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Oregon Bulletin

July 1, 2011

 

Oregon Health Authority,
Division of Medical Assistance Programs
Chapter 410

Rule Caption: July ‘11 — Clarify rule regarding individual practitioner enrollment, amend rule to ensure is consistent with general rules.

Adm. Order No.: DMAP 7-2011

Filed with Sec. of State: 6-6-2011

Certified to be Effective: 7-1-11

Notice Publication Date: 5-1-2011

Rules Amended: 410-146-0440, 410-146-0460

Subject: The American Indian/Alaska Native Services Program rules govern the Division of Medical Assistance Programs’ (Division) payments for services provided to certain clients. The Division amended 410-146-0440 and 410-146-0460 as follows:

      • Eliminate barriers to AI/AN providers enrolling individual practitioners employed by the health center, and to reference OAR 410-120-0045 and not an outreach agreement administered by the Division.

      • Reflect the Oregon Health Authority name change and updated statutory reference.

      • Other text may be revised to improve readability and to take care of necessary “housekeeping” corrections.

Rules Coordinator: Darlene Nelson—(503) 945-6927

410-146-0440

Prepaid Health Plan Supplemental Payments

(1) Effective January 1, 2001, the Division of Medical Assistance Programs (Division) is required by 42 USC 1396a(bb), to make supplemental payments to eligible Federally Qualified Health Centers (FQHC) and Rural Health Clinics (RHC) that contract with Prepaid Health Plans (PHP). American Indian/Alaska Native (AI/AN) Program providers that are not FQHCs, and that elect to receive payment under Title XIX and XXI according to the Indian Health Services (IHS) rate under the Memorandum of Agreement (MOA) effective July 11, 1996 will also be eligible to receive supplemental payments in the same manner as an FQHC under 1902(bb)(5).

(2) AI/AN providers reimbursed according to a cost-based rate under the Prospective Payment System (PPS) are directed to Oregon administrative rule (OAR) 410-147-0460, Prepaid Health Plan Supplemental Payments.

(3) The PHP supplemental payment represents the difference, if any, between the payment received by the AI/AN provider from the PHP for treating the PHP enrollee and the payment to which the AI/AN provider would be entitled if they had billed the Division directly for these encounters according to the clinic’s IHS rate (refer to OAR 410-146-0020).

(4) In accordance with federal regulations, the provider must take all reasonable measures to ensure that in most instances, with the exception of IHS, Medicaid will be the payer of last resort. Providers must make reasonable efforts to obtain payment first from other resources before submitting claims to the PHP (refer to OAR 410-120-1140, Verification of Eligibility).

(5) When any other coverage is known to the provider, the provider must bill the other resource prior to billing the PHP. When a provider receives a payment from any source prior to the submission of a claim to the PHP, the amount of the payment must be shown as a credit on the claim in the appropriate field (see OAR 410-120-1280, Billing and 410-120-1340, Payment).

(6) Supplemental payment by the Division for encounters submitted by AI/AN providers for purposes of this rule is reduced by any and all payments received by the AI/AN provider from outside resources, including Medicare, private insurance or any other coverage. AI/AN providers are required to report all payments received on the Managed Care Data Submission Worksheet, including:

(a) Medicaid PHPs;

(b) Medicare Advantage Managed Care Organizations (MCO);

(c) Medicare, including Medicare MCO supplemental payments; and

(d) Any Third party resources (TPR).

(7) The Division shall calculate the PHP supplemental payment in the aggregate of the difference between total payments received by the AI/AN provider, to include payments as listed in section (6) of this rule and the payment to which the AI/AN provider would have been eligible to claim as an encounter if they had billed the Division directly according to the IHS encounter rate.

(8) AI/AN providers must submit their clinic’s data using the Managed Care Data Submission Template developed by the Division to report all PHP encounter and payment activity.

