Or. Admin. Code § 410-123-1000

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

Section 410-123-1000 - Eligibility, Services Reviewed by the Division, Billing and the Dental Billing Invoice

(1) Eligibility:

(a) Providers must verify member eligibility and benefit coverage of members on each day of service, and shall do so before providing any service or billing to the:

(A) Oregon Health Authority (referred to as "Authority" throughout these rules);

(B) Health Systems Division (referred to as "Division" throughout these rules);

(C) Oregon Health Plan (referred to as "OHP" throughout these rules); or

(D) Managed Care Entity (referred to as "MCE" throughout these rules).

(b) A member medical identification card does not guarantee eligibility on the date of service. The Division does not reimburse for services provided to an ineligible member, even if services were authorized before a member loses benefit coverage due to changes in income, household size, redetermination status, or any other factor. Refer to General Rules OAR 410-120-1140 (Verification of Eligibility) for details.

(2) Services Reviewed by the Division:

(a) Services requiring Prior Authorization (PA): See OAR 410-123-1160 and 410-120-1320 for information about services that require PA or how to request PA.

(b) By Report Pricing:

(A) Most dental services are included in a standard fee schedule. However, some services are not included in the fee schedule because they are unique. Procedures for such services are "by report" meaning the provider shall submit a written report to justify the services;

(B) Dental services listed as "By Report" (BR) shall be submitted with an adequate definition or description of the nature, extent, and need for the procedure, the time, effort and necessary equipment medically necessary to provide the service, and any relevant operative or clinical history reports and/or radiographs. Payment for BR procedures will be approved in consultation with a Division dental consultant;

(C) Refer to the OHP Medical/Dental Fee Schedule for a list of procedure codes noted as BR. See OAR 410-123-1220.

(3) Billing:

(a) Providers are prohibited from billing or seeking to collect payment from an OHP member (or any financially responsible relative or representative of that member) for Medicaid covered services outside of any cost-sharing, coinsurance or copay required by the plan. See 42 CFR 447.20 (a) for more detail;

(b) For non-covered services, a provider may bill a Medicaid member when all of the following conditions are met:

(A) The provider has an established policy for billing all patients for services not covered by a third party. The charges may not only apply to Medicaid members;

(B) The member is advised prior to receiving a non-covered service that Medicaid will not pay for the service;

(C) The member or member's parent or legal guardian agrees to be personally responsible for the service;

(D) An Agreement to Pay (OHP 3165/3166) form or other form that contains all of the elements of the OHP 3165/3166 is signed and dated by the member;

(E) The member's Medicaid Identification Card may not be held by the provider as guarantee of payment by the member;

(F) The estimated fee for the service does not change;

(G) The procedure or service is provided within 30 days of the patient's signature.

(c) Providers shall follow the Division rules in effect on the date of service. All Division rules are intended to be used in conjunction with the Division's General Rules Program (chapter 410, division 120), the OHP Administrative Rules (chapter 410, division 141), Pharmaceutical Services Rules (chapter 410, division 121) and other relevant Division OARs applicable to the service provided, where the service is delivered, and the qualifications of the person providing the service including the requirement for a current signed provider enrollment agreement;

(d) Providers shall comply with OAR 410-120-1280 Billing rules and OAR 410-120-1360 requirements to develop and maintain adequate financial and clinical records and other Documentation that supports the specific care, items, or services for which payment has been requested:

(A) The Authority will only pay for services that are adequately documented;

(B) Documentation shall support the dates of service, the amounts billed, the specific services provided, who provided the services, and the medical necessity of those services;

(C) Financial records shall indicate that the amount billed to the Authority was appropriate and that all other resources were pursued before billing the Authority;

(D) FFS providers shall keep clinical information on file for seven years, and financial records five years. Providers contracted with an MCE shall retain all clinical records for a minimum of ten (10) years after the date of services for which claims are made, as in OAR 410-141-3520. If an audit, litigation, research and evaluation, or other action involving the records is started before the end of the retention period, the clinical records shall be retained until all issues arising out of the action are resolved.

