULES › Section 407-120-0360 - Consequences of Non-Compliance and Provider Sanctions

Current through Register Vol. 63, No. 7, July 1, 2024
(1) There are two classes of provider
			 sanctions, mandatory and discretionary, that may be imposed for non-compliance
			 with the provider enrollment agreement.
(2) Except as otherwise provided, the
			 Department shall impose provider sanctions at the direction of the assistant
			 director of the Department's division whose budget includes payment for the
			 services involved.
(3) Mandatory
			 Sanctions. The Department shall impose mandatory sanctions and suspend the
			 provider from participation in the Department's programs:
(a) When a provider has been convicted (as
			 that term is defined in  42 CFR part 1001.2) of a felony or misdemeanor related
			 to a crime, or violation of Title XVIII, XIX, or XX of the Social Security Act
			 or related state laws, or other disqualifying criminal conviction pursuant to
			 program-specific rules or contract;
(b) When a provider is excluded from
			 participation in federal or state health care programs by the Office of the
			 Inspector General of DHHS or from the Medicare (Title XVIII) program of the
			 Social Security Act as determined by the Secretary of DHHS. The provider shall
			 be excluded and suspended from participation with the Department for the
			 duration of exclusion or suspension from the Medicare program or by the Office
			 of the Inspector General; or
(c) If
			 the provider fails to disclose ownership or control information required under
			  42 CFR part 455.104  that is required to be reported at the time the provider
			 submits a provider enrollment form or when there is a material change in the
			 information that must be reported, or information related to business
			 transactions required to be provided under  42 CFR part 455.105  upon request of
			 federal or state authorities.
Oregon Administrative Rules › Chapter 407 - DEPARTMENT OF HUMAN SERVICES › Division 120 - PROVIDER RULES › Section 407-120-0370 - Requirements for Financial, Clinical, and Other Records

Current through Register Vol. 63, No. 7, July 1, 2024
(1) The Department shall analyze and monitor
			 the operation of its programs and audit and verify the accuracy and
			 appropriateness of payment, utilization of services, or items.
(2) The Department shall comply with client
			 coverage criteria and requirements for the level of care or service or item
			 authorized or reimbursed by the Department and the quality of covered services
			 or items and service or item delivery, and access to covered services or
			 items.
(3) The provider and the
			 provider's designated billing service or other entity responsible for the
			 maintenance of financial, service delivery, and other records must:
(a) Develop and maintain adequate financial
			 and service delivery records and other documentation which supports the
			 specific care, items, or services for which payment has been requested. The
			 Department shall not make payment for services that are not adequately
			 documented. The following documentation must be completed before the service is
			 billed to the Department:
(A) All records
			 documenting the specific service provided, the number of services or items
			 comprising the service provided, the extent of the service provided, the dates
			 on which the service was provided, and identification of the individual who
			 provided the service. Patient account and financial records must also 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. For cost reimbursed services,
			 the provider must maintain adequate records to thoroughly and accurately
			 explain how the amounts reported on the cost statement were
			 determined.
(B) Service delivery,
			 clinical records, and visit data, including records of all therapeutic
			 services, must document the basis for service delivery and record visit data if
			 required under program-specific rules or contracts. A client's clinical record
			 must be annotated each time a service is provided and signed or initialed by
			 the individual providing the service or must clearly identify the individual
			 providing the service. Information contained in the record must be sufficient
			 in quality and quantity to meet the professional standards applicable to the
			 provider or practitioner and any additional standards for documentation found
			 in this rule, program-specific rules, and any pertinent contracts.
(C) All information about a client obtained
			 by the provider or its officers, employees, or agents in the performance of
			 covered services, including information obtained in the course of determining
			 eligibility, seeking authorization, and providing services, is confidential.
			 The client information must be used and disclosed only to the extent necessary
			 to perform these functions.