OAR 407-120-0330
Billing Procedures
(1)
These rules only apply to covered services and items provided to clients that are paid for by the Department based on a Department fee schedule or other reimbursement method (often referred to as fee-for-service), or for services that are paid for by the Department at the request of a county for county-authorized services, in accordance with program-specific rules or contract.(a)
If a client’s service or item is paid for by a PHP, the provider must comply with the billing and procedures related to claim submission established under contract with that PHP, or the rules applicable to non-participating providers if the provider is not under contract with that PHP.(b)
If the client is enrolled in a PHP, but the client is permitted by a contract or program-specific rules to obtain covered services reimbursed by the Department (such as family planning services that may be obtained from any provider), the provider must comply with the billing and claim procedures established under these rules.(2)
All Department-assigned provider numbers are issued at enrollment and are directly associated with the provider as defined in OAR 407-120-0320 (Provider Enrollment)(12) and have the following uses:(a)
Log-on identification for the Department web portal;(b)
Claim submission in the approved paper formats; and(c)
For electronic claims submission including the web portal for atypical providers pursuant to 45 CFR 160 and 162 where an NPI is not mandated. Use of the Department-assigned provider number shall be considered authorized by the provider and the Department shall hold the provider accountable for its use.(3)
Except as provided in section (4) below, an enrolled provider may not seek payment for any covered services from:(a)
A client for covered benefits; or(b)
A financially responsible relative or representative of that client.(4)
Providers may seek payment from an eligible client or client representative as follows:(a)
From any applicable coinsurance, co-payments, deductibles, or other client financial obligation to the extent and as expressly authorized by program-specific rules or contract;(b)
From a client who failed to inform the provider of Department program eligibility, of OHP or PHP enrollment, or of other third party insurance coverage at the time the service was provided or subsequent to the provision of the service or item. In this case, the provider could not bill the Department, the PHP, or third party payer for any reason, including but not limited to timeliness of claims and lack of prior authorization. The provider must document attempts to obtain information on eligibility or enrollment;(c)
The client became eligible for Department benefits retroactively but did not meet other established criteria described in the applicable program-specific rules or contracts.(d)
The provider can document that a TPR made payments directly to the client for services provided that are subject to recovery by the provider in accordance with program-specific rules or contract;(e)
The service or item is not covered under the client’s benefit package. The provider must document that prior to the delivery of services or items, the provider informed the client the service or item would not be covered by the Department;(f)
The client requested continuation of benefits during the administrative hearing process and the final decision was not in favor of the client. The client shall be responsible for any charges since the effective date of the initial notice of denial; or(g)
In exceptional circumstances, a client may request continuation of a covered service while asserting the right to privately pay for that service. Under this circumstance, a provider may bill the client for a covered service only if the client is informed in advance of receiving the specific service of all of the following:(A)
The requested service is a covered service and the provider would be paid in full for the covered service if the claim is submitted to the Department or the client’s PHP;(B)
The estimated cost of the covered service, including all related charges, that the Department or PHP would pay, and for which the client is billed cannot be an amount greater than the maximum Department or PHP reimbursable rate or PHP rate;(C)
The provider cannot require the client to enter into a voluntary payment agreement for any amount for the covered service; and(D)
The provider must be able to document, in writing, signed by the client or the client’s representative, that the client was provided the information described above; was provided an opportunity to ask questions, obtain additional information, and consult with the client’s caseworker or client representative; and the client agreed to be responsible for payment by signing an agreement incorporating all of the information described above. The provider must provide a copy of the signed agreement to the client. The provider must not submit a claim for payment for the service or item to the Department or to the client’s PHP that is subject to such an agreement.(5)
Reimbursement for Non-Covered Services.(a)
A provider may bill a client for services that are not covered by the Department or a PHP, except as provided in these rules. The client must be informed 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 provide written documentation, signed by the client, or the client’s representative, dated prior to the delivery of services or item indicating that the client was provided this information and that the client knowingly and voluntarily agreed to be responsible for payment.(b)
Providers must not bill or accept payment from the Department or a PHP for a covered service when a non-covered service has been provided and additional payment is sought or accepted from the client. Examples include but are not limited to charging the client an additional payment to obtain a gold crown (not covered) instead of the stainless steel crown (covered) or charging an additional client payment to obtain eyeglass frames not on the covered list of frames. This practice is called buying-up, which is not permitted, and a provider may be sanctioned for this practice regardless of whether a client waiver is documented.(c)
Providers must not bill clients or the Department for a client’s missed appointment.(d)
Providers must not bill clients or the Department for services or items provided free of charge. This limitation does not apply to established sliding fee schedules where the client is subject to the same standards as other members of the public or clients of the provider.(e)
Providers must not bill clients for services or items that have been denied due to provider error such as required documentation not submitted or prior authorization not obtained.(6)
Providers must verify that the individual receiving covered services is, in fact, an eligible client on the date of service for the service provided and that the services is covered in the client’s benefit package.(a)
Providers are responsible for costs incurred for failing to confirm eligibility or that services are covered.(b)
Providers must confirm the Department’s client eligibility and benefit package coverage using the web portal, or the Department telephone eligibility system, and by other methods specified in program-specific or contract instructions.
Source:
Rule 407-120-0330 — Billing Procedures, https://secure.sos.state.or.us/oard/view.action?ruleNumber=407-120-0330.