Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 133 - SCHOOL-BASED HEALTH SERVICES › Section 410-133-0140 - School Medical Provider Enrollment Provisions

Current through Register Vol. 63, No. 7, July 1, 2024
(1) This rule applies only to providers
			 seeking reimbursement from the Division, except as otherwise provided in OAR
			 410-120-1295.
(2) Only Educational
			 Agency (EA) providers of SBHS that meet the criteria for the provision of
			 special education programs approved by the State Superintendent of Public
			 Instruction qualifying such programs for state reimbursement under OAR
			 581-015-2005  will be enrolled with the Division as school medical (SM)
			 providers allowed to seek reimbursement for the provision of covered health
			 services pursuant to a Medicaid eligible child's Individualized Education
			 Program (IEP) or Individualized Family Service Plan (IFSP).
(3) The provider enrollment process will
			 consist of: The completion and submission of the School Medical (SM) provider
			 enrollment application and the required attachments, disclosure documents, and
			 provider agreement with the Division of Medical Assistance Programs.
(4) An approved enrollment application by the
			 Division or the Authority unit responsible for enrolling the SM provider is a
			 contractual agreement that binds the SM provider to comply with the Authority
			 administrative rules OAR 943-120-0300  through 943-120-0380, the Division
			 General Rules 410-120-1260  and School-Based Health Services (SBHS)
			 rules.
(5) Signing the SM provider
			 agreement enclosed in the application package constitutes agreement by
			 performing, and billing providers for provision of SBHS to comply with all
			 applicable rules of the Medical Assistance Program and federal and state laws
			 and regulations.
(6) An SM provider
			 is a performing provider. A performing provider is the provider of a service or
			 item. A billing provider is an individual, agent, business, corporation,
			 clinic, group, institution, or other entity who in connection with the
			 submission of claims to the Authority, receives or directs the payment (either
			 in the name of the performing provider or the name of the billing provider)
			 from the Authority, on behalf of a performing provider and has been delegated
			 the authority to obligate or act on behalf of the performing provider (See OAR
			 410-120-1260):
(a) A billing provider is
			 responsible for identifying to the Division and keeping current the
			 identification of all performing providers for whom they bill, or receive or
			 direct payments. This identification must include the providers' names,
			 Authority provider numbers, NPIs, and either the performing provider's Social
			 Security Number (SSN) or Employer Identification Number (EIN). The SSN or EIN
			 of the performing provider cannot be the same as the Tax Identification Number
			 (TIN) of the billing provider. In order to facilitate timely claims processing
			 and claims payment consistent with applicable privacy and security
			 requirements, the Authority requires billing providers to be enrolled
			 consistent with the provider enrollment process described in OAR
			 410-120-1260(7);
(b) If the SM
			 performing provider uses electronic media to conduct transactions with the
			 Authority, or authorizes a billing provider to conduct such electronic
			 transactions, the SM performing provider must comply with the Electronic Data
			 Interchange (EDI). Enrollment as a SM performing provider or billing provider
			 is a necessary requirement for submitting electronic claims, but the provider
			 must also register as a trading partner and identify the EDI
			 Submitter;
(c) A school medical
			 (SM) performing provider that uses electronic media to conduct transaction with
			 the Authority or authorizes a billing provider to conduct such electronic
			 transactions, must comply with the electronic data interchange (EDI).
			 Enrollment as an SM performing provider or billing provider is a necessary
			 requirement for submitting electronic claims. If the SM provider intends to use
			 an electronic data interchange (EDI) submitter, the SM performing provider must
			 register with the Authority as a trading partner and shall complete the
			 "Trading Partner Authorization of EDI Submitter" and the EDI submitter
			 information required in the application in compliance with the trading partner
			 requirements of identifying the authority of the EDI submitter to submit claims
			 on its behalf. The EDI submitter must sign the EDI certification and meet other
			 Authority EDI submission requirements pursuant to the EDI rules, before the
			 Authority may accept an electronic submission from the EDI submitter on behalf
			 of the performing provider. Information about the EDI transaction requirements
			 is available on the Authority's web site.