Or. Admin. Code § 943-120-0330

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

Section 943-120-0330 - Billing Procedures

(1) These rules only apply to covered services and items provided to clients that are paid for by the Authority based on an Authority fee schedule or other reimbursement method (often referred to as fee-for-service), or for services that are paid for by the Authority at the request of a county for county-authorized services.

(a) If a client's service or item is paid for by a PHP or CCO, the provider must comply with the billing and procedures related to claim submission established under contract with that PHP, CCO, or the rules applicable to non-participating providers if the provider is not under contract with that PHP or CCO.

(b) If the client is enrolled in a PHP or CCO, but the client is permitted by a contract or program-specific rules to obtain covered services reimbursed by the Authority (such as family planning services that may be obtained from any provider). In addition to this rule, the provider must comply with the billing and claim procedures established in OAR chapter 410 division 120.

(2) All Authority-assigned provider numbers are issued at enrollment and are directly associated with the provider as defined in OAR 410-120-1260 and have the following uses:

(a) Log-on identification for the Authority web portal;

(b) Claim submission in the approved paper formats; and

(c) For electronic claims submission including the web portal for atypical providers pursuant to 45 CFR 160 and 162 where an NPI is not mandated. Use of the Authority-assigned provider number shall be considered the providers authorization and the provider shall be accountable for its use.

(d) Providers may not bill clients or the Authority for services or items provided free of charge. This limitation does not apply to established sliding fee schedules where the client is subject to the same standards as other members of the public or clients of the provider.

(e) Providers shall pay for costs incurred for failing to confirm eligibility or that services are covered.

Or. Admin. Code § 943-120-0330

OHA 14-2011(Temp), f. & cert. ef. 7-1-11 thru 12-27-11; OHA 20-2011, f. 8-30-11, cert. ef. 9-1-11; OHA 8-2012, f. 10-30-12, cert. ef. 11-1-12

Stat. Auth.: ORS 413.042

Stats. Implemented: ORS 414.065