Oregon Administrative Code

333-010-0120 Covered Services (1) ScreenWise BCC covers screening and diagnostic services specific to breast and cervical cancer. Contracted providers will only be reimbursed for services related to breast and cervical cancer screening and diagnosis. (2) Screening and diagnostic …

333-010-0125 Excluded Services (1) Services and laboratory tests not directly related to breast and cervical cancer screening and diagnosis are not covered by ScreenWise BCC for any eligible client. If the client accepts financial responsibility for a non-covered service that is …

333-010-0130 Standards of Care for Breast and Cervical Cancer Screening and Diagnostic Services Participating ScreenWise BCC providers must agree to provide screening and diagnostic services according to the following standards: (1) Informed Consent. The client’s decision to part…

333-010-0135 Provider Enrollment (1) This rule applies only to providers participating in ScreenWise BCC through an approved provider agreement with the Center. (2) An individual or organization must meet applicable licensing or regulatory requirements set forth by federal and st…

333-010-0140 Billing (1) Only clinics providing breast and cervical cancer screening and diagnostic services pursuant to an approved medical services agreement, and who have been assigned an agency number may submit claims for ScreenWise BCC services. (2) All services must be bil…

333-010-0145 Claims and Data Submission (1) In addition to submitting standard claims information, enrolling providers are required to submit client data in order to receive payment for the claim. The data is used to collect information pertaining to breast and cervical cancer pr…

333-010-0150 Timely Submission of Claims and Data (1) All claims for services must be submitted within 120 days of the date of service. Claims older than 120 days from the date of service will not be paid, except as provided for in section (2) and (3) of this rule. (2) If a claim…

333-010-0155 Payment (1) The Center will make payment only to providers that have a medical services agreement with the ScreenWise BCC and are billing for an eligible client. (2) The ScreenWise BCC reimbursement amount will be up to the Medicare reimbursement rate for the Portlan…

333-010-0160 Requirements for Financial, Clinical and Other Records (1) The Center is responsible for analyzing and monitoring the operation of ScreenWise BCC and for auditing and verifying the accuracy and appropriateness of payment, utilization of services, the quality of care,…

333-010-0165 Compliance with Federal and State Statutes (1) Submission of a claim for medical services or supplies provided to a ScreenWise BCC client shall be deemed a representation by the medical provider to the Center of the medical provider’s compliance with the applicable s…

333-010-0170 Denial or Recovery of Reimbursement Resulting from Review or Audit (1) The Center’s staff, contractor or auditor may review a claim for assurance that the specific medical service was provided in accordance with the program’s policies and rules and the generally acce…

333-010-0175 Recovery of Overpayments to Providers Resulting from Review or Audit (1) When the Center determines that an overpayment has been made to a provider, the amount of overpayment is subject to recovery: (a) To determine the overpayment amount, the Center may use a statis…

333-010-0180 Provider Sanctions The following are conditions that may result in the imposition of a sanction on a provider. (1) Basis for Sanction: (a) Conviction of a provider of a felony or misdemeanor related to a crime or violation of Title XVIII, XIX, or XX of the Social Sec…

333-010-0185 Provider Appeals A provider may appeal certain decisions affecting the provider made by the Center. There are two levels of appeal. Level 1 is a reconsideration on a claim. Level 2 is a contested case hearing. Statutory/Other Authority: ORS 413.042 Statutes/Other Imp…

333-010-0190 Provider Appeals (Level 1) — Claims Reconsideration A provider disputing the Center’s claim decision may request reconsideration. The provider must submit the request in writing to the Center. The request must include the reason for the dispute, and any information p…

333-010-0195 Provider Appeals (Level 2) — Contested Case Hearing Contested case hearings will be held in accordance with ORS 183. Statutory/Other Authority: ORS 413.042 Statutes/Other Implemented: ORS 413.042 History: PH 9-2008, f. & cert. ef. 6-16-08

333-010-0197 Presumptive Eligibility for BCCTP (1) Any licensed health care provider who can diagnose breast or cervical cancer may presumptively enroll a client into BCCTP and refer the client to the Oregon Health Plan if she meets the presumptive eligibility criteria as describ…

