OAR 333-010-0140
Billing

(1)

Only clinics providing breast and cervical cancer screening and diagnostic services pursuant to an approved medical services agreement, and who have been assigned an agency number may submit claims for ScreenWise BCC services.

(2)

All services must be billed by submitting claim information in the method specified by the ScreenWise BCC.

(3)

A primary diagnosis code is required on all claims. All billings must be coded with the most current and appropriate International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM), incorporated by reference and the most appropriate Current Procedural Terminology (CPT) codes. Information regarding CPT code lists, including required notice to providers regarding CPT code list revisions, may be found in the provider’s Medical Services Agreement. Claims including primary diagnosis codes that are not listed on the approved CPT code list will not be paid without program approval.

(4)

The provider must use CLIA certified laboratories for all tests whether done at the clinic site or by an outside clinic.

(5)

Enrolled providers with ScreenWise BCC must not seek payment from an eligible client, or from a financially responsible relative or representative of that individual, for any services covered by ScreenWise BCC.

(a)

A client may be billed for services that are not covered by ScreenWise BCC. However, the provider must inform the client in advance of receiving the specific service that it is not covered, the estimated cost of the service, and that the client or client’s representative is financially responsible for payment for the specific service. Providers must document in writing that the client was provided this information and the client knowingly and voluntarily agreed to be responsible for payment. The client or client’s representative must sign the documentation.

(b)

Services not covered by ScreenWise BCC are those outside of the scope of standard breast and cervical cancer screening and diagnosis, or those not included in the ICD-10 list, incorporated by reference and approved CPT code lists.

(6)

Prior to submission of a claim to the Center for payment, an approved provider agreement must be in place.

(7)

All claims must be submitted with data, as described in the claims section of the rules.

(a)

Except for services performed by a CLIA certified laboratory outside of the clinic, all billings must be for services provided within the provider’s licensure or certification.

(b)

Providers must submit true and accurate information when billing the Center.

(c)

A claim may not be submitted prior to providing services.

(8)

Diagnosis Code Requirement:

(a)

A primary diagnosis code is required on all claims.

(b)

Use the highest degree of specificity within the diagnosis codes listed in the ICD-10-CM codes, incorporated by reference, for breast and cervical screening or diagnostic testing.

(9)

No provider shall submit to the Center:

(a)

Any false claim for payment;

(b)

Any claim altered in such a way as to result in a payment for a service that has already been paid;

(c)

Any claim upon which payment has been made by another source unless the amount paid is clearly entered on the claim form;

(10)

The provider must submit a billing error edit correction, or refund the amount of the overpayment, on any claim where the provider identifies an overpayment made by the Center.

(11)

A provider who, after having been previously warned in writing by the Authority or the Department of Justice about improper billing practices, is found to have continued such improper billing practices and has had an opportunity for a contested case hearing, shall be liable to the Center for up to triple the amount of the established overpayment received as a result of such violation.

(12)

Third Party Resources:

(a)

Providers must make all reasonable efforts to ensure that ScreenWise BCC will be the payor of last resort with the exception of clinic or offices operated by the Indian Health Service (IHS) or individual American Indian tribes;

(b)

Providers must make all reasonable efforts to obtain payment first from other resources. For the purposes of this rule reasonable efforts include:

(A)

Determining the existence of insurance coverage or other resource by asking the client;

(B)

Except in the case of the underinsured, when third party coverage is known to the provider, by any other means available:
(i)
The provider must bill the third party resource;
(ii)
Comply with the insurer’s billing and authorization requirements.

(C)

Providers are required to submit a billing error edit correction showing the amount of the third party payment or to refund the amount received from another source within 30 days of the date the payment is received. Failure to submit a billing error edit correction within 30 days of receipt of the third party payment or to refund the appropriate amount within this time frame is considered concealment of material facts and grounds for recovery or sanction.

Source: Rule 333-010-0140 — Billing, https://secure.­sos.­state.­or.­us/oard/view.­action?ruleNumber=333-010-0140.

