Claim and PHP Encounter Submission
(1)Claim and PHP Encounter Submission. All claims must be submitted using one of the following methods:
(a)Paper forms, using the appropriate form as described in the program-specific rules or contract;
(b)Electronically using the web portal accessed by provider-specific PIN and password. Initial activation by provider of Department-assigned provider number and PIN for web portal access invokes provider’s agreement to meet all of the standards for HIPAA privacy, security, and transactions and codes sets standards as defined in 45 CFR 162;
(c)Electronically in a manner authorized by the Department’s EDT rules (OAR 407-120-0100 (Definitions) to 407-120-0200 (Department System Administration)); or
(d)Electronically, for PHP encounters, in the manner required by the PHP contract with the Department and authorized by the Department’s EDT rules.
(2)Claims must not be submitted prior to delivery of service unless otherwise authorized by program-specific rules or contracts. A claim for an item must not be submitted prior to dispensing, shipping, or mailing the item unless otherwise specified in the Department’s program-specific rules or contracts.
(3)Claims and PHP encounters must be submitted in compliance HIPAA transaction and code set rules. The HIPAA transaction and code set rules, 45 CFR 162, apply to all electronic transactions for which DHHS has adopted a standard.
(a)The Department may deny or reject electronic transactions that fail to comply with the federal standard.
(b)The Department is required to comply with the HIPAA code set requirements in 45 CFR 162.1000 through 162.1011, regardless of whether a request is made verbally, or a claim is submitted on paper or electronically, and with regard to the electronic claims and encounter remittance advice information, including the web portal. Compliance with the code set requirements includes the codes and the descriptors of the codes established by the official entity that maintains the code set. These federal code set requirements are mandatory and the Department has no authority to delay or alter their application or effective dates as established by DHHS.
(A)The issuance of a federal code does not mean that the Department covers the item or service described by the federal code. In the event of a variation between a Department-listed code and a national code, the provider should seek clarification from the Department program. The Department shall apply the national code in effect on the date of request or date of service and the Department-listed code may be used for the limited purpose of describing the Department’s intent in identifying whether the applicable national code represents a Department covered service or item.
(B)For purposes of maintaining HIPAA code set compliance, the Department adopts by reference the required use of the version of all national code set revisions, deletions, and additions in accordance with the HIPAA transaction and code set rules in effect on the date of this rule. This code set adoption may not be construed as Department coverage or that the existence of a particular national code constitutes a determination by the Department that the particular code is a covered service or item. If the provider is unable to identify an appropriate procedure code to use on the claim or PHP encounter, the provider should contact the Department for assistance in identifying an appropriate procedure code reference in but not limited to the following:
(i)Current Procedural Terminology, Fourth Edition (CPT-4), (American Medical Association);
(ii)Current Dental Terminology (CDT), (American Dental Association);
(iii)Diagnosis Related Group (DRG), (DHHS);
(iv)Health Care Financing Administration Common Procedural Coding System (HCPCS), (DHHS);
(v)National Drug Codes (NDC), (DHHS); or
(vi)HIPAA related codes, DHHS, claims adjustment reason, claim status, taxonomy codes, and decision reason available at the Washington Publishing Company web site: http://www.wpc.edi.com/content/view/180⁄223.
(C)For electronic claims and PHP encounters, the appropriate HIPAA claim adjustment reason code for third party payer, including Medicare, explanation of payment must be used.
(c)Diagnosis Code Requirement.
(A)For claims and PHP encounters that require the listing of a diagnosis code as the basis for the service provided, the code listed on the claim must be the code that most accurately describes the client’s condition and the service or item provided.
(B)A primary diagnosis code is required on all claims, using the HIPAA nationally required diagnosis code set including the code and the descriptor of the code by the official entity that maintains the code set, unless the requirement for a primary diagnosis code is specifically excluded in the Department’s program-specific rules or contract. All diagnosis codes are required to the highest degree of specificity. Providers must use the ICD-9-CM diagnosis coding system when a diagnosis is required unless otherwise specified in the appropriate program-specific rules or contract.