333-010-0200 ScreenWise WISEWOMAN Program: Description of the WISEWOMAN Program The WISEWOMAN (WW) Program is a federal program, administered by the Oregon Health Authority, that provides heart disease, stroke and diabetes screening support to develop and maintain healthy behavio…

333-010-0205 Definitions (1) "Agency number" means the administrative number assigned to the service provider by the Center for Prevention and Health Promotion (Center) for identification as a BCCP/WW provider. (2) "Ancillary provider" means an individual or entity that has met t…

333-010-0210 Client Eligibility A person must meet the following WW Program eligibility criteria in order to be enrolled in the WW Program: (1) Be a woman 40 to 64 years of age; and (2) Be enrolled in the BCCP program. Statutory/Other Authority: ORS 413.042 Statutes/Other Impleme…

333-010-0215 Client Enrollment (1) A person is determined eligible for the WW Program after submitting a completed and signed BCCP/WW Program enrollment form. (2) Eligibility is effective for one year. (3) A person who enrolled in the WW Program but who is later found to be ineli…

333-010-0220 Provider Enrollment (1) An individual or organization that wishes to be an enrolling provider or an ancillary provider with the WW Program shall apply to the Center on a form prescribed by the Center. (2) In order to be eligible for enrollment, an individual or organ…

333-010-0225 Standards of Care for WISEWOMAN Program Screening and Services An enrolling provider shall: (1) Inform each client, verbally and with supplementary written materials in a language the client understands, without bias or coercion, that the client’s decision to partici…

333-010-0230 Submission of Information by Ancillary Providers Ancillary providers shall provide results of services to enrolled providers within 14 calendar days from the date of service. Statutory/Other Authority: ORS 413.042 Statutes/Other Implemented: ORS 413.042 & 431.150 His…

333-010-0235 Covered Services The WW Program Manual, October 2014, incorporated by reference, includes a complete list of covered services. [Publications: Publications referenced are available from the Oregon WW Program]. Statutory/Other Authority: ORS 413.042 Statutes/Other Impl…

333-010-0240 Excluded Services (1) Services and laboratory tests not directly related to heart disease, stroke and diabetes, or not included in the ICD-10 and CPT code lists provided in the WW Program Manual are not covered by the WW Program. (2) No payment will be made for any e…

333-010-0245 Claims and Billing (1) Only an enrolling or ancillary provider providing WW Program covered services pursuant to a fully executed medical services agreement, and who has been assigned an agency number may submit claims for payment to the Center for providing WW Progr…

333-010-0250 Payment (1) The Center shall only pay claims submitted by an enrolling or ancillary provider for a client. (2) The Center shall reimburse an enrolling or ancillary provider an amount up to the Medicare reimbursement rate for the Portland metropolitan area for WW Prog…

333-010-0255 Denial or Recovery of Reimbursement Resulting from Review or Audit (1) The Center’s staff, contractor or auditor may review a claim for assurance that the specific medical service was provided in accordance with the WW Program’s rules or the generally accepted standa…

333-010-0260 Recovery of Overpayments to Providers Resulting from Review or Audit (1) If the Center determines that an overpayment has been made to an enrolling or ancillary provider, the Center shall seek to recover the amount of overpayment. The Center may use a statistically v…

333-010-0265 Client Data Submission (1) In addition to submitting the claim information required in OAR 333-010-0225, in order to receive payment an enrolling provider shall submit client data to the Center. The data shall be used by the WW Program to monitor the delivery of serv…

333-010-0270 Requirements for Financial, Clinical and Other Records (1) An enrolling provider shall: (a) Develop and maintain adequate financial and clinical records and other documentation that supports the services for which payment has been requested; (b) Ensure that all medic…

333-010-0275 Compliance with Federal and State Statutes (1) Submission of a claim for medical services or supplies provided to a client shall be deemed a representation by the enrolling or ancillary provider to the Center of the provider’s compliance with the applicable sections …

333-010-0280 Provider Sanctions (1) The Center may sanction an enrolling provider if the provider: (a) Is convicted of a felony or misdemeanor related to a crime or violation of Title XVIII, XIX, or XX of the Social Security Act or related state laws (or entered a plea of nolo co…