333–010–0000
Cancer Reporting Regulations: Definitions 333–010–0020
Cancer Reporting Regulations: Reporting Requirements for Health Care Facilities 333–010–0030
Cancer Reporting Regulations: Reporting Requirements for Practitioners 333–010–0032
Cancer Reporting Regulations: Reporting Requirements for Clinical Laboratories 333–010–0035
Cancer Reporting Regulations: Patient Notification Requirement 333–010–0040
Cancer Reporting Regulations: Quality Standards 333–010–0050
Cancer Reporting Regulations: Confidentiality and Access to Data 333–010–0055
Cancer Reporting Regulations: Research Studies 333–010–0060
Cancer Reporting Regulations: Special Studies 333–010–0070
Cancer Reporting Regulations: Advisory Committee 333–010–0080
Cancer Reporting Regulations: Training and Consultation 333–010–0090
Cancer Reporting Regulations: Fees 333–010–0100
ScreenWise Breast and Cervical Cancer Program: Description of the ScreenWise Breast and Cervical Cancer Program 333–010–0105
Definitions 333–010–0110
Client Eligibility 333–010–0115
Client Enrollment 333–010–0120
Covered Services 333–010–0125
Excluded Services 333–010–0130
Standards of Care for Breast and Cervical Cancer Screening and Diagnostic Services 333–010–0135
Provider Enrollment 333–010–0140
Billing 333–010–0145
Claims and Data Submission 333–010–0150
Timely Submission of Claims and Data 333–010–0155
Payment 333–010–0160
Requirements for Financial, Clinical and Other Records 333–010–0165
Compliance with Federal and State Statutes 333–010–0170
Denial or Recovery of Reimbursement Resulting from Review or Audit 333–010–0175
Recovery of Overpayments to Providers Resulting from Review or Audit 333–010–0180
Provider Sanctions 333–010–0185
Provider Appeals 333–010–0190
Provider Appeals (Level 1) — Claims Reconsideration 333–010–0195
Provider Appeals (Level 2) — Contested Case Hearing 333–010–0197
Presumptive Eligibility for BCCTP 333–010–0200
ScreenWise WISEWOMAN Program: Description of the WISEWOMAN Program 333–010–0205
Definitions 333–010–0210
Client Eligibility 333–010–0215
Client Enrollment 333–010–0220
Provider Enrollment 333–010–0225
Standards of Care for WISEWOMAN Program Screening and Services 333–010–0230
Submission of Information by Ancillary Providers 333–010–0235
Covered Services 333–010–0240
Excluded Services 333–010–0245
Claims and Billing 333–010–0250
Payment 333–010–0255
Denial or Recovery of Reimbursement Resulting from Review or Audit 333–010–0260
Recovery of Overpayments to Providers Resulting from Review or Audit 333–010–0265
Client Data Submission 333–010–0270
Requirements for Financial, Clinical and Other Records 333–010–0275
Compliance with Federal and State Statutes 333–010–0280
Provider Sanctions 333–010–0285
Provider Appeals (Level 1) — Claims Reconsideration 333–010–0290
Provider Appeals (Level 2) — Contested Case Hearing 333–010–0300
Tobacco Prevention and Education Program: Definitions 333–010–0310
Tobacco Prevention and Education Program: Purpose and Intent 333–010–0320
Tobacco Prevention and Education Program: Framework for Grant Awards 333–010–0330
Tobacco Prevention and Education Program: Local Coalitions and Community-Based Programs 333–010–0350
Tobacco Prevention and Education Program: Statewide Public Awareness and Education Programs 333–010–0360
Tobacco Prevention and Education Program: Statewide and Regional Projects Programs 333–010–0370
Tobacco Prevention and Education Program: Reporting 333–010–0600
Childhood Diabetes Database: Definitions 333–010–0610
Childhood Diabetes Database: General Authority and Purpose 333–010–0620
Childhood Diabetes Database: Reporting Requirements for Schools 333–010–0630
Childhood Diabetes Database: Reporting Requirements for Practitioners 333–010–0640
Childhood Diabetes Database: Confidentiality and Access to Data 333–010–0650
Childhood Diabetes Database: Research Studies 333–010–0660
Childhood Diabetes Database: Advisory Committee 333–010–0700
Dental Pilot Projects: Purpose 333–010–0710
Dental Pilot Projects: Definitions 333–010–0720
Dental Pilot Projects: Application Procedure 333–010–0730
Dental Pilot Projects: Application Review Process 333–010–0740
Dental Pilot Projects: Project Application Provisional Approval or Denial 333–010–0750
Dental Pilot Projects: Provisional Approval 333–010–0760
Dental Pilot Projects: Minimum Standards 333–010–0770
Dental Pilot Projects: Informed Consent 333–010–0780
Dental Pilot Projects: Pilot Project Evaluation and Monitoring by Sponsor 333–010–0790
Dental Pilot Projects: Authority Responsibilities 333–010–0800
Dental Pilot Projects: Project Modifications 333–010–0810
Dental Pilot Projects: Discontinuation or Completion of Project 333–010–0820
Dental Pilot Projects: Suspension, Denial or Termination of Project
Last Updated

Jun. 8, 2021

Rule 333-010-0140’s source at or​.us