(C)Hospitals must follow national coding guidelines and must bill using the 5th digit, in accordance with methodology used in the Medicare Diagnosis Related Groups.
(d)Providers are required to provide and identify the following procedures codes.
(A)The appropriate procedure code on claims and PHP encounters as instructed in the appropriate Department program-specific rules or contract and must use the appropriate HIPAA procedure code set, set forth in 45 CFR 162.1000 through 162.1011, which best describes the specific service or item provided.
(B)Where there is one CPT, CDT, or HCPCS code that according to those coding guidelines or standards, describes an array of services, the provider must use that code rather than itemizing the services under multiple codes. Providers must not “unbundle” services in order to increase payment or to mischaracterize the service.
(4)Prohibition of False Claims. No provider or its contracted agent (including billing service or billing agent) shall submit or cause to be submitted to the Department:
(a)Any false claim for payment or false PHP encounter;
(b)Any claim or PHP encounter altered in such a way as to result in a duplicate payment for a service that has already been paid;
(c)Any claim or PHP encounter upon which payment has been made or is expected to be made by another source unless the amount paid or to be paid by the other party is clearly entered on the claim form or PHP encounter format; or
(d)Any claim or PHP encounter for providing services or items that have not been provided.
(5)Third Party Resources.
(a)A provider shall not refuse to furnish covered services or items to an eligible client because of a third party’s potential liability for the service or item.
(b)Providers must take all reasonable measures to ensure that the Department shall be the payer of last resort, consistent with program-specific rules or contracts. If available, private insurance, Medicare, or worker’s compensation must be billed before the provider submits a claim for payment to the Department, county, or PHP. For services provided to a Medicare and Medicaid dual eligible client, Medicare is the primary payer and the provider must first pursue Medicare payment (including appeals) prior to submitting a claim for payment to the Department, county, or PHP. For services not covered by Medicare or other third party resource, the provider must follow the program-specific rules or contracts for appropriate billing procedures.
(c)When another party may be liable for paying the expenses of a client’s injury or illness, the provider must follow program-specific rules or contract addressing billing procedures.
(6)Full Use of Alternate Community Resources.
(a)The Department shall generally make payment only when other resources are not available for the client’s needs. Full use must be made of reasonable alternate resources in the local community; and
(b)Providers must not accept reimbursement from more than one resource for the same service or item, except as allowed in program-specific or contract TPR requirements.
(7)Timely Submission of Claim or Encounter Data.
(a)Subsection (a) through (c) below apply only to the submission of claims data or other reimbursement document to the Department, including provider reimbursement by the Department pursuant to an agreement with a county. Unless requirements for timely filing provided for in program-specific rules or applicable contracts are more specific than the timely filing standard established in this rule, all claims for services or items must be submitted no later than 12 months from the date of service.
(b)A denied claim submitted within 12 months of the date of service may be resubmitted (with resubmission documentation, as indicated within the program-specific rules or contracts) within 18 months of the date of service. These claims must be submitted to the Department in writing. The provider must present documentation acceptable to the Department verifying the claim was originally submitted within 12 months of the date of service, unless otherwise stated in program-specific rules or contracts. Acceptable documentation is:
(A)A remittance advice or other claim denial documentation from the Department to the provider showing the claim was submitted before the claim was one year old; or
(B)A copy of a billing record or ledger showing dates of submission to the Department.
(c)Exceptions to the 12-month requirement that may be submitted to the Department are as follows:
(A)When the Department confirms the Department or the client’s branch office has made an error that caused the provider not to be able to bill within 12 months of the date of service;
(B)When a court or an administrative law judge in a final order has ordered the Department to make payment;
(C)When the Department determines a client is retroactively eligible for Department program coverage and more than 12 months have passed between the date of service and the determination of the client’s eligibility, to the extent authorized in the program-specific rules or contracts.
(d)PHP encounter data must be submitted in accordance with 45 CFR part 162.1001 and 162.1102 and the time periods established in the PHP contract with the Department.
Rule 407-120-0340 — Claim and PHP Encounter Submission,