(e) Third Party Resources: A Third Party Resource (TPR) is an alternate insurance resource, other than the Division, available to pay for medical/dental services and items on behalf of OHP members. Any alternate insurance resource shall be billed before the Division or any OHP MCE can be billed. Indian Health Services or Tribal facilities are not considered to be a TPR pursuant to the Division's General Rules Program rule 410-120-1280;

(f) For Medicaid covered services, the provider shall not:

(A) Bill the Authority more than the provider's usual charge (see definitions) or the reimbursement specified in the applicable Authority program rules;

(B) Bill the member for missed appointments. A missed appointment is not considered a distinct Medicaid service by the federal government and as such is not billable to the member or the Authority;

(C) Bill the member for services or treatments that have been denied due to provider error (e.g., required Documentation not submitted, prior authorization not obtained, etc.).

(g) Refer to OAR 410-123-1160 for information regarding dental services requiring prior authorization (PA);

(h) The member's records shall include Documentation to support the appropriateness of the service and level of care rendered;

(i) The Division shall only reimburse for dental services that are Dentally Appropriate as defined in OAR 410-123-1060;

(j) Refer to OAR chapter 410, division 147 for information about reimbursement for dental services provided through a Federally Qualified Health Center (FQHC) or Rural Health Center (RHC);

(k) Treatment Plans: Being consistent with established dental office protocol and the standard of care within the community, scheduling of appointments is at the discretion of the dentist. The agreed upon treatment plan established by the dentist and member shall establish appointment sequencing. Eligibility for medical assistance programs does not entitle a member to any services or consideration not provided to all clients;

(l) Fabricated Prosthetics:

(A) If a dentist or denturist provides an eligible member with fabricated prosthetics that require the use of a dental laboratory, the date of the final impressions shall have occurred prior to the member's loss of eligibility;

(B) The dentist/denturist should use the date of final impression as the date of service only when criteria in (A) is met and the fabrication extends beyond the member's OHP eligibility;

(C) The date of delivery shall be within 45 days of the date of the final impression and the date of delivery shall also be indicated on the claim. All other services shall be billed using the date the service was provided.

(4) Billing Invoice:

(a) Providers shall refer to the Dental Services Provider Guide for information regarding claims submissions and billing information;

(b) Providers billing dental services on paper shall use the 2019 version of the American Dental Association (ADA) claim form;

(c) Submission of electronic claims directly or through an agent shall comply with the Electronic Data Interchange (EDI) rules. OAR 943-120-0100 et seq;

(d) Specific information regarding Health Insurance Portability and Accountability Act (HIPAA) requirements can be found on the Division Web site;

(e) Upon submission of a claim to the Authority for payment, the provider agrees that it has complied with all Authority program rules and understands that payment of the claim will be from federal and state funds, and that any falsification, or concealment of material fact, may be prosecuted under federal and state laws. Submission of a claim or encounter does not relieve the provider from the requirement of a signed provider enrollment agreement.

(5) A provider enrolled with the Authority shall bill using the Authority assigned provider number, or the National Provider Identification (NPI) number, pursuant to OAR 410-120-1260.

(6) Unless otherwise specified, claims shall be submitted after:

(a) Delivery of service; or

(b) Dispensing, shipment or mailing of the item.

(7) The provider shall submit true, accurate and complete information when billing the Division. Use of a billing provider does not abrogate the performing provider's responsibility for the truth and accuracy of submitted information.

