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Oregon Bulletin

December 1, 2012

Oregon Health Authority, Chapter 943

Rule Caption: Provider Enrollment and Claiming using Medicaid Management Information System.

Adm. Order No.: OHA 8-2012

Filed with Sec. of State: 10-30-2012

Certified to be Effective: 11-1-12

Notice Publication Date: 10-1-2012

Rules Amended: 943-120-0300, 943-120-0310, 943-120-0320, 943-120-0330, 943-120-0350

Rules Repealed: 943-120-0325, 943-120-0340, 943-120-0360, 943-120-0370, 943-120-0380, 943-120-0400

Subject: The Authority is amending these rules to ensure clarity and remove duplicative rule text. As a continued effort to make administrative rules more efficient, the Authority is repealing OAR 943-120-0325, 943-120-0340, 943-120-0360, 943-120-0370, 943-120-0380 and 943-120-0400 removing outdated language and duplicative text already covered in chapter 410 division 120 rules. The rule amendments provide information on which chapter 410 administrative rules must be complied with by providers seeking reimbursement from the Authority, PHP, CCO, or county for the provision of covered services.

Rules Coordinator: Evonne Alderete—(503) 932-9663

943-120-0300

Definitions

In addition to the definitions in OAR chapter 410 division 120, the following definitions apply to OAR 943-120-0300 to 943-120-0350:

(1) “Claim” means a bill for services, a line item of a service, or all services for one client within a bill. Claim includes a bill or an encounter associated with requesting reimbursement, whether submitted on paper or electronically. Claim also includes any other methodology for requesting reimbursement that may be established in contract or program-specific rules.

(a) Temporary Assistance to Needy Families (TANF) are categorically eligible families with income levels under current TANF eligibility rules;

(b) CHIP children under one year of age whose household has income under 185% Federal Poverty Level (FPL) and do not meet one of the other eligibility classifications;

(c) Poverty Level Medical (PLM) adults under 100% of the FPL and clients who are pregnant women with income under 100% of FPL;

(d) PLM adults over 100% of the FPL are clients who are pregnant women with income between 100% and 185% of the FPL;

(e) PLM children under one year of age who have family income under 133% of the FPL or were born to mothers who were eligible as PLM adults at the time of the child’s birth;

(f) PLM or CHIP children one through five years of age who have family income under 185% of the FPL and do not meet one of the other eligibility classifications;

(g) PLM or CHIP children six through 18 years of age who have family income under 185% of the FPL and do not meet one of the other eligibility classifications;

(h) OHP adults and couples are clients age 19 or over and not Medicare eligible, with income below 100% of the FPL who do not meet one of the other eligibility classifications, and do not have an unborn child or a child under age 19 in the household;

(i) OHP families are clients, age 19 or over and not Medicare eligible, with income below 100% of the FPL who do not meet one of the other eligibility classifications, and have an unborn child or a child under the age of 19 in the household;

(j) General Assistance (GA) recipients are clients who are eligible by virtue of their eligibility under the GA program, ORS 411.710 et seq.;

(k) Assistance to Blind and Disabled (AB/AD) with Medicare eligibles are clients with concurrent Medicare eligibility with income levels under current eligibility rules;

(l) AB/AD without Medicare eligibles are clients without Medicare with income levels under current eligibility rules;

(m) Old Age Assistance (OAA) with Medicare eligibles are clients with concurrent Medicare Part A or Medicare Parts A and B eligibility with income levels under current eligibility rules;

(n) OAA with Medicare Part B only are OAA eligibles with concurrent Medicare Part B only with income under current eligibility rules;

(o) OAA without Medicare eligibles are clients without Medicare with income levels under current eligibility rules; or

(p) Children, Adults and Families (CAF) children are clients with medical eligibility determined by CAF or Oregon Youth Authority (OYA) receiving OHP under ORS 414.025, 418.034, and 418.189 to 418.970. These individuals are generally in placement outside of their homes and in the care or custody of CAF or OYA.

(2) “Covered Services” means medically appropriate health services or items that are funded by the legislature and described in ORS Chapter 414, including OHP authorized under ORS 414.705 to 414.750, and applicable Authority rules describing the benefit packages of covered services except as excluded or limited under OAR 410-141-0500 or other public assistance services provided to eligible clients under program-specific requirements or contracts by providers required to enroll with the Authority under OAR 943-120-0300 to 943-120-0350.