(9) To facilitate the Division processing PHP supplemental payments, the AI/AN must submit the following:

(a) To PHPs:

(A) Claims within the required timelines outlined in the contract with the PHP and in OAR 410-141-0420, Oregon Health Plan Prepaid Health Plan Billing Payment Under the Oregon Health Plan;

(B) The AI/AN National Provider Identifier (NPI) number and applicable associated taxonomy code registered with the Division for the health center must be used when submitting all claims to the PHPs;

(b) To the Division:

(A) Report total payments for all services submitted to the PHP:

(i) Including laboratory, radiology, nuclear medicine, and diagnostic ultrasound; and

(ii) Excluding any bonus or incentive payments;

(B) Report total payments for each category listed in the “Amounts Received During the Settlement Period” section of the Managed Care Data Submission Template coversheet;

(C) Payments must be reported at the detail line level on the Managed Care Data Submission Template worksheet, except for capitated payments, or per member per month and risk pool payments received from the PHP;

(D) The total number of actual encounters. An encounter represents all services for a like service element (medical, dental, mental health, or alcohol and chemical dependency) provided to an individual client on a single date of service. The total number of encounters is not the total number of clients assigned to the IHS or Tribal 638 facility or the total detail lines submitted on the Managed Care Data Submission Template worksheet;

(E) A list of individual practitioners with active Division enrollment including, names, legacy Division provider number and NPI number assigned to practitioners associated with the IHS or Tribal 638 facility. “Associated” refers o a practitioner who is either subcontracted or employed by the AI/AN provider.

(F) A current list of all PHP contracts. An updated list of all PHP contracts must be submitted annually to the Division no later than October 31 of each year.

(10) PHP supplemental payment process:

(a) The Division processes PHP supplemental payments on a quarterly basis. The quarterly settlement includes a final reconciliation for the reported time period.

(b) Upon processing a clinic’s data and the PHP supplemental payment, the Division shall:

(A) Send a check to the AI/AN provider for PHP supplemental payment calculated from clinic data the Division was able to process;

(B) Provide a cover letter and summary of the payment calculation; and

(C) Return data that is incomplete, unmatched, or cannot otherwise be processed by the Division;

(c) The AI/AN provider is responsible for reviewing the data the Division was unable to process for accuracy and completeness. The clinic has 30 days, from the date of the Division’s cover letter under section (9) of this rule, to make any corrections to the data and resubmit to the Division for processing. Documentation supporting any and all changes must accompany the resubmitted data. A request for extension must be received by the Division prior to expiration of the 30 days, and must:

(A) Be in writing;

(B) Accompanied by a cover letter fully explaining the reason for the late submission; and

(C) Provide an anticipated date for providing the Division the clinic’s resubmitted data and supporting documentation;

(d) Within 30 days of the Division’s receipt of the re-submitted data, the Division shall:

(A) Review the data and issue a check for all encounters the Division verifies to be valid; and

(B) For quarterly data submissions, send a letter outlining the final quarterly settlement including any other pertinent information to accompany the check;

(e) The AI/AN provider must submit data to the Division within the timelines provided by the Division.

(11) Clinics must carefully review in a timely fashion the data that the Division was unable to process and returns to the AI/AN provider. If clinics do not bring any incomplete, inaccurate or missing data to the Division’s attention within the time frames outlined, Division may not process an adjustment.

(12) The Division encourages AI/AN providers to request PHP supplemental payment in a timely manner.

(13) Clinics must exclude from a clinic’s data submission for PHP supplemental payment, services provided to a PHP-enrolled non-AI/AN client denied by the PHP because the clinic does not have a contract or agreement with the PHP. This may not apply to family planning services, or HIV/ AIDS prevention services. Family planning and HIV/AIDS prevention services provided to a PHP-enrolled client when a clinic does not have a contract or agreement with the PHP:

(a) Must be reported in the clinic’s data submission for PHP supplemental payment if the clinic receives payment from the PHP;

(b) Cannot be reported in the clinic’s data submission for PHP supplemental payment if the clinic is denied payment by the PHP. If the PHP denies payment to the clinic, the clinic can bill these services directly to the Division (see OAR 410-146-0060).

