Oregon Administrative Code

410-120-0003 OHP Standard Benefit Package The OHP Standard benefit package is eliminated effective January 1, 2014. Although references to OHP Standard exist elsewhere in rule, the benefit package currently is not funded and is not offered as a benefit. Those enrolled in OHP Stan…

410-120-0006 Medical Eligibility Standards As the state Medicaid and CHIP agency, the Oregon Health Authority (Authority) is responsible for establishing and implementing eligibility policies and procedures consistent with applicable law. As outlined in OAR 943-001-0020, the Auth…

410-120-0025 Administration of Division of Medical Assistance Programs, Regulation and Rule Precedence (1) The Oregon Health Authority (Authority) and its Division of Medical Assistance Programs (Division) may adopt reasonable and lawful policies, procedures, rules, and interpret…

410-120-0030 Children’s Health Insurance Program (1) The Children’s Health Insurance Program (CHIP) is a federal non-entitlement program. The Oregon Health Authority (Authority), Division of Medical Assistance Program (Division) administers two programs funded under CHIP in accor…

410-120-0035 Public Entity (1) This rule pertains to Centers for Medicare and Medicaid (CMS) regulations for payments to and from Oregon Health Authority (Authority) and public entities. (2) Effective July 1, 2008, unit of government providers responsible by rule or contract for …

410-120-0045 Applications for Medical Assistance at Provider Locations (1) The Oregon Health Authority (Authority) allows Division enrolled providers the opportunity to assist applicants applying for public and private health coverage offered through the Authority and the Oregon …

410-120-0250 Managed Care Entity (1) The Authority provides clients with health services through contracts with a Managed Care Entity (MCE). (2) The MCE is responsible for providing, arranging, and making reimbursement arrangements for covered services as governed by state and fe…

410-120-1140 Verification of Eligibility and Coverage (1) To ensure Division reimbursement of services, providers are responsible to verify the following before rendering services: (a) Client eligibility: That the person is an eligible Oregon Health Plan (OHP) client on the date(…

410-120-1160 Medical Assistance Benefits and Provider Rules (1) Providers enrolled with and seeking reimbursement for services through the Health Systems Division (Division) are responsible for compliance with current federal and state laws and regulations governing Medicaid serv…

410-120-1180 Medical Assistance Benefits: Out-of-State Services (1) A provider located in a state other than Oregon whose services are rendered in that state shall be licensed and otherwise certified by the proper agencies in the state of residence as qualified to render the serv…

410-120-1190 Medically Needy Benefit Program The Medically Needy Program is eliminated effective February 1, 2003. Although references to this benefit exist elsewhere in rule, the program currently is not funded and is not offered as a benefit. Statutory/Other Authority: ORS 413.…

410-120-1200 Excluded Services and Limitations (1) Certain services or items are not covered under any program or for any group of eligible clients. Service limitations are subject to either: (a) the Health Evidence Review Commission (HERC) Prioritized List of Health Services as …

410-120-1210 Medical Assistance Benefit Packages and Delivery System (1) The services clients are eligible to receive are based on their benefit package. Not all packages receive the same benefits. (2) The Health Systems Division (Division), Medical Assistance Programs benefit pa…

410-120-1260 Provider Enrollment (1) This rule applies to providers requesting enrollment, currently enrolled, and previously enrolled with the Oregon Health Authority (Authority), Health Systems Division (Division). (2) Providers signing the Provider Enrollment Agreement constit…

410-120-1280 Billing (1) A provider enrolled with the Authority or providing services to a client in a Managed Care Entity (MCE) under the Oregon Health Plan (OHP) may not seek payment from the client for any services covered by Medicaid fee-for-service or through contracted heal…

410-120-1285 Recoupment and Data Sharing with Third-Party Insurers (1) The Oregon Health Authority (Authority) delegates to the Department of Human Services (Department), Office of Payment Accuracy and Recovery (OPAR) (for OPAR see Administrative Rules chapter 407 division 120, o…

