Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 141 - OREGON HEALTH PLAN › Section 410-141-3510 - Provider Contracting and Credentialing

Current through Register Vol. 63, No. 7, July 1, 2024
(1) Managed Care
			 Entity's (MCEs)shall develop policies and procedures for credentialing
			 providers to include quality standards and a process to remove providers from
			 their provider network if they fail to meet the objective quality standards.
(a) MCEs shall ensure that all participating
			 providers as defined in OAR 410-141-3500  providing coordinated care services to
			 members are credentialed upon initial contract with the MCE and re-credentialed
			 no less frequently than every three (3) years. The credentialing and
			 re-credentialing process shall include review of any information in the
			 National Practitioners Databank. MCEs shall accept both the Oregon Practitioner
			 Credentialing Application and the Oregon Practitioner Recredentialing
			 Application;
(b) MCEs shall screen
			 their participating providers to be in compliance with  42 CFR 455  Subpart E
			 (42 CFR
			 455.410 through
			 42 CFR
			 455.470) and retain all resulting
			 documentation for audit purposes, except in the following circumstances for
			 credentialing COVID-19 vaccine administration providers for the sole purpose of
			 administering COVID-19 vaccines or the administration of the flu vaccine when
			 administered in conjunction with the COVID-19 vaccination. For the purpose of
			 this rule, COVID-19 vaccination administration provider means a healthcare
			 provider that has successfully enrolled with the Authority's Public Health
			 Division to be a COVID-19 vaccination administration provider, completed all
			 required training, and has agreed to all terms of program participation.
(A) MCEs may rely upon the most recent weekly
			 update of the Authority's active file of vaccine administration providers to
			 meet contractual and regulatory requirements for credentialing COVID-19 vaccine
			 administration providers.
(B) MCEs
			 may enroll COVID-19 vaccine administration providers who are included in the
			 Authority's most recent active file of vaccine administration
			 providers.
(C) MCEs shall monitor
			 changes in the Authority's weekly active file of vaccine administration
			 providers for terminations and changes.
(c) MCEs shall screen their contracted HRSN
			 Service Providers to be in compliance with
			 42 CFR §§
										455.410 through
			 455.436,
			 455.450,
			 455.452, and
			 455.470, and retain all resulting
			 documentation for audit purposes.
(d) MCEs may elect to contract for or
			 delegate responsibility for the credentialing and screening processes; however,
			 MCEs shall be solely and ultimately responsible for adhering with all terms and
			 conditions held in its contract with the state. For the following activities
			 including oversight of the following processes regardless of whether the
			 activities are provided directly, contracted, or delegated, MCEs shall:
(A) Ensure that coordinated care services are
			 provided within the scope of license or certification of the participating
			 provider or facility and within the scope of the participating provider's
			 contracted services. They shall ensure participating providers are
			 appropriately supervised according to their scope of practice;
(B) Provide training for MCE staff and
			 participating providers and their staff regarding the delivery of coordinated
			 care services, applicable administrative rules, and the MCEs administrative
			 policies.
(e) The MCE
			 shall provide accurate and timely information to the Authority about:
(A) License or certification expiration and
			 renewal dates;
(B) Whether a
			 provider's license or certification is expired or not renewed or is subject to
			 licensing termination, suspension, or certification sanction;
(C) If an MCE knows or has reason to know
			 that a provider has been convicted of a felony or misdemeanor related to a
			 crime or violation of federal or state laws under Medicare, Medicaid, or Title
			 XIX (including a plea of "nolo contendere");
(D) If an MCE removes a provider or fails to
			 renew a provider's contract if the provider fails to meet objective quality
			 standards.
(f) MCEs may
			 not refer members to or use providers that:
(A) Have been terminated from
			 Medicaid;
(B) Have been excluded as
			 a Medicaid provider by another state;
(C) Have been excluded as Medicare/Medicaid
			 providers by CMS; or
(D) Are
			 subject to exclusion for any lawful conviction by a court for which the
			 provider may be excluded under
			 42 CFR
			 1001.101.
(g) MCEs may not accept billings for services
			 to members provided after the date of the provider's exclusion, conviction, or
			 termination. MCEs shall recoup any monies paid for services to members provided
			 after the date of the provider's exclusion, conviction, or
			 termination;
(h) MCEs shall require
			 each atypical provider to be enrolled with the Authority. MCEs shall also
			 require each atypical provider, except HRSN Service Providers, to obtain and
			 use registered National Provider Identifiers (NPIs), and taxonomy codes
			 reported to the Authority in the Provider Capacity Report for purposes of
			 encounter data submission prior to submitting encounter data in connection with
			 services by the provider. MCEs shall require each qualified provider, except
			 HRSN Service Providers, to have and use an NPI as enumerated by the National
			 Plan and Provider Enumeration System (NPPES),;
(i) The provider enrollment request (for
			 encounter purposes) and credentialing documents require the disclosure of
			 taxpayer identification numbers. The Authority shall use taxpayer
			 identification numbers for the administration of this program including
			 provider enrollment, internal verification, and administrative purposes for the
			 medical assistance program for administration of tax laws. The Authority may
			 use taxpayer identification numbers to confirm whether the individual or entity
			 is subject to exclusion from participation in the medical assistance program.
			 Taxpayer identification number includes Employer Identification Number (EIN),
			 Social Security Number (SSN), and Individual Tax Identification Number (ITIN)
			 used to identify the individual or entity on the enrollment request form or
			 disclosure statement. Disclosure of all tax identification numbers for these
			 purposes is mandatory. Failure to submit the requested taxpayer identification
			 numbers may result in denial of enrollment as a provider and denial of a
			 provider number for encounter purposes or denial of continued enrollment as a
			 provider and deactivation of all provider numbers used by the provider for
			 encounters.