(14) If a PHP denies payment to a contracted AI/AN provider for all services, items and supplies provided to a client on a single date of service and meeting the definition of an “encounter” as defined in OAR 410-146-0085, for the reason that all services, items and supplies are non-covered by the plan, the Division may or may not make a supplemental payment to the clinic. The following examples are excluded from the provision of this rule:

(a) Encounters that will later be billed to the PHP as a covered global procedure (e.g. Obstetrics Global Encounter);

(b) Had payment received by Medicare, and any other third party resource not have exceeded the payment the PHP would have made, the PHP would have made payment;

(c) At least one of the detail lines reported for all services, items and supplies provided to a client on a single date of service and represents an “encounter,” has a reported payment amount by the PHP.

(15) The Division will not reimburse some Medicaid-covered services that are only reimbursed by PHPs, and are not reimbursed by the Division. The Division will not make PHP supplemental payment for these services, as the Division does not reimburse these services when billed directly to the Division.

(16) It is the responsibility of the AI/AN provider to refer PHP-enrolled non-AI/AN clients back to their PHP if the AI/AN provider does not have a contract with the PHP, and the service to be provided is not family planning or HIV/AIDS prevention. The provider assumes full financial risk in serving a person not confirmed by the Division as eligible on the date of service. See OAR 410-120-1140, Verification of Eligibility. The provider must verify:

(a) That the individual receiving medical services is eligible on the date of service for the service provided; and

(b) Whether a client is enrolled with a PHP or receives services on an “open card” or fee-for-service basis.

Stat. Auth.: ORS 413.042, 414.065

Stats. Implemented: ORS 414.065

Hist.: OMAP 62-2004, f. 9-10-04, cert. ef. 10-1-04; DMAP 19-2007, f. 12-5-07, cert. ef. 1-1-08; DMAP 24-2008, f. 6-13-08, cert. ef. 7-1-08; DMAP 34-2008, f. 11-26-08, cert. ef. 12-1-08; DMAP 7-2011, f. 6-6-11, cert. ef. 7-1-11

410-146-0460

Compensation for Outstationed Eligibility Workers

(1) The Division of Medical Assistance Programs (Division) may provide reasonable compensation for activities directly related to the receipt and initial processing of applications for individuals, including low-income pregnant women and children, to apply for Medicaid at outstation locations other than state offices.

(2) The Division may provide reasonable compensation to eligible AI/AN providers for outreach activities performed by Out-stationed Outreach Workers (OSOW) equal to 100% of direct costs.

(3) American Indian/Alaska Native (AI/AN) Program providers must submit a budget each December 1st to the Division for review of the clinic OSOW costs for approval before any OSOW compensation is made each January 1st.

(4) AI/AN providers must be compliant with OAR 410-120-0045 Applications for Medical Assistance at provider locations, to be eligible for compensation under this rule.

(5) For staff employed by a clinic and performing outreach activities at less than full time, the clinic must calculate the percent of time spent performing OSOW services and maintain adequate documentation to support the percentage of time claimed. The percent must be used to calculate personnel expenses incurred by an AI/AN provider as outlined in section (7) of this rule and that are directly attributed to outreach activities performed by the employee.

(6) Case management is excluded from OSOW reimbursement. If an OSOW also does case management, calculate the OSOW expense as outlined in section (5) above.

(7) Direct cost expenses allowed for OSOW reimbursement:

(a) Personnel costs for OSOWs:

(A) Salary/wages;

(B) Taxes;

(C) Fringe benefits provided to OSOW;

(D) Premiums paid by the AI/AN Program provider for private health insurance;

(b) Travel expenses incurred by the AI/AN provider for the Division training on OSOW activities;

(c) Phone bills, if a dedicated line. Otherwise an estimate of telephone usage and resulting costs;

(d) Reasonable equipment necessary to perform outreach activities. A Tribal 638 provider reimbursed according to a cost-based rate will not include expenses for replacing equipment if the original cost of the equipment was reported on the cost statement when the clinic’s initial cost-based encounter rate was calculated;

(e) Rent or space costs. A Tribal 638 provider reimbursed according to a cost-based rate will not include rent or space costs if 100% of facility costs were reported on the cost statement when the clinic’s initial cost-based encounter rate was calculated;

(f) Reasonable office supplies necessary to perform outreach activities; and

(g) Postage.