(3) “Medicaid Management Information System (MMIS)” means the automated claims processing and information retrieval system for handling all Medicaid transactions.

(4) “Non-Participating Provider” means a provider who does not have a contractual relationship with the PHP or CCO.

(5) “Prepaid Health Plan (PHP)” means a managed health, dental, chemical dependency, physician care organization, or mental health care organization that contracts with the Division or Addictions and Mental Health Division (AMH) on a case managed, prepaid, capitated basis under the OHP. PHP’s may be a Dental Care Organization (DCO), Fully Capitated Health Plan (FCHP), Mental Health Organization (MHO), Primary Care Organization (PCO), or Chemical Dependency Organization (CDO).

(6) “Provider” means an individual, facility, institution, corporate entity, or other organization which supplies health care or other covered services or items, also termed a performing provider, that must be enrolled with the Authority pursuant to OAR 943-120-0300 to 943-120-0350 to seek reimbursement from the Authority, including services provided, under program-specific rules or contracts with the Authority or with a county, PHP, or CCO.

(7) “Quality Improvement” means the effort to improve the level of performance of key processes in health services or health care. A quality improvement program measures the level of current performance of the processes, finds ways to improve the performance and implements new and better methods for the processes. Quality improvement includes the goals of quality assurance, quality control, quality planning, and quality management in health care where “quality of care is the degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge.”

(8) “Visit Data” means program-specific or contract data collection requirements associated with the delivery of service to clients on the basis of an event such as a visit.

Stat. Auth.: ORS 413.042
Stats. Implemented: ORS 414.065
Hist.: OHA 14-2011(Temp), f. & cert. ef. 7-1-11 thru 12-27-11; OHA 20-2011, f. 8-30-11, cert. ef. 9-1-11; OHA 8-2012, f. 10-30-12, cert. ef. 11-1-12

943-120-0310

Provider Requirements

(1) All providers seeking reimbursement from the Authority, a PHP, CCO, or a county pursuant to a county agreement with the Authority for the provision of covered services or items to eligible recipients, must comply with:

(a) These rules, OAR 943-120-0300 to 943-120-0350: and

(b) The applicable rules or contracts of the specific programs described below:

(A) Programs administered by the Division of Medical Assistance Programs (Division) including the OHP medical assistance program and the CHIP program that reimburse providers for services or items provided to eligible recipients, subject to OAR chapter 410 divisions 120 and 141 and provider rules in chapter 410 applicable to the provider’s service category;

(B) Programs administered by the Addictions and Mental Health Division (AMH) that reimburse providers for services or items provided to eligible AMH recipients (OAR chapters 309 and 415); or

(C) Programs administered by Aging and People with Disabilities (APD) that reimburse providers for services or items provided to eligible APD recipients (OAR chapter 411).

(2) Providers must submit visit data pursuant to program-specific rules or contract. Authority programs use visit data to monitor service delivery, planning, and quality improvement activities. Visit data is not a HIPAA transaction and is not a claim for reimbursement.

[Publications: Publications referenced are available from the agency.]

Stat. Auth.: ORS 413.042
Stats. Implemented: ORS 414.065, 414.115; 414.125; 414.135; & 414.145
Hist.: OHA 14-2011(Temp), f. & cert. ef. 7-1-11 thru 12-27-11; OHA 20-2011, f. 8-30-11, cert. ef. 9-1-11; OHA 8-2012, f. 10-30-12, cert. ef. 11-1-12

943-120-0320

Provider Enrollment

(1) In some Authority program areas, being an enrolled Authority provider is a condition of eligibility for an Authority contract for certain services or activities. Billing providers must be enrolled with the Authority as providers consistent with the provider enrollment processes set forth in OAR 410-120-0310 through 0350 and 410-120-1260. If reimbursement for covered services is made under a contract with the Authority, the provider must also meet the Authority’s contract requirements. Contract requirements are separate from the requirements of these rules. Enrollment as a provider with the Authority is not a promise that the enrolled provider shall receive any amount of work from the Authority, a CCO, PHP, or a county.

(2) Provider enrollment establishes essential Authority provider participation requirements for becoming an enrolled Authority 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 instructions and requirements are contained in Authority program-specific rules in chapter 410 or contract.

