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) 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 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) CCOs 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) CCOs may enroll COVID-19 vaccine
			 administration providers who are included in the Authority's most recent active
			 file of vaccine administration providers.
(C) CCOs shall monitor changes in the
			 Authority's weekly active file of vaccine administration providers for
			 terminations and changes.
(c) MCEs may elect to contract for or to
			 delegate responsibility for the credentialing and screening processes; however,
			 CCOs 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.
(d) 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.
(e) 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 could be excluded under
			 42 CFR
			 1001.101.
(f) 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;
(g) MCEs shall require
			 each atypical provider to be enrolled with the Authority and shall 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 to have and use an NPI
			 as enumerated by the National Plan and Provider Enumeration System
			 (NPPES);
(h) 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.