(8) The Division excludes indirect costs relating to OSOW activities to Tribal 638 providers reimbursed according to a cost-based rate. Excluded indirect costs include and are not limited to the following:

(a) Any costs included in the initial calculation of a Tribal 638 clinic’s cost-based encounter rate;

(b) Contracted interpretation services;

(c) Administrative overhead costs; and

(d) Operating expenses including utilities, building maintenance and repair, and janitorial services

(9) IHS and Tribal 638 Facilities that have a Medicaid Administrative Match contract that includes outreach costs are not eligible for separate outreach payments. IHS and Tribal 638 facilities cannot participate in the Medicaid Administrative Claiming (MAC) program if they are receiving OSOW compensation according to this rule.

Stat. Auth.: ORS 413.042, 414.065

Stats. Implemented: ORS 414.065

Hist.: OMAP 62-2004, f. 9-10-04, cert. ef. 10-1-04; DMAP 19-2007, f. 12-5-07, cert. ef. 1-1-08; DMAP 7-2011, f. 6-6-11, cert. ef. 7-1-11

 

Rule Caption: July ‘11 — Clarify rule regarding individual practitioner enrollment, amend rule to ensure is consistent with general rules.

Adm. Order No.: DMAP 8-2011

Filed with Sec. of State: 6-6-2011

Certified to be Effective: 7-1-11

Notice Publication Date: 5-1-2011

Rules Amended: 410-147-0340, 410-147-0400

Subject: The Federally Qualified Health Centers and Rural Health Clinics (FQHC/RHC) Program rules govern the Division of Medical Assistance Programs’ (Division) payments for services provided to certain clients. The Division amended 410-147-0340 and 410-147-0400 as follows:

      • To eliminate barriers to FQHC/RHC’s enrolling individual practitioners employed by the health center, and to reference OAR 410-120-0045 and not an outreach agreement administered by the Division.

      • All above rules will reflect the Oregon Health Authority name change and updated statutory reference.

      Other text may be revised to improve readability and to take care of necessary “housekeeping” corrections.

Rules Coordinator: Darlene Nelson—(503) 945-6927

410-147-0340

Federally Qualified Health Centers and Rural Health Clinics Provider Numbers

(1) Pursuant to National Provider Identifier (NPI) requirements in 45 CFR Part 162 providers must use a NPI, and in specific situations associated taxonomy code(s), when billing the Division of Medical Assistance Programs (Division).

(2) A Federally Qualified Health Center (FQHC) or Rural Health Clinic (RHC) shall register the NPI number and associated taxonomy code, obtained for the FQHC or RHC at the time of enrollment. Multiple sites are not separately enrolled, unless each site has a different tax identification number.

(3) The Division may grant an exception to section (2) of this rule upon written request to the Division of Medical Assistance Programs – Attn: FQHC/RHC Program Manager. The request must include a detailed explanation describing the:

(a) Need for separate enrollment of an additional site; and

(b) Mechanisms in place to assure no duplication of billings.

(4) If the Division finds evidence of duplicate or inappropriate billing resulting from provider misuse under multiple enrollments, the Division may terminate the exception upon written notice to the clinic.

(5) If the Division grants an exception to section (2) of this rule, the Division shall separately enroll each clinic site. When granted multiple provider enrollments, clinics must register:

(a) A separate NPI number for each clinic; or

(b) One NPI number and separate taxonomy codes for each clinic.

(6) If an FQHC or RHC has several clinic sites and one or more of the clinics are not designated as an FQHC or RHC, the non-FQHC or non-RHC (each individual clinic) must:

(a) Enroll as a billing provider; and

(b) Each practitioner must individually enroll.