410-120-1295 Non-Participating Provider (1) For purposes of this rule, a provider enrolled with the Health Systems Division (Division) that does not have a contract with a Division-contracted Managed Care Entity (MCE) is referred to as a non-participating provider. (2) For servic…

410-120-1300 Timely Submission of Claims (1) In order to be reimbursed for services rendered, providers must comply with the following: (a) Medicaid fee-for-service only claims must be filed within 12 months of the date of service. The date of service for an inpatient hospital st…

410-120-1320 Authorization of Payment (1) Some services or items covered by the Oregon Health Authority require authorization before the service can be provided. See the appropriate Oregon Health Authority rules for information on services requiring authorization and the process …

410-120-1340 Payment (1) The Division shall make payment only to the enrolled provider (see OAR 410-120-1260) who actually performs the service or to the provider's enrolled billing provider for covered services rendered to eligible clients. (2) Division reimbursement for service…

410-120-1350 Buying-Up (1) Providers are not permitted to bill and accept payment from the Division or a managed care plan for a covered service: (a) When a non-covered service has been provided; and (b) Additional payment is sought or accepted from the Division client. (2) Examp…

410-120-1360 Requirements for Financial, Clinical and Other Records (1) The Authority shall analyze, monitor, audit, and verify the accuracy and appropriateness of payment, utilization of services, medical necessity, medical appropriateness, quality of care, and access to care of…

410-120-1380 Compliance with Federal and State Statutes (1) When a Provider submits a claim for medical services or supplies provided to a Division of Medical Assistance Programs (Division) client, Division shall deem the submission as a representation by the medical Provider to …

410-120-1385 Compliance with Public Meetings Law (1) Advisory committees with the authority to make decisions for, conduct policy research for, or make recommendations on administration or policy related to the medical assistance programs operated by the Authority pursuant to ORS…

410-120-1390 Premium Sponsorships (1) Premium donations made for the benefit of one or more specified the Division of Medical Assistance Programs (Division) clients will be referred to as a Premium Sponsorship and the donor shall be referred to as a sponsor. (2) The Authority may…

410-120-1395 Program Integrity (1) The Oregon Health Authority (Authority) uses several approaches to promote program integrity. These rules describe program integrity actions related to provider payments. Our program integrity goal is to pay the correct amount to a properly enro…

410-120-1396 Provider and Contractor Audits (1) Individual providers or business entities (providers) enrolled with or under contract with the Oregon Department of Human Services (ODHS) or the Oregon Health Authority (Authority) (hereafter referred to as “provider”) receiving pay…

410-120-1397 Recovery of Overpayments to Providers — Recoupments and Refunds (1) The Authority requires Providers to submit true, accurate, and complete claims or encounters. The Authority treats the submission of a claim or encounter, whether on paper or electronically, as certi…

410-120-1400 Provider Sanctions (1) The Authority recognizes two classes of Medicaid provider sanctions, mandatory and discretionary, outlined in sections (4) and (5) of this rule. (2) The Authority shall impose sanctions on Medicaid providers at the discretion of the Authority D…

410-120-1460 Type and Conditions of Sanction (1) The Health Systems Division (Division) may impose mandatory Sanctions on a Provider pursuant to OAR 410-120-1400(4), in which case: (a) The Provider shall be either Terminated or Suspended from participation in Oregon's medical ass…

410-120-1510 Fraud and Abuse (1) This rule sets forth requirements for reporting, detecting and investigating fraud and abuse. The terms fraud and abuse are defined in OAR 410-120-0000. For the purpose of these rules, the following definitions apply: (a) “Credible allegation of f…

410-120-1560 Provider Appeals (1) For purposes of Division provider appeal rules in chapter 410, division 120, the following terms and definitions are used: (a) “Provider” means an individual or entity enrolled with the Division or under contract with the Division that is subject…

410-120-1570 Claim Re-Determinations (1) If a provider disagrees with an initial claim determination made by the Division of Medical Assistance Program (Division), the provider may request a review for re-determination of the denied claim payment. (2) This rule does not apply to …

410-120-1580 Provider Appeals — Administrative Review (1) An administrative review is a provider appeal process that allows an opportunity for the Administrator of the Division of Medical Assistance Programs (Division) or designee to review a Division decision affecting the provi…

