Or. Admin. Code § 410-133-0140

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

Section 410-133-0140 - Provider Enrollment

(1) This rule applies to education agencies seeking Medicaid reimbursement for Medicaid-covered School-Based Health Services (SBHS). Enrollment with the Authority is subject to and in compliance with OAR 410-120-1260.

(2) Education agencies must be enrolled with the Authority to bill and receive reimbursement for Medicaid-covered SBHS.

(3) Supervisory-level medically-qualified individuals providing services in education settings, for which the education agency intends to seek Medicaid reimbursement, must be enrolled with the Authority and must be entered as the referring provider on the school medical claim for the service.

(4) Education agencies enrollment as school medical providers with the Authority:

(a) Education agencies may enroll with the Authority as school medical providers subject to and in compliance with SBHS rules and OARs 410-120-1260 and 943-120-0320.

(b) To enroll and maintain enrollment as a school medical provider with the Authority, an education agency must:

(A) Have a current, active National Provider Identifier (NPI);

(B) Submit updates to Oregon Health Plan Provider Enrollment within thirty (30) calendar days of the change under the EDMS Coversheet. Changes include address, contact information, NPI, and Federal Tax Identification Number (TIN); and

(C) Notify the Authority if a medically-qualified staff member or an agent or managing employee of the school provider has been convicted of a criminal offense related to that person's involvement in any program under Medicare or Medicaid.

(5) An enrolled school medical provider is a billing provider for Medicaid-covered SBHS and may seek reimbursement for the provision of Medicaid-covered SBHS pursuant to a Medicaid-enrolled child or young adult's Individual Plan of Care (IPOC). A billing provider, in connection with the submission of claims to the Authority, receives and directs the payment from the Authority. A billing provider is responsible to:

(a) Bill Medicaid-covered SBHS and receive and direct payments on behalf of medically-qualified individuals providing Medicaid-covered services in education settings pursuant to a child or young adult's IPOC.

(b) Report to the Authority current identification of each medically-qualified individual providing Medicaid-covered services in the school medical provider's district pursuant to a child or young adult's IPOC. Identification must include the medically-qualified individual's:

(A) Full legal name;

(B) National Provider Identifier (NPI);

(C) Medicaid Provider ID (if applicable); and

(D) Either the Social Security Number (SSN) or Employer Identification Number (EIN). The SSN or EIN of the performing provider cannot be the same as the Tax Identification Number (TIN) of the billing provider.

(c) Comply with Oregon Health Plan electronic business practices when Electronic Data Interchange (EDI) practices are used for Medicaid eligibility verification or Medicaid claims submission.

(6) A medically-qualified individual, to enroll and maintain enrollment with the Authority, must:

(a) Have a current, active National Provider Identifier (NPI).

(b) Submit updates to Oregon Health Plan Provider Enrollment within thirty (30) calendar days of the change under the EDMS Coversheet. Changes include address, contact information, NPI, and Federal Tax Identification Number (TIN). A school medical provider contact may submit updates on behalf of medically-qualified individuals that are employed by the school medical provider when listed as a provider contact on the medically-qualified individual's Authority provider file.

(7) Authority Medicaid provider enrollment process:

(a) For an education agency enrolling as a school medical provider, the education agency must complete and submit a school medical provider enrollment application including the EDMS Coversheet (MSC 3970), all required Oregon Medicaid forms (i.e., OHA 3972, OHA 3974, and OHA 3975), and the Provider Enrollment Attachment (OHP 3120); or

(b) For supervisory-level medically-qualified individuals, the individual must complete and submit a provider enrollment application including the EDMS Coversheet (MSC 3970) and all required Oregon Medicaid forms.

(A) Required forms are unique to each discipline and are available on the Oregon Health Plan Provider Enrollment website.

(B) The school medical provider may submit completed enrollment forms on behalf of medically-qualified individuals that are employed by the school medical provider.

(c) Upon submission of a provider enrollment application, the Authority shall:

(A) Enroll a school medical provider or supervisory-level medically-qualified individual that has satisfied the provider enrollment criteria;

(B) Notify the applicant if information is missing or invalid; or

(C) Deny enrollment if the school medical provider or supervisory-level medically-qualified individual has not satisfied the provider enrollment criteria.

(d) Upon enrollment, the Authority shall notify the contact listed on the provider enrollment application of the enrolled, assigned Medicaid Identification number.

(8) Authority shall revalidate all enrolled providers at least every five (5) years subject to and in compliance with OAR 410-120-1260.

(9) Termination of provider enrollment is subject to and in compliance with OAR 410-120-1260.

Or. Admin. Code § 410-133-0140

HR 39-1991, f. & cert. ef. 9-16-91; OMAP 31-1998, f. & cert. ef. 9-1-98; OMAP 53-2003, f. 8-13-03 cert. ef. 9-1-03; OMAP 24-2005(Temp), f. & cert. ef. 4-5-05 thru 10-1-05; OMAP 53-2005, f. 9-30-05, cert. ef. 10-1-05; DMAP 43-2008, f. 12-17-08, cert. ef. 12-28-08; DMAP 19-2009, f. 6-12-09, cert.ef. 7-1-09; DMAP 33-2016, f. 6-29-16, cert. ef. 7/1/2016; DMAP 121-2024, amend filed 09/06/2024, effective 9/6/2024

Statutory/Other Authority: ORS 413.042

Statutes/Other Implemented: ORS 413.042