(7) Upon enrollment and each October thereafter, FQHCs and RHCs must submit to the Division:

(a) A list including names and NPI numbers of individual practitioners associated with the FQHC/RHC; and

(b) A list including business names, addresses and facility NPI numbers for all Division-enrolled clinics affiliated or owned by the FQHC or RHC including any clinics that do not have FQHC or RHC status

(8) An FQHC or RHC that operates a retail pharmacy, provides durable medical equipment (DME), prosthetics, orthotics, and supplies (DMEPOS), must enroll separately as a pharmacy and/or DMEPOS provider. Refer to OAR chapter 410, division 121, Pharmaceutical and OAR chapter 410, division 122, DMEPOS; for specific information. These services are not billed under FQHC or RHC enrollment.

(9) The Division shall coincide registration of a clinic’s NPI number and associated taxonomy codes if applicable, effective the date of enrollment with the Division as an FQHC or RHC, and after the encounter rate is established.

(10) Prepaid Health Plans (PHP) are required to report all PHP encounters using the FQHC/RHC’s NPI and associated taxonomy code, if required, and not individual practitioner NPI numbers and taxonomy codes.

Stat. Auth.: ORS 413.042, 414.065

Stat. Implemented: ORS 414.065

Hist.: OMAP 63-2002, f. & cert. ef. 10-1-02; OMAP 71-2003, f. 9-15-03, cert. ef. 10-1-03; OMAP 63-2004, f. 9-10-04, cert. ef. 10-1-04; DMAP 25-2008, f. 6-13-08, cert. ef. 7-1-08; DMAP 34-2008, f. 11-26-08, cert. ef. 12-1-08; DMAP 8-2011, f. 6-6-11, cert. ef. 7-1-11

410-147-0400

Compensation for Outstationed Outreach Activities

(1) This rule provides reasonable compensation for activities directly related to the receipt and initial processing of applications for individuals, including low-income pregnant women and children, to apply for Medicaid at outstation locations other than state offices.

(2) A federally qualified health center (FQHC) eligible in accordance with Oregon Administrative Rule (OAR) 410-120-0045 Applications for Medical Assistance at provider locations, will be eligible for compensation under this rule.

(3) ‘’Initial processing’’ includes the following activities:

(a) Taking applications;

(b) Assisting applicants in completing the application;

(c) Providing information as outlined in OAR 410-120-0045;

(d) Obtaining required documentation to complete processing of the application;

(e) Ensuring that the information contained on the application form is complete; and

(f) Conducting any necessary interviews.

(4) “Initial processing” does not include evaluating the information contained on the application and the supporting documentation or making a determination of eligibility or ineligibility.

(5) At locations that are infrequently used by the designated low-income eligibility groups, the Division of Medical Assistance Programs (Division) may use the following resources:

(a) Volunteers, provider or contractor employees; or

(b) Its own eligibility staff, or

(c) Telephone assistance by:

(A) The FQHC as outlined in section (8); or

(B) Prominently displaying a notice that includes the telephone number for the state OHP Application Center or the local branch office that applicants may call for assistance.

(6) Eligible FQHCs may be able to receive reasonable compensation for outreach activities performed by Outstationed Outreach Workers (OSOW) that is equal to 100% of direct costs:

(a) The Division will calculate an OSOW rate based on reasonable direct costs described in section (11) of this rule, and reported by a clinic according to section (7) of this rule;

(b) The Division will add the OSOW to the clinic’s current base medical Prospective Payment System (PPS) encounter rate.

(7) Changes to OSOW compensation applied to the PPS encounter rate:

(a) Clinics must submit to the Division a cost statement for the preceding fiscal year no earlier than October 1, and no later than October 31, of each year for Division review and approval of the clinic’s OSOW direct costs;

(b) Any change to the OSOW rate, based on the October cost statement submission, will be effective January 1 of the following year;

(c) If the Division determines that the OSOW rate is inflated, the clinics OSOW rate will be adjusted effective immediately.

(8) Clinic locations with limited operating hours, or that limit access to the general public during their regular operating hours must calculate the actual time an OSOW meets face-to-face with the general public for receipt and the initial processing of applications. For example, if a clinic employs an OSOW at a satellite school-based health center (SBHC), and the SBHC can only be accessed by the general public outside of the school’s normal hours of operation, use the percent of time an OSOW is available to meet face-to-face with potential applicants when reporting compensation as outlined in section (11) (c) of this rule.