333-010-0285 Provider Appeals (Level 1) — Claims Reconsideration An enrolling or ancillary provider disputing a claim or sanction decision by the Center may request reconsideration. The provider must submit the request for reconsideration in writing to the Center. The request mus…

333-010-0290 Provider Appeals (Level 2) — Contested Case Hearing An enrolling or ancillary provider may request a contested case hearing within 30 calendar days of the date of a decision affecting the provider. Contested case hearings will be held in accordance with ORS Chapter 1…

333-010-0300 Tobacco Prevention and Education Program: Definitions (1) “Centers for Disease Control and Prevention” means the federal agency of the Department of Health and Human Services responsible for promoting health and quality of life through the prevention and control of d…

333-010-0310 Tobacco Prevention and Education Program: Purpose and Intent The purpose of this rule is to implement Chapter 2 of Oregon Laws of 1997, approved by the people as Ballot Measure 44, at the November 5, 1996 General Election, which: (1) Authorizes 5.77% of the money rec…

333-010-0320 Tobacco Prevention and Education Program: Framework for Grant Awards (1) These rules describe provisions for awarding grants and contracts for local, regional, and statewide activities in four program areas. The program areas are: (a) Local Coalitions and Community-B…

333-010-0330 Tobacco Prevention and Education Program: Local Coalitions and Community-Based Programs The goal of the Oregon Public Health Division under this section is to fulfill the purpose and intent of Chapter 2 of Oregon Laws of 1997, approved by the people as Ballot Measure…

333-010-0350 Tobacco Prevention and Education Program: Statewide Public Awareness and Education Programs The goal of the Oregon Public Health Division under this section is to fulfill the purpose and intent of Chapter 2 of Oregon Laws of 1997, approved by the people as Ballot Mea…

333-010-0360 Tobacco Prevention and Education Program: Statewide and Regional Projects Programs The goal of the Oregon Public Health Division under this section is to fulfill the purpose and intent of Chapter 2 of Oregon Laws of 1997, approved by the people as Ballot Measure 44, …

333-010-0370 Tobacco Prevention and Education Program: Reporting (1) During each biennium the Director shall prepare a report regarding the awarding of grants from the Tobacco Use Reduction Account and the formation of public-private partnerships in connection with the receipt of…

333-010-0600 Childhood Diabetes Database: Definitions (1) “Case” means a reportable case of type 1 or type 2 diabetes in an individual who is 18 years of age or younger, and a resident of Oregon. (2) “Diabetes Program” means the Oregon Diabetes Prevention and Control Program of O…

333-010-0610 Childhood Diabetes Database: General Authority and Purpose According to ORS 444.300(1), subject to available funding, including gifts, grants or donations, the Diabetes Program shall establish a uniform, statewide database for the collection of information on type 1 …

333-010-0620 Childhood Diabetes Database: Reporting Requirements for Schools (1) The Diabetes Program shall conduct an annual survey to collect information about diabetes occurring in students age 18 years or younger. Preferably the survey will be completed and returned to the Di…

333-010-0630 Childhood Diabetes Database: Reporting Requirements for Practitioners (1) Upon diagnosing or first treating a case of type 1 or type 2 diabetes in an Oregon child, a practitioner shall report the following information to the Diabetes Program: (a) The name and address…

333-010-0640 Childhood Diabetes Database: Confidentiality and Access to Data (1) All identifying information regarding individual patients, reporting schools, and practitioners reported pursuant to OAR 333-010-0620 and 333-010-0630 shall be confidential and privileged. Except as …

333-010-0650 Childhood Diabetes Database: Research Studies (1) Prior to any confidential data from the database being released to a researcher, the researcher must: (a) Obtain approval from Oregon Health Authority, Public Health Division Institutional Review Board, established in…

333-010-0660 Childhood Diabetes Database: Advisory Committee (1) The Diabetes Program may convene an advisory committee to make recommendations regarding the Diabetes Program's use of the database, and to assist in reviewing research proposals under OAR 333-010-0650. (2) Advisory…