Or. Admin. Code § 943-120-0112

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

Section 943-120-0112 - Scope and Sequence of Electronic Data Transmission Rules

(1) The Authority communicates with and receives communications from its providers, CCOs, PHPs, and allied agencies using a variety of methods appropriate to the services being provided, the nature of the entity providing the services, and constantly changing technology. These rules describe some of the basic ways that the Authority will exchange data electronically. Additional details may be provided in the Authority's access control rules, provider-specific rules, or the applicable contract documents.

(2) Access to eligibility information about covered individuals may occur using one or more of the following methods:

(a) Automated voice response, via a telephone;

(b) Web portal access;

(c) EDI submitter access; or

(d) Point of sale (POS) for pharmacy providers.

(3) Claims for which the Authority is responsible for payment or encounter submissions made to the Authority may occur using one or more of the following methods:

(a) Paper, using the form specified in the provider specific rules and supplemental billing guidance. Providers may submit paper claims, except that pharmacy providers are required to use the POS process for claims submission, and CCOs and PHPs must use the 837 electronic formats;

(b) Web portal access;

(c) EDI submitter access; or

(d) POS for pharmacy providers.

(4) Authority informational updates, provider record updates, depository for CCO or PHP reports, or EDT as specified by the Authority for contract compliance.

(5) Other Authority network and information system access is governed by specific program requirements, which may include but is not limited to IUP access. Affected providers, CCOs, PHPs, and allied agencies shall be separately instructed about the access and requirements. Incidents are subject to these rules.

(6) Providers and allied agencies that continue to use only paper formats for claims transactions are only subject to the confidentiality and security rule, OAR 943-120-0170.

Or. Admin. Code § 943-120-0112

OHA 13-2011(Temp), f. & cert. ef. 7-1-11 thru 12-27-11; OHA 26-2011, f. 10-31-11, cert. ef. 11-1-11; OHA 4-2012(Temp), f. & cert. ef. 7-12-12 thru 1-6-13; OHA 7-2012, f. 10-9-12, cert. ef. 10-10-12

Stat. Auth.: ORS 413.042 &414.065

Stats. Implemented: ORS 413.042 & 414.065