(a) Clinics must display a notice in a prominent place that advises potential applicants when an OSOW will be available;

(b) The notice must include a telephone number that applicants may call for assistance.

(9) For staff employed by a clinic and performing outreach activities at less than full time, the clinic must calculate the percent of time spent performing OSOW services and maintain adequate documentation to support the percentage of time claimed. The percent must be used to calculate personnel expenses incurred by an FQHC as outlined in Section (10) (c) of this rule and that are directly attributed to outreach activities performed by the employee. Outreach activities:

(a) May include assisting individuals with completing applications for other Department of Human Services (Department) and Authority-administered programs where eligibility is determined by staff at local branch offices;

(b) Does not include assisting individuals with applying for non-Department and non-Authority-administered programs.

(10) A clinic is prohibited from claiming reimbursement for costs associated with personnel positions where 100% of costs were included in the FQHC’s Prospective Payment System (PPS) encounter rate calculation;

(11) Direct cost expenses allowed for OSOW reimbursement:

(a) Travel expenses incurred by the FQHC for Division training on OSOW activities;

(b) Phone bills, if a dedicated line. Otherwise an estimate of telephone usage and resulting costs;

(c) Personnel costs for OSOWs:

(A) Wages will be the lesser of:

(i) Reported wages by the FQHC; or

(ii) Wages paid by the State of Oregon to an employee of the state providing enrollment assistance to clients applying for the Oregon Health Plan;

(B) Taxes;

(C) Fringe benefits provided to OSOW;

(D) Premiums paid by the FQHC for private health insurance.

(d) Reasonable equipment necessary to perform outreach activities. Do not include expenses for replacing equipment if the original cost of the equipment was reported on the cost statement when the clinic’s initial PPS encounter rate was calculated;

(e) Rent or space costs. Do not include rent or space costs if 100% of facility costs were reported on the cost statement when the clinic’s initial PPS encounter rate was calculated;

(f) Reasonable office supplies necessary to perform outreach activities; and

(g) Postage.

(12) The Division excludes indirect costs relating to OSOW activities from calculation of the OSOW rate. Excluded indirect costs include and are not limited to the following:

(a) Any costs included in the initial calculation of a clinic’s Prospective Payment System (PPS) encounter rate;

(b) Contracted interpretation services;

(c) Administrative overhead costs;

(d) Supervision costs; and

(e) Operating expenses including utilities, building maintenance and repair, and janitorial services.

(13) A Public Health Department designated as an FQHC or a School Based Health Center (SBHC) within the scope of an FQHC designation cannot participate in the Medicaid Administrative Claiming (MAC) program.

(14) If a clinic fails to submit the OSOW budget by November 1 of the required year, a clinic may not be eligible for compensation of OSOW costs as of January 1 for the coming year.

Stat. Auth.: ORS 413.042, 414.065

Stats. Implemented: ORS 414.065

Hist.: HR 13-1993, f. & cert. ef. 71-1-93; OMAP 35-1999, f. & cert. ef. 10-1-99; OMAP 20-2000, f. 9-28-00, cert. ef. 10-1-00; OMAP 62-2002, f. & cert. ef. 10-1-02, Renumbered from 410-128-0330; OMAP 71-2003, f. 9-15-03, cert. ef. 10-1-03; OMAP 27-2006, f. 6-14-06, cert. ef. 7-1-06; DMAP 47-2009, f. 12-15-09, cert. ef. 1-1-10; DMAP 8-2011, f. 6-6-11, cert. ef. 7-1-11

 

Rule Caption: Move Law Enforcement Medical Liability Program from chapter 461 to 410.

Adm. Order No.: DMAP 9-2011

Filed with Sec. of State: 6-6-2011

Certified to be Effective: 7-1-11

Notice Publication Date: 5-1-2011

Rules Ren. & Amend: 461-012-0100 to 410-160-0000, 461-012-0150 to 410-160-0100

Subject: The Law Enforcement Medical Liability Act (LEMLA) program administrative rules govern Division payments for services to certain clients. The LEMLA Program is an existing program that is being moved from chapter 461 (Children, Adult and Families) to chapter 410 (Division of Medical Assistance Programs). The Division renumbered and amended the rules with current information, name changes, codification, punctuation and formatting consistent with other Division rules.