(a) A claim is considered a valid claim only if it contains all data required for processing. See the appropriate provider rules and supplemental information for specific instructions and requirements;

(b) A provider or its contracted agency, including billing providers, may not submit or cause to be submitted:

(A) Any false claim for payment;

(B) Any claim altered in such a way as to result in a payment for a service that has already been paid;

(C) Any claim upon which payment has been made or is expected to be made by another source until after the other source has been billed., with the exception of OAR 410-120-1280(10)(c) (A-D). If the other source denies the claim or pays less than the Medicaid allowable amount, a claim may be submitted to the Authority. Any amount paid by the other source shall be clearly entered on the claim form;

(D) Any claim for furnishing specific care, items, or services that has not been provided;

(E) Any claim for specific care, items or services that is not supported by the Documentation, the member's treatment or care plan, as applicable, and compliant with program specific rules. All Documentation shall be complete and signed by the rendering provider prior to submitting a claim to the Authority or MCE for payment.

(c) If an Overpayment has been made by the Authority, the provider shall do one of the following within 30 calendar days of the date on which the overpayment was identified:

(A) Adjust the original claim to show the Overpayment as a credit in the appropriate field;

(B) Submit an Individual Adjustment Request (OHP 1036);

(C) Adjust the claim on the Provider Web Portal available online at all times at: https://www.or-medicaid.gov;

(D) Refund the amount of the Overpayment on any claim;

(E) Void the claim via the Provider Web Portal if the Authority overpaid due to erroneous billing;

(F) If the Overpayment occurred because of a payment from a third-party payer, refer to OAR 410-120-1280(10)(f) Billing rule.

(8) Procedure code requirement:

(a) For claims requiring a procedure code the provider shall bill as instructed in the appropriate Authority program rules and shall use the appropriate HIPAA procedure code set such as CPT, HCPCS, ICD-10-PCS, ADA CDT, NDC, established according to 45 CFR 162.1000 to 162.1011, which best describes the specific service or item provided;

(b) For claims that require the listing of a procedure code as a condition of payment, the reported procedure code shall be supported by the member's medical record and the codes that most accurately describes the services provided. All providers, including Hospitals, billing the Authority shall follow national coding guidelines;

(c) When there is no appropriate descriptive procedure code to bill the Authority, the provider shall use the code for "unlisted services." A complete and accurate description of the specific care, item, or service shall be documented on the claim;

(d) Where there is one CPT, CDT, or HCPCS code that, according to CPT, CDT, and HCPCS coding guidelines or standards, describes an array of services, the provider shall bill the Authority using that code rather than itemizing the services under multiple codes. Providers may not "unbundle" services.

Or. Admin. Code § 410-123-1000

HR 3-1994, f. & cert. ef. 2-1-94; HR 20-1995, f. 9-29-95, cert. ef. 10-1-95; OMAP 13-1998(Temp), f. & cert. ef. 5-1-98 thru 9-1-98; OMAP 28-1998, f. & cert. ef. 9-1-98; OMAP 23-1999, f. & cert. ef. 4-30-99; OMAP 17-2000, f. 9-28-00, cert. ef. 10-1-00; OMAP 48-2002, f. & cert. ef. 10-1-02; OMAP 65-2003, f. 9-10-03 cert. ef. 10-1-03; DMAP 25-2007, f. 12-11-07, cert, ef. 1-1-08; DMAP 18-2008, f. 6-13-08, cert. ef. 7-1-08; DMAP 41-2009, f. 12-15-09, cert. ef. 1-1-10; DMAP 14-2010, f. 6-10-10, cert. ef. 7-1-10; DMAP 31-2010, f. 12-15-10, cert. ef. 1-1-11; DMAP 45-2011, f. 12-21-11, cert. ef. 12-23-11; DMAP 46-2011, f. 12-23-11, cert. ef. 1-1-12; DMAP 61-2020, amend filed 12/11/2020, effective 1/1/2021; DMAP 50-2021, amend filed 12/24/2021, effective 1/1/2022; DMAP 7-2022, minor correction filed 02/04/2022, effective 2/4/2022; DMAP 57-2024, minor correction filed 02/21/2024, effective 2/21/2024

Statutory/Other Authority: ORS 413.042 & ORS 414.065

Statutes/Other Implemented: ORS 414.065