410-120-1600 Provider Appeals — Contested Case Hearings (1) A contested case procedure is a hearing that is conducted by the Office of Administrative Hearings where a contested case is appropriate and consistent with the provider appeal rules OAR 410-120-1560. If the request for …

410-120-1855 Client’s Rights and Responsibilities (1) Division of Medical Assistance Programs (Division) clients shall have the following rights: (a) To be treated with dignity and respect; (b) To be treated by providers the same as other people seeking health care benefits to wh…

410-120-1860 Contested Case Hearing Procedures (1) These rules apply to all contested case hearings provided by the Authority involving a client's health care benefits, except as otherwise provided in OAR 410-141-3890. The hearings are conducted in accordance with ORS 183.411 thr…

410-120-1865 Denial, Reduction, or Termination of Services (1) The purpose of this rule is to describe the requirements governing the denial, reduction, or termination of medical assistance and access to the Authority administrative hearings process for clients requesting or rece…

410-120-1875 Agency Hearing Representatives (1) Subject to the approval of the Attorney General, an agency officer or employee is authorized to appear (but not make legal argument) on behalf of the Authority in the following classes of hearings: (a) Contested case hearings reques…

410-120-1880 Contracted Services (1) Except as otherwise provided in OAR 410-120-1260 et seq. applicable to provider enrollment or 410-141-3500, 410-141-3700 et seq. governing CCO or PHPs, insurance and service contracts as provided for under ORS 414.115, 414.125, 414.135 and 414…

410-120-1920 Institutional Reimbursement Changes (1) The Division of Medical Assistance Programs (Division) is required under federal regulations, 42 CFR 447, to submit specific assurances and related information to the Centers for Medicare and Medicaid Services (CMS) whenever it…

410-120-1940 Interest Payments on Overdue Claims (1) Upon request by the provider, the Division will pay interest on an overdue claim: (a) A claim is considered “overdue” if Division does not make payment within 45 days of receipt of a valid claim; (b) The interest rate shall be …

410-120-1960 Payment of Private Insurance Premiums (1) Private Insurance Premium (PHI) and Health Insurance Premium Payment (HIPP) are cost saving programs administered by the Authority and the Department for Medicaid enrollees. When a Medicaid client or eligible enrollee is cove…

410-120-1980 Requests for Information and Public Records (1) The Division of Medical Assistance Programs (Division) will make non-exempt public records available for inspection to persons making a public records request under ORS 192.410 to 192.500. (2) Division may charge a fee …

410-120-1990 Telehealth (1) The following definitions apply to the Oregon Health Authority (Authority) administrative rules applicable to the medical assistance programs: (a) “Asynchronous” means not simultaneous or concurrent in time. For the purpose of this general rule, asynch…

410-120-2000 HRSN Services Delivery The purpose of this rule is to establish the processes, standards, and obligations required to be followed or met in administering and delivering Health Related Social Needs (HRSN) Services. (1) HRSN Services General Requirements; Overview of A…

410-120-2005 HRSN Service Eligibility; Identifying HRSN Eligible Members; HRSN Outreach and Engagement Services. (1) A Member is authorized to receive HRSN Services so long as they meet the definition of HRSN Eligible in OAR 410-120-0000 and all other eligibility requirements app…

410-120-2010 HRSN Service Requests (1) MCEs and the Authority shall accept and document all requests for HRSN Services (“HRSN Request(s)”) received through the pathways identified in OAR 410-120-2005 which utilize the methods described in section (11) of this rule. MCEs and the A…

410-120-2015 HRSN Eligibility Screening. (1) The purpose of this rule is to establish the processes, standards, and obligations required to be followed or met in administering, determining eligibility, and delivering Health Related Social Needs (HRSN) Services when a Member initi…

410-120-2020 Authorization of HRSN Services; Referral to HRSN Service Provider. (1) If, after completing the HRSN Eligibility Screening in accordance with OAR 410-120-2015, an MCE or, as applicable, the Authority, determines the Member meets all of the applicable HRSN Eligibility…