Or. Admin. Code § 410-160-0100

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

Section 410-160-0100 - Process and Procedure

(1) The purpose of the Law Enforcement Medical Liability Account (LEMLA) is to provide a fund to reimburse a claimant for emergency medical services provided to a LEMLA patient.

(2) The time limit for submitting claims to LEMLA is one year after the date of injury. If a claimant has been paid by a LEMLA patient's insurer or health care contractor and the LEMLA patient's insurer or health care contractor subsequently demands return of the payment, a claimant must bill LEMLA not later than 180 days from the date of the demand letter or one year from the date of injury, whichever is later.

(3) The Division shall process all claims received in accordance with the following procedures:

(a) The claim shall be date stamped on the date received by LEMLA;

(b) The Division shall review each claim submitted to verify that the claim contains all of the following required information:

(A) The LEMLA claim form, with the following information:

(i) Certification by an authorized representative of the law enforcement agency involved with an injury that the injury is related to law enforcement activity;

(ii) The release date, if any, as determined by the law enforcement agency. If the LEMLA patient has not yet been released, state that on the LEMLA claim form;

(iii) LEMLA patient's name;

(iv) Prior payment amount;

(v) Date of injury;

(vi) Claimant's Medicaid provider number;

(vii) Claimant's name;

(viii) LEMLA claim amount;

(ix) Cause or nature of injury.

(B) Attached to the LEMLA form, the following information:

(i) Documentation that demonstrates the claimant has billed the LEMLA patient or the LEMLA patient's insurer or health care contractor for the charges or expenses owed to the claimant and that the claimant has made a reasonable effort to collect from the LEMLA patient or the LEMLA patient's insurer or health care contractor;

(ii) A copy of the hospital or provider billing document that shows the usual charge and date of service.

(c) The Division shall reject claims that do not contain all of the information required in subsection (3)(b) of this rule;

(d) The Division shall review the documentation of reasonable collection effort. If 45 days have not elapsed since the claimant billed the LEMLA patient or the LEMLA patient's insurer or health care contractor, the claim may be rejected;

(e) The Division shall review the date of injury. If the date stamped on the claim under subsection (3)(a) of this rule is more than one year after the date of injury, the claim shall be rejected. The one-year time limit may not apply if the provisions of section (2) of this rule apply with regards to an insurer or health care contractor demanding repayment of a previously paid claim.

(4) Using the LEMLA claim amount, the Division shall pay claimants, subject to any adjustment made under section (5) of this rule, according to the following:

(a) For hospitals, by the current "Hospital Fee Schedule-Adjusted Cost/Charge Ratios for Oregon Hospitals," established by the Director of the Department of Consumer and Business Services;

(b) For all Medicaid providers except hospitals, the Division shall pay 75 percent of the LEMLA claim amount.

(5) After determining the amount under section (4) of this rule, the Division shall add the amount received in section (6) of this rule. If the total is more than the usual charge, the Division shall reduce the amount of its payment by the amount in excess of the usual charge.

(6) The claimant is responsible for making reasonable effort to collect from the LEMLA patient or the LEMLA patient's insurer or health care contractor. Claimants are required to report all collections made when a claimant submits a claim to the Division for payment.

(7) If the Division has paid a claimant and the claimant subsequently receives payment from any other source, the claimant is required to repay the Division the amount received, minus the difference between the usual amount billed and the amount the Division paid. This means claimants are entitled to reimburse themselves for the amount the Division did not pay, with the excess due to the Division as repayment of an overpayment. The repayment is due and payable by check to the Division within 30 days after the claimant has received the funds from the other source.

(8) The Division shall continue to pay for medical services for injuries related to law enforcement activities while the LEMLA patient is incarcerated. Upon release of the LEMLA patient from physical custody, the Division shall no longer pay for

further medical expenses incurred. If the LEMLA patient is cited in lieu of arrest or released instead of booked, the Division shall no longer pay for further medical expenses upon discharge or release from the hospital or other medical facility.

(9) The Division shall pay all accepted claims to the extent that the Division has sufficient funds available, subject to the maximum limit for payment of expenses authorized by law. The Division shall monitor the expenses and if the Division determines that the authorized limit may be exceeded, or that insufficient funds are available, the Division shall take the following actions:

(a) The Division shall continue to accept claims and date stamp them in the order the claims are received. The Division shall then suspend further processing of the claim;

(b) The Division shall notify each claimant that the claim has been suspended and the reason for the action;

(c) The Division shall maintain a file of suspended claims and await further legislative direction regarding the disposition of the claims.

Or. Admin. Code § 410-160-0100

AFS 1-1992, f. 1-14-92, cert. ef. 2-1-92; AFS 6-1992, f. & cert. ef. 3-9-92; AFS 24-1993, f. 10-27-93, cert. ef. 11-1-93; AFS 18-1995, f. & cert. ef. 8-1-95; AFS 10-2002, f. & cert. ef. 7-1-02; Renumbered from 461-012-0150, DMAP 9-2011, f. 6-6-11, cert. ef. 7-1-11

Stat. Auth.: ORS 413.042, ORS 414.065

Stats. Implemented: ORS 414.805 -- ORS 414.815