OAR 333-010-0260
Recovery of Overpayments to Providers Resulting from Review or Audit

(1)

If the Center determines that an overpayment has been made to an enrolling or ancillary provider, the Center shall seek to recover the amount of overpayment. The Center may use a statistically valid random sampling, with sufficient sample size allowing a confidence interval of 95 percent to determine if an overpayment has been made.

(2)

The amount of the review or audit overpayment to be recovered:

(a)

Will be the entire amount determined by the Center;

(b)

Is not limited to amounts determined by criminal or civil proceedings; and

(c)

Will include interest to be charged at allowable state rates.

(3)

The Center shall provide an enrolling provider in writing, by registered or certified mail or in person, notice of an overpayment and a request for repayment of the overpayment, along with documentation to support the amount owed.

(4)

An enrolling or ancillary provider shall pay the overpayment amount within 30 calendar days from the date the Center mails the notice of overpayment. A request for a hearing does not change the date the repayment of the overpayment is due.

(5)

The Center may extend the 30-day repayment period or accept an offer of repayment terms. Any change in reimbursement period or terms must be documented in writing by the Center.

(6)

If the provider disagrees with the Center’s determination or the amount of overpayment the provider may:

(a)

Appeal the decision by requesting a contested case hearing; or

(b)

Request a 100 percent audit of all billings submitted to the Center for heart disease, stroke, and diabetes screenings and services provided during the period in question.

(7)

A written request for hearing must be submitted to the Center by the provider within 30 calendar days of the date of the decision affecting the provider. The request must specify the areas of disagreement. Failure to request a hearing or administrative review in a timely manner constitutes acceptance by the provider of the amount of the overpayment.

(8)

If a 100 percent audit is requested:

(a)

An enrolling or ancillary provider is responsible for arranging and paying for the audit; and

(b)

The audit must be conducted by a certified public accountant that is knowledgeable about the Oregon Administrative Rules covering the payments in question, and must be conducted within 120 calendar days of the request to use such an audit in lieu of the Center’s random sample.

(9)

If the provider refuses to reimburse the overpayment or does not adhere to an agreed upon payment schedule, the Center may:

(a)

Recoup future provider payments up to the amount of the overpayment; or

(b)

Pursue civil action to recover the overpayment.

(10)

The Center may, at any time, change the amount of the overpayment upon receipt of additional information from an enrolling provider. If the Center changes an overpayment amount it will provide written notice to the enrolling provider. Any monies paid to the Center that exceed an overpayment will be refunded to the provider.

(11)

The Center may pursue civil action to recover any amounts due and payable to the WW Program.

Source: Rule 333-010-0260 — Recovery of Overpayments to Providers Resulting from Review or Audit, https://secure.­sos.­state.­or.­us/oard/view.­action?ruleNumber=333-010-0260.

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 333-010-0260’s source at or​.us