OAR 309-015-0030
Billing Requirements
(1)
Bill submission time limits. Bills shall be submitted to the Division through the Division of Medical Assistance Programs, on forms designated by the Medicaid Intermediary, as soon as possible after the date service is rendered. Payment shall not be made for services which were provided more than 12 months prior to presentation of the claim unless the hospital shows that the delay was caused by factors outside its control.(2)
Billing charge limits. Billings to the Division shall in no case exceed the customary charges to private patients for any like item or service charged by the hospital.(3)
Customary charge criteria. In determining the customary charges to a private patient for use in billings or calculating interim or settlement rates, the following criteria will be applied:(a)
The private patient billing rate must be for items and services comparable to the items and services included in the rate for Medicaid services;(b)
When private patient rates are based on the number of beds in a room, the Medicaid intermediary considers the lowest room charge as the usual and customary charge for services;(c)
When ancillary charges are made to private patients in addition to a basic charge, the Medicaid Intermediary considers the usual and customary charge to be the lowest basic room charge plus the average ancillary charge for those items included in the Medicaid rate. The average ancillary charge is determined by dividing the ancillary costs by the number of patient days; or(d)
Where charges are based on the classification of the patient (i.e., Medicare, Medicaid and Private), the Medicaid Intermediary considers the usual and customary charge to be the rate for private patients exclusive of ancillary charges.(4)
Payment restrictions. Payment will be made only for those days a patient is actually in residence at the hospital in active treatment or when a patient is on therapeutic leave.(5)
Payment credit. Any payment received by the hospital prior to the submission of an invoice to the Division of Medical Assistance Programs shall be indicated as a credit on the invoice.(6)
Post-payment receipt of funds. Any payments to the provider from any source subsequent to payment by the Division of Medical Assistance Programs shall be reported to that Division on an adjustment form specified by the Division of Medical Assistance Programs, giving full particulars. Failure to report such payments will be considered concealment of material facts and is grounds for recovery and/or sanction (see OAR 309-015-0052 (Provider Sanctions)).
Source:
Rule 309-015-0030 — Billing Requirements, https://secure.sos.state.or.us/oard/view.action?ruleNumber=309-015-0030.