Or. Admin. Code § 137-084-0030

Current through Register Vol. 63, No. 12, December 1, 2024

Section 137-084-0030 - Payment Restrictions and Disqualifications

(1) The Fund will not pay for any service not specifically described in ORS 147.397 or OAR 137-084-0001 through 137-084-0030. Examples of services not covered by the Fund include, but are not limited to: DNA testing; prescriptions filled off-site of the location of a medical examination; follow-up services; anesthesia services; and transportation. Nothing in this rule is intended to preclude an eligible medical services provider from submitting a claim against the victim, the victim's insurance carrier or any other source for payment for services not specifically described in ORS 147.395 through 147.397 or OAR 137-084-0001 through 137-084-0030.

(2) The Fund reserves the right not to pay for medical services described in ORS 147.395 through 147.397 or OAR 137-084-0001 through 137-084-0030 for any one of the following reasons:

(a) Services were not provided by an eligible medical services provider.

(b) Services were provided to someone other than an eligible victim.

(c) Services were provided after the date of the sexual assault exam.

(d) Services were not provided in accordance with the requirements in ORS 147.395 through 147.397 or OAR 137-084-0001 through 137-084-0030, including the timeliness requirements for complete medical assessments (within 84 hours (three and one-half days) of the sexual assault) and partial medical assessments (within 168 hours (seven days) of the sexual assault).

(e) Services provided were duplicate services for the same incident. Examples of duplicate services not covered by the Fund include, but are not limited to: multiple sexual assault exams for the same incident of sexual assault; and duplicate charges from a transferring hospital that does not conduct the sexual assault exam.

(f) Failure of the eligible medical services provider to submit a completed Application Form, submission of incomplete invoice(s) for medical services or submission of the Application Form or invoice(s) for medical services more than one year after the date services were provided. At the Department's discretion, the Department may choose to pay claims that are received after one year of the date the medical services are provided.

(g) Insufficient funds in the Fund to cover the services provided.

(3) If the Attorney General or the Attorney General's designee determines that the Fund will not pay for one or more of the services described in ORS 147.395 through 147.397 or OAR 137-084-0020(1) and (2) for reasons other than those set out in 137-084-0030(2)(e) above, the Attorney General or the Attorney General's designee will provide notice to the medical services provider(s) affected. After receiving such notice, a medical services provider may bill the victim, the victim's insurance carrier or any other source for those medical services provided but not paid for by the Fund.

Or. Admin. Code § 137-084-0030

DOJ 3-2004, f. & cert. ef. 1-29-04; DOJ 12-2016, f. & cert. ef. 10/24/2016; DOJ 7-2019, amend filed 06/27/2019, effective 7/1/2019; DOJ 62-2020, amend filed 12/14/2020, effective 12/16/2020

Forms referenced are available from the agency.

Statutory/Other Authority: 2003 OL Ch. 789 (SB 752)

Statutes/Other Implemented: 2003 OL Ch. 789 (SB 752)