Oregon Administrative Code

407-043-0020 Cooperative Relationship with Oregon Health Authority (1) The Department of Human Services (Department) will cooperate and collaborate with Oregon Health Authority (Authority) in order to effectively coordinate services to individuals, families and communities and re…

407-050-0000 Purpose These rules set forth parameters concerning who can make decisions and take action on behalf of individuals who are incapable of making their own Medicare Part D Decisions. The decisions and actions include choosing a Medicare Part D prescription drug plan or…

407-050-0005 Definitions (1) "Authorized Representative" for purposes of these rules means one of the following, as determined in accordance with these rules: (a) Closest Available Relative; (b) Friend or Advocate; (c) Department Case Manager/Eligibility Specialist or Department …

407-050-0010 Authorized Decision Makers (1) These rules only pertain to those Part D-eligible Individuals who receive benefits or services, which are provided by, operated by, authorized or funded by the Department. Those acting under the authority of this rule must do so with th…

407-070-0000 Race, Ethnicity, Language, and Disability Demographic Data Collection Standards (1) Pursuant to ORS 413.161, the Oregon Health Authority, in collaboration with the Oregon Department of Human Services, established uniform standards, based on local, statewide and natio…

407-100-0010 Purpose and Scope (1) OAR 407-100 establishes the Resilience Hubs and Networks Grant Program within the Oregon Department of Human Services (ODHS) Office of Resilience and Emergency Management (OREM). The Program offers grants to organizations or individuals who wish…

407-100-0020 Definitions The following definitions apply to OAR 407-100: (1) “Awardee” means a Resilience Hubs and Networks Grant Program applicant that is selected for a grant award. (2) “Department” means the Oregon Department of Human Services. (3) “Grant Agreement” means the …

407-100-0030 Eligibility Individuals or organizations in Oregon are eligible to apply for the Resilience Hubs and Networks Grant Program. In accordance with ORS 409.760, the Oregon Department of Human Services (ODHS), Office of Resilience and Emergency Management (OREM) encourage…

407-100-0040 Evaluation Criteria Individuals or organizations may apply for grants by submitting an application that must include: (1) A description of the purposes for which grant moneys will be expended; (2) A plan for implementing specific strategies to build resilience in a c…

407-100-0050 Technical Review Process (1) Applications will be scored on objective criterion and subjective essay questions, which will be combined to calculate a combined total score. The applications combined total score will be used to inform funding decisions. (2) Objective s…

407-100-0060 Funding Decision Awards may be funded in-whole or in-part. Statutory/Other Authority: ORS 409.760 & ORS 409.050 Statutes/Other Implemented: ORS 409.760 History: DHS 9-2024, adopt filed 07/10/2024, effective 07/10/2024 DHS 6-2024, temporary adopt filed 01/16/2024, eff…

407-100-0070 Grant Agreement Conditions (1) Awards may not be used as pass-through funds to be distributed as a grant to other organizations; grant awards will be issued directly to the individual or organization that will be using the awarded resources. (a) However, if an organi…

407-100-0080 Waiver and Periodic Review of Rules The Oregon Department of Human Services (ODHS) Office of Resilience and Emergency Management (OREM) may waive the requirements of these rules for individual grant applications unless required by statute, when doing so will result i…

407-120-0100 Definitions The following definitions apply to OAR 407-120-0100 through 407-120-0200: (1) "Access" means the ability or means necessary to read, write, modify, or communicate data or information or otherwise use any information system resource. (2) "Agent" means a th…

407-120-0110 Purpose (1) These rules establish requirements applicable to providers, PHPs, and allied agencies that want to conduct electronic data transactions with the Department. These rules govern the conduct of all web portal or EDI transactions with the Department. These ru…

407-120-0112 Scope and Sequence of Electronic Data Transmission Rules (1) The Department communicates with and receives communications from its providers, PHPs, and allied agencies using a variety of methods appropriate to the services being provided, the nature of the entity pro…

407-120-0114 Provider Enrollment Agreement (1) When a provider applies to enroll, the application form will include information about how to participate in the web portal for use of DDE and automated voice response (AVR) inquiries. The enrollment agreement will include a section …

