OAR 410-120-0025
Administration of Division of Medical Assistance Programs, Regulation and Rule Precedence

(1)

The Oregon Health Authority (Authority) and its Division of Medical Assistance Programs (Division) may adopt reasonable and lawful policies, procedures, rules, and interpretations to promote the orderly and efficient administration of medical assistance programs including the Oregon Health Plan pursuant to ORS 414.065 (Determination of health care and services covered) (generally, fee-for-service), 414.651(Coordinated Care Organizations), and 414.115 (Medical assistance by insurance or service contracts) to 414.145 (Implementation of ORS 414.115, 414.125 or 414.135) (services contracts), subject to the rulemaking requirements of the Oregon Revised Statutes and Oregon Administrative Rule (OAR) procedures.

(2)

In applying its policies, procedures, rules, and interpretations, the Division shall construe them as much as possible to be complementary. In the event that Division policies, procedures, rules and interpretations may not be complementary, the Division shall apply the following order of precedence to guide its interpretation:

(a)

For purposes of the provision of covered medical assistance to Division clients, including but not limited to authorization and delivery of service or denials of authorization or services, the Division, clients, enrolled providers, Coordinated Care Organizations, and the Prepaid Health Plans shall apply the following order of precedence:

(A)

Oregon Revised Statutes governing medical assistance programs;

(B)

Consistent with ORS 413.071 (Authorization to request federal waivers),those federal laws and regulations governing the operation of the medical assistance program and any waivers granted the Authority by the Centers for Medicare and Medicaid Services to operate medical assistance programs including the Oregon Health Plan;

(C)

Generally for Coordinated Care Organizations, the requirements applicable to the providing covered medical assistance to Division clients are found in OAR 410-141-3000 through 410-141-3485; and where applicable, 410-120-0000 (Acronyms and Definitions) through 410-120-1980 (Requests for Information and Public Records); and the provider rules applicable to the category of medical service;

(D)

Generally for Prepaid Health Plans, the requirements applicable to providing covered medical assistance to Division clients are found in OAR 410-141-0000 through 410-141-0860; and where applicable, 410-120-0000 (Acronyms and Definitions) through 410-120-1980 (Requests for Information and Public Records); and the provider rules applicable to the category of medical service;

(E)

Generally for enrolled fee-for-service providers or other contractors, the requirements applicable to providing covered medical assistance to Division clients are found in OAR 410-120-0000 (Acronyms and Definitions) through 410-120-1980 (Requests for Information and Public Records), the Prioritized List and program coverage set forth in410-141-0480 to 410-141-0520, and the provider rules applicable to the category of medical service;

(F)

Any other applicable duly promulgated rules issued by the Division and other offices or units within the Oregon Health Authority or Department of Human Services necessary to administer the State of Oregon’s medical assistance programs, such as electronic data transaction rules in OAR 943-120-0100 (Definitions) to 943-120-0200 (Authority System Administration); and

(G)

The basic framework for provider enrollment in OAR 943-120-0300 (Definitions) through 943-120-0380 that generally apply to providers enrolled with the Authority or Department, subject to more specific requirements applicable to the administration of the Oregon Health Plan and medical assistance programs administered by the Authority. For purposes of this rule, “more specific” means the requirements, laws and rules applicable to the provider type and covered services described in paragraphs (A)–(F) of this section.

(b)

For purposes of contract administration solely as between the Authority and its Coordinated Care Organizations or Prepaid Health Plans, the terms of the applicable contract and the requirements in section (2)(a) of this rule apply to the provision of covered medical assistance to Division clients:

(A)

Nothing in this rule shall be deemed to incorporate into contracts provisions of law not expressly incorporated into such contracts, nor shall this rule be deemed to supersede any rules of construction of such contracts that may be provided for in such contracts;

(B)

Nothing in this rule gives, is intended to give, or shall be construed to give or provide any benefit or right, whether directly or indirectly or otherwise, to any individual or entity unless the individual or entity is identified as a named party to the contract.

Source: Rule 410-120-0025 — Administration of Division of Medical Assistance Programs, Regulation and Rule Precedence, https://secure.­sos.­state.­or.­us/oard/view.­action?ruleNumber=410-120-0025.

410‑120‑0000
Acronyms and Definitions 410‑120‑0003
OHP Standard Benefit Package 410‑120‑0006
Medical Eligibility Standards 410‑120‑0011
Effect of COVID-19 Emergency Authorities on Administrative Rules 410‑120‑0025
Administration of Division of Medical Assistance Programs, Regulation and Rule Precedence 410‑120‑0030
Children’s Health Insurance Program 410‑120‑0035
Public Entity 410‑120‑0045
Applications for Medical Assistance at Provider locations 410‑120‑0250
Managed Care Entity 410‑120‑1140
Verification of Eligibility and Coverage 410‑120‑1160
Medical Assistance Benefits and Provider Rules 410‑120‑1180
Medical Assistance Benefits: Out-of-State Services 410‑120‑1190
Medically Needy Benefit Program 410‑120‑1195
SB 5548 Population 410‑120‑1200
Excluded Services and Limitations 410‑120‑1210
Medical Assistance Benefit Packages and Delivery System 410‑120‑1