      Other text may be revised to improve readability and to take care of necessary “housekeeping” corrections.

Rules Coordinator: Darlene Nelson—(503) 945-6927

410-160-0000

Definitions

For the purposes of OAR 410-160-0000 through 410-160-0100, the following definitions shall apply:

(1) LEMLA means the Law Enforcement Medical Liability Account.

(2) LEMLA Patient means a person who has suffered injuries related to law enforcement activity.

(3) Injuries Related to Law Enforcement Activity means injuries sustained prior to booking, citation in lieu of arrest or release instead of booking that occur during and as a result of efforts by a law enforcement officer to restrain or detain, or to take or retain custody of, the individual. Whether injuries related to law enforcement activity have occurred shall be determined by the law enforcement agency.

(4) Release Date means the date the LEMLA patient was released from actual physical custody, as determined by the law enforcement agency.

(5) Cost of Such Services means “usual charge” as defined in OAR 410-120-0000.

(6) Hospital means a hospital as defined in OAR 410-120-0000.

(7) Overpayment means payment made by LEMLA to a claimant in excess of the amount due for the covered services and items billed.

(8) Claimant means a Medicaid provider.

(9) Medicaid Provider means a provider who has been issued a provider number by the Division and is not currently subject to sanction by the Division.

(10) Prior Payment Amount means the total of all payments received by the claimant from all other sources, including the LEMLA patient, prior to submitting a LEMLA claim.

(11) LEMLA Claim Amount means the total cost of such services provided to a LEMLA patient that are directly connected to injuries related to law enforcement activity. It shall not include any charges for services provided to a LEMLA patient for a preexisting disease or condition, or services that are unrelated to the “injuries related to law enforcement activities.”

Stat. Auth.: ORS 413-042, ORS 414.065

Stats. Implemented: ORS 414.805 -- ORS 414.815

Hist.: AFS 1-1992, f. 1-14-92, cert. ef. 2-1-92; AFS 6-1992, f. & cert. ef. 3-9-92; AFS 24-1993, f. 10-27-93, cert. ef. 11-1-93; AFS 10-2002, f. & cert. ef. 7-1-02; Renumbered from 461-012-0100, DMAP 9-2011, f. 6-6-11, cert. ef. 7-1-11

410-160-0100

Process and Procedure

(1) The purpose of the Law Enforcement Medical Liability Account (LEMLA) is to provide a fund to reimburse a claimant for emergency medical services provided to a LEMLA patient.

(2) The time limit for submitting claims to LEMLA is one year after the date of injury. If a claimant has been paid by a LEMLA patient’s insurer or health care contractor and the LEMLA patient’s insurer or health care contractor subsequently demands return of the payment, a claimant must bill LEMLA not later than 180 days from the date of the demand letter or one year from the date of injury, whichever is later.

(3) The Division shall process all claims received in accordance with the following procedures:

(a) The claim shall be date stamped on the date received by LEMLA;

(b) The Division shall review each claim submitted to verify that the claim contains all of the following required information:

(A) The LEMLA claim form, with the following information:

(i) Certification by an authorized representative of the law enforcement agency involved with an injury that the injury is related to law enforcement activity;

(ii) The release date, if any, as determined by the law enforcement agency. If the LEMLA patient has not yet been released, state that on the LEMLA claim form;

(iii) LEMLA patient’s name;

(iv) Prior payment amount;

(v) Date of injury;

(vi) Claimant’s Medicaid provider number;

(vii) Claimant’s name;

(viii) LEMLA claim amount;

(ix) Cause or nature of injury.