407-120-0116 Web Portal Submitter (1) Any provider activating their web portal access for web portal submission may be a web portal submitter. The provider will be referred to as the web portal submitter when functioning in that capacity, and shall be required to comply with thes…

407-120-0118 Conduct of Direct Data Entry Using Web Portal (1) The web portal submitter is responsible for the conduct of the DDE transactions submitted on behalf of the provider, as follows: (a) Accuracy of Web Portal Submissions. The web portal submitter must take reasonable ca…

407-120-0120 Registration Process — EDI Transactions (1) The EDI transaction process is preferred by providers, PHPs, and allied agencies for conducting batch or real time transactions, rather than the individual data entry process used for DDE. EDI registration is an administrat…

407-120-0130 Trading Partner as EDI Submitter – EDI Transactions (1) A trading partner may be an EDI submitter. Registered trading partners that also qualify as an EDI submitter may submit their own EDI transactions directly to the Department. A trading partner will be referred t…

407-120-0140 Trading Partner Agents as EDI Submitters — EDI Transactions (1) Responsibility for Agents. If a trading partner uses the services of an agent, including but not limited to an EDI submitter in any capacity in order to receive, transmit, store, or otherwise process dat…

407-120-0150 Testing — EDI Transactions (1) When a trading partner or authorized EDI submitter registers an EDI transaction with the Department, the Department may require testing before authorizing the transaction. Testing may include third party and business-to-business testing…

407-120-0160 Conduct of Transactions — EDI Transactions (1) EDI Submitter Obligations. An EDI submitter is responsible for the conduct of the EDI transactions registered on behalf of a trading partner, including the following: (a) EDI Transmission Accuracy. An EDI submitter shall…

407-120-0165 Pharmacy Point of Sale Access Pharmacy providers who electronically bill pharmaceutical claims must participate in and submit claims using the POS system, except as provided in OAR 410-121-0150. Statutory/Other Authority: ORS 409.050 & 414.065 Statutes/Other Implemen…

407-120-0170 Confidentiality and Security (1) Individually Identifiable Health Information. All providers, PHPs, and allied agencies are responsible for ensuring the confidentiality of individually identifiable health information, consistent with the requirements of the privacy s…

407-120-0180 Record Retention and Audit (1) Records Retention. A provider, web portal submitter, trading partner, and EDI submitter shall maintain, for a period of no less than seven years from the date of service, complete, accurate, and unaltered copies of all source documents …

407-120-0190 Material Changes (1) Changes in Any Material Information – EDT Process. A trading partner must submit an updated TPA, application for authorization, or EDI registration form to the Department within ten business days of any material change in information. A material …

407-120-0200 Department System Administration (1) No individual or entity shall be registered to conduct a web portal or an EDI transaction with the Department except as authorized under these the rules. Eligibility and continued participation as a provider, PHP, allied agency, o…

407-120-0300 Definitions The following definitions apply to OAR 407-120-0300 to 407-120-0400: (1) "Abuse" means provider practices that are inconsistent with sound fiscal, business, or medical practices resulting in an unnecessary cost to the Department, or in reimbursement for s…

407-120-0310 Provider Requirements (1) Scope of Rule. All providers seeking reimbursement from the Department, a PHP, or a county pursuant to a county agreement with the Department for the provision of covered services or items to eligible recipients, must comply with these rules…

407-120-0320 Provider Enrollment (1) In some Department program areas, being an enrolled Department provider is a condition of eligibility for a Department contract for certain services or activities. The Department requires billing providers to be enrolled as providers consisten…

407-120-0325 Compliance with Federal and State Statutes (1) When a provider submits a claim for services or supplies provided to a Department client, the Department shall consider the submission as the provider’s representation to the Department of the provider's compliance with …

407-120-0330 Billing Procedures (1) These rules only apply to covered services and items provided to clients that are paid for by the Department based on a Department fee schedule or other reimbursement method (often referred to as fee-for-service), or for services that are paid …

