OAR 333-010-0160
Requirements for Financial, Clinical and Other Records

(1)

The Center is responsible for analyzing and monitoring the operation of ScreenWise BCC and for auditing and verifying the accuracy and appropriateness of payment, utilization of services, the quality of care, and access to care. The provider shall:

(a)

Develop and maintain adequate financial and clinical records and other documentation which supports the services for which payment has been requested. Payment will be made only for services that are adequately documented.

(b)

All medical records must document the service provided, primary diagnosis code for the services, the date on which the service was provided, and the individual who provided the services. Patient account and financial records must also include documentation of charges, identify other payment resources pursued, indicate the date and amount of all debit or credit billing actions, and support the appropriateness of the amount billed and paid. The records must be accurate and in sufficient detail to substantiate the data reported.

(2)

Clinical records must sufficiently document that the client’s services were primarily for breast or cervical cancer screening or diagnosis of breast or cervical cancer. The client’s record must be annotated each time a service is provided and signed or initialed by the individual who provided the service or must clearly indicate the individual who provided the service. Information contained in the record must meet the standards of care for breast and cervical cancer screening and diagnosis, and must be appropriate in quality and quantity to meet the professional standards applicable to the provider or practitioner and any additional standards for documentation set forth in this rule.

(3)

The provider must have policies and procedures to ensure the maintenance of the confidentiality of medical record information. These procedures ensure that the provider may release such information in accordance with federal and state statutes, ORS 179.505 (Disclosure of written accounts by health care services provider), 411.320 (Disclosure and use of records limited to purposes connected to administration of public assistance programs), 45 CFR 205.50.

(4)

The provider must retain clinical, financial and other records described in this rule for at least four years from the date of last activity.

(5)

Upon written request from the Center, the Authority, the Oregon Department of Justice Medicaid Fraud Unit, the Oregon Secretary of State, or their authorized representatives (Requestor), the provider must furnish requested documentation, without charge, immediately or within the time-frame specified in the written request. Copies of the documents may be furnished unless the originals are requested. At their discretion, representatives of the Requestor may review and copy the original documentation in the provider’s place of business. Upon the written request of the provider, the Requestor may, at their sole discretion, modify or extend the time for provision of such records if, in the opinion of the Center, good cause for such extension is shown. Factors used in determining whether good cause exists include:

(a)

Whether the written request was made in advance of the deadline for production;

(b)

If the written request is made after the deadline for production, the amount of time elapsed since that deadline;

(c)

The efforts already made to comply with the request;

(d)

The reasons the deadline cannot be met;

(e)

The degree of control that the provider had over its ability to produce the records prior to the deadline; and

(f)

Other extenuating factors.

(6)

Access to records, inclusive of medical charts and financial records, does not require authorization or release from the client if the purpose of such access is to:

(a)

Perform billing review activities;

(b)

Perform utilization review activities;

(c)

Review quality, quantity and services provided;

(d)

Facilitate payment authorization and related services;

(e)

Investigate a client’s fair hearing request;

(f)

Facilitate investigation by the Authority;

(g)

Where review of records is necessary to the operation of the program.

(7)

Failure to comply with requests for documents and within the specified time-frames means that the records subject to the request may be deemed by the Authority not to exist for purposes of verifying appropriateness of payment, medical appropriateness, the quality of care, and the access to care in an audit or overpayment determination, and accordingly subjects the provider to possible denial or recovery of payments made by the Authority, or to sanctions.

Source: Rule 333-010-0160 — Requirements for Financial, Clinical and Other Records, https://secure.­sos.­state.­or.­us/oard/view.­action?ruleNumber=333-010-0160.

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 333-010-0160’s source at or​.us