(B) Attached to the LEMLA form, the following information:

(i) Documentation that demonstrates the claimant has billed the LEMLA patient or the LEMLA patient’s insurer or health care contractor for the charges or expenses owed to the claimant and that the claimant has made a reasonable effort to collect from the LEMLA patient or the LEMLA patient’s insurer or health care contractor;

(ii) A copy of the hospital or provider billing document that shows the usual charge and date of service.

(c) The Division shall reject claims that do not contain all of the information required in subsection (3)(b) of this rule;

(d) The Division shall review the documentation of reasonable collection effort. If 45 days have not elapsed since the claimant billed the LEMLA patient or the LEMLA patient’s insurer or health care contractor, the claim may be rejected;

(e) The Division shall review the date of injury. If the date stamped on the claim under subsection (3)(a) of this rule is more than one year after the date of injury, the claim shall be rejected. The one-year time limit may not apply if the provisions of section (2) of this rule apply with regards to an insurer or health care contractor demanding repayment of a previously paid claim.

(4) Using the LEMLA claim amount, the Division shall pay claimants, subject to any adjustment made under section (5) of this rule, according to the following:

(a) For hospitals, by the current “Hospital Fee Schedule-Adjusted Cost/Charge Ratios for Oregon Hospitals,” established by the Director of the Department of Consumer and Business Services;

(b) For all Medicaid providers except hospitals, the Division shall pay 75 percent of the LEMLA claim amount.

(5) After determining the amount under section (4) of this rule, the Division shall add the amount received in section (6) of this rule. If the total is more than the usual charge, the Division shall reduce the amount of its payment by the amount in excess of the usual charge.

(6) The claimant is responsible for making reasonable effort to collect from the LEMLA patient or the LEMLA patient’s insurer or health care contractor. Claimants are required to report all collections made when a claimant submits a claim to the Division for payment.

(7) If the Division has paid a claimant and the claimant subsequently receives payment from any other source, the claimant is required to repay the Division the amount received, minus the difference between the usual amount billed and the amount the Division paid. This means claimants are entitled to reimburse themselves for the amount the Division did not pay, with the excess due to the Division as repayment of an overpayment. The repayment is due and payable by check to the Division within 30 days after the claimant has received the funds from the other source.

(8) The Division shall continue to pay for medical services for injuries related to law enforcement activities while the LEMLA patient is incarcerated. Upon release of the LEMLA patient from physical custody, the Division shall no longer pay for further medical expenses incurred. If the LEMLA patient is cited in lieu of arrest or released instead of booked, the Division shall no longer pay for further medical expenses upon discharge or release from the hospital or other medical facility.

(9) The Division shall pay all accepted claims to the extent that the Division has sufficient funds available, subject to the maximum limit for payment of expenses authorized by law. The Division shall monitor the expenses and if the Division determines that the authorized limit may be exceeded, or that insufficient funds are available, the Division shall take the following actions:

(a) The Division shall continue to accept claims and date stamp them in the order the claims are received. The Division shall then suspend further processing of the claim;

(b) The Division shall notify each claimant that the claim has been suspended and the reason for the action;

(c) The Division shall maintain a file of suspended claims and await further legislative direction regarding the disposition of the claims.

Stat. Auth.: ORS 413.042, ORS 414.065

Stats. Implemented: ORS 414.805 -- ORS 414.815

Hist.: AFS 1-1992, f. 1-14-92, cert. ef. 2-1-92; AFS 6-1992, f. & cert. ef. 3-9-92; AFS 24-1993, f. 10-27-93, cert. ef. 11-1-93; AFS 18-1995, f. & cert. ef. 8-1-95; AFS 10-2002, f. & cert. ef. 7-1-02; Renumbered from 461-012-0150, DMAP 9-2011, f. 6-6-11, cert. ef. 7-1-11

Notes
1.) This online version of the OREGON BULLETIN is provided for convenience of reference and enhanced access. The official, record copy of this publication is contained in the original Administrative Orders and Rulemaking Notices filed with the Secretary of State, Archives Division. Discrepancies, if any, are satisfied in favor of the original versions. Use the OAR Revision Cumulative Index found in the Oregon Bulletin to access a numerical list of rulemaking actions after November 15, 2010.

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