407-120-0340 Claim and PHP Encounter Submission (1) Claim and PHP Encounter Submission. All claims must be submitted using one of the following methods: (a) Paper forms, using the appropriate form as described in the program-specific rules or contract; (b) Electronically using th…

407-120-0350 Payments and Overpayments (1) Authorization of Payment. (a) Some services or items covered by the Department require authorization before a service, item, or level of care can be provided or before payment shall be made. Providers must check the appropriate program-s…

407-120-0360 Consequences of Non-Compliance and Provider Sanctions (1) There are two classes of provider sanctions, mandatory and discretionary, that may be imposed for non-compliance with the provider enrollment agreement. (2) Except as otherwise provided, the Department shall i…

407-120-0370 Requirements for Financial, Clinical, and Other Records (1) The Department shall analyze and monitor the operation of its programs and audit and verify the accuracy and appropriateness of payment, utilization of services, or items. (2) The Department shall comply wit…

407-120-0380 Fraud and Abuse (1) Providers shall promptly refer all suspected fraud and abuse, including fraud or abuse by its employees or in Department administration, to the MFCU, or to the Department's audit unit. (2) Providers must permit the MFCU and the Department to inspe…

407-120-0400 MMIS Replacement Communication Plan (1) The purpose of this rule is to describe the Department’s plan for communicating instructions and guidance related to the Department’s implementation of the replacement MMIS that began on December 9, 2008. System issues are anti…

407-120-1505 Provider and Contractor Audits, Appeals, and Post Payment Recoveries (1) Providers or entities under contract with the Department of Human Services (Department) or the Oregon Health Authority (Authority) (hereafter referred to as “provider”) receiving payments from t…

409-001-0005 Model Rules of Procedure The Oregon Health Authority, Health Policy and Analytics Division adopts the Attorney General’s Uniform and Model Rules of Procedure applicable to rulemaking, effective July 2016. [ED. NOTE: The full text of the Attorney General’s Model Rules…

409-015-0005 Definitions The following definitions apply to OAR 409-015-0005 through 409-015-0040: (1) “Authority” means the Oregon Health Authority. (2) "Charity care" means the uncollectible value, at the hospital's full established rates, of services provided to financially in…

409-015-0010 Report Forms (1) All health care facilities shall file the required reports and data on forms provided or approved by the Authority. (2) The Authority adopts and incorporates by reference the Patient Revenue and Unreimbursed Care form, Form FR-3. (3) The Authority sh…

409-015-0012 Filing Date The date of filing for the Databank Monthly Data electronically, is the date of receipt by the Oregon Association of Hospitals and Health Systems. The date of filing for the Patient Revenue and Unreimbursed Care (Form FR-3) is the postmark date. [ED. NOTE…

409-015-0015 Reports Required (1) Each health care facility shall file with the Authority financial statements, with attached certification of audit, not later than 120 days following the close of each fiscal year. If the financial statements of the facility are a part of the com…

409-015-0022 Instructions to Form RR-4 Text in ORMS History: OHP 1-1999, f. 10-22-99, cert. ef. 10-23-99 HP 2-1990, f. & cert. ef. 2-12-90 HP 2-1988, f. & cert. ef. 3-25-88 SHPD 18-1984, f. & ef. 12-20-84 Reverted to OHP 1-1999, f. 10-22-99, cert. ef. 10-23-99 Sunset on 09-28-201…

409-015-0030 Modification of Reporting Requirements (1) The Authority, upon request of a health care facility and for good cause, may relieve or modify the reporting requirements provided for in these rules when the reporting requirement is proven to the satisfaction of the Autho…

409-015-0035 Civil Penalties (1) Pursuant to ORS 442.445, the Authority adopts the following schedule of civil penalties: (a) $250.00 per day for the first five days of failure to file in accord with ORS 442.425; and (b) $500.00 per day from the sixth day until filing in accordan…

409-017-0121 Dental Therapy Definition of Underserved Populations (1) The purpose of this rule is to define the term “underserved population” per ORS 679.624 for the Board of Dentistry Dental Therapy rules. (2) The term “Underserved Population” refers to populations experiencing …