(3) Prior to enrollment, providers must:

(a) Meet all program-specific or contract requirements identified in program-specific rules or contracts and the requirements set forth in these rules and OAR 410-120-1260;

(b) Meet Authority contracting requirements, as specified by the Authority’s Office of Contracts and Procurement (OC&P);

(c) Meet Authority and federal licensing and certification requirements for the type of service for which the provider is enrolling; and

(d) Obtain a provider number from the Authority subject to OAR 410-120-1260.

(4) A provider may request to conduct electronic transactions with the Authority by enrolling and completing the appropriate authorization forms pursuant to the electronic data transaction rules (OAR 943-120-0100 to 943-120-0200).

[Publications: Publications referenced are available from the agency.]

Stat. Auth.: ORS 413.042
Stats. Implemented: ORS 414.065
Hist.: OHA 14-2011(Temp), f. & cert. ef. 7-1-11 thru 12-27-11; OHA 20-2011, f. 8-30-11, cert. ef. 9-1-11; OHA 8-2012, f. 10-30-12, cert. ef. 11-1-12

943-120-0330

Billing Procedures

(1) These rules only apply to covered services and items provided to clients that are paid for by the Authority based on an Authority fee schedule or other reimbursement method (often referred to as fee-for-service), or for services that are paid for by the Authority at the request of a county for county-authorized services.

(a) If a client’s service or item is paid for by a PHP or CCO, the provider must comply with the billing and procedures related to claim submission established under contract with that PHP, CCO, or the rules applicable to non-participating providers if the provider is not under contract with that PHP or CCO.

(b) If the client is enrolled in a PHP or CCO, but the client is permitted by a contract or program-specific rules to obtain covered services reimbursed by the Authority (such as family planning services that may be obtained from any provider). In addition to this rule, the provider must comply with the billing and claim procedures established in OAR chapter 410 division 120.

(2) All Authority-assigned provider numbers are issued at enrollment and are directly associated with the provider as defined in OAR 410-120-1260 and have the following uses:

(a) Log-on identification for the Authority web portal;

(b) Claim submission in the approved paper formats; and

(c) For electronic claims submission including the web portal for atypical providers pursuant to 45 CFR 160 and 162 where an NPI is not mandated. Use of the Authority-assigned provider number shall be considered the providers authorization and the provider shall be accountable for its use.

(d) Providers may not bill clients or the Authority for services or items provided free of charge. This limitation does not apply to established sliding fee schedules where the client is subject to the same standards as other members of the public or clients of the provider.

(e) Providers shall pay for costs incurred for failing to confirm eligibility or that services are covered.

Stat. Auth.: ORS 413.042
Stats. Implemented: ORS 414.065
Hist.: OHA 14-2011(Temp), f. & cert. ef. 7-1-11 thru 12-27-11; OHA 20-2011, f. 8-30-11, cert. ef. 9-1-11; OHA 8-2012, f. 10-30-12, cert. ef. 11-1-12

943-120-0350

Payments and Overpayments

(1) Payments.

(a) This rule only applies to covered services and items provided to eligible clients within the program-specific or contract covered services or items in effect on the date of service that are paid for by the Authority based on program-specific or contract fee schedules or other reimbursement methods, or for services that are paid for by the Authority at the request of a county for county-authorized services.

(b) If the client’s service or item is paid for by a PHP or CCO, the provider must comply with the payment requirements established under contract with that PHP or CCO, and pursuant to OAR 410-120 and 410-141, applicable to non-participating providers.

(c) The Authority shall pay for services or items based on the reimbursement rates and methods specified in the applicable program-specific rules or contract. Provider reimbursement on behalf of a county must include county service authorization information.

Stat. Auth.: ORS 413.042
Stats. Implemented: ORS 414.065
Hist.: OHA 14-2011(Temp), f. & cert. ef. 7-1-11 thru 12-27-11; OHA 20-2011, f. 8-30-11, cert. ef. 9-1-11; OHA 8-2012, f. 10-30-12, cert. ef. 11-1-12

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, 2011.

2.) Copyright 2012 Oregon Secretary of State: Terms and Conditions of Use

Oregon Secretary of State • 136 State Capitol • Salem, OR 97310-0722
Phone: (503) 986-1523 • Fax: (503) 986-1616 • oregon.sos@state.or.us

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