OAR 333-010-0245
Claims and Billing


(1)

Only an enrolling or ancillary provider providing WW Program covered services pursuant to a fully executed medical services agreement, and who has been assigned an agency number may submit claims for payment to the Center for providing WW Program covered services.

(2)

An enrolling or ancillary provider shall, as applicable:

(a)

Submit claim information in the manner specified by the WW Program;

(b)

Include a primary diagnosis code on all claims;

(c)

Code all claims with the most current and appropriate International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM) diagnosis codes and the most appropriate Current Procedural Terminology (CPT) codes as noted in the WW Program Manual;

(d)

Submit to the Center all claims for services within 12 months of the date of service;

(e)

Submit a billing error edit correction, or refund the amount of the overpayment, on any claim where a provider identifies an overpayment made by the Center;

(f)

Make all reasonable efforts to ensure that the WW Program is the payor of last resort with the exception of clinics or offices operated by the Indian Health Service (IHS) or individual American Indian tribes. For the purposes of this rule “reasonable efforts” include:

(A)

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

(B)

Except in the case of the underinsured, billing any known insurer in compliance with that insurer’s billing and authorization requirements.

(g)

Submit to the Center a billing error edit correction if it receives a third party payment and refund to the Center the amount received from the other source within 30 days of the date the payment is received.

(3)

The Center may not pay a claim older than 12 months, except as provided for in section (4) of this rule. An enrolling or ancillary provider that has a claim rejected because of an error must resolve the error within 12 months of the date of service.

(4)

If the Center makes an error that makes it impossible for an enrolling or ancillary provider to bill within 12 months of the date of service, the enrolling or ancillary provider shall notify the Center of the alleged error and submit the claim to the Center. The Center shall confirm that it made an error prior to payment being made.

(5)

The Center may not pay a claim that includes a primary diagnosis code that is not in the WW Program Manual.

(6)

An enrolling or ancillary provider with the WW Program may not seek payment from a client, or from a financially responsible relative or representative of that client for any services covered by the WW Program.

(7)

An enrolling or ancillary provider may bill a client for services that are not covered by the WW Program. 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.

(8)

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

(9)

A provider who has been suspended or terminated from participation in a federal or state medical program, such as Medicare or Medicaid, or whose license to practice has been suspended or revoked by a state licensing board, may not submit claims for payment, either personally or through claims submitted by any billing provider or other provider, for any services or supplies provided under the WW Program, except those services provided prior to the date of suspension or termination.
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 333-010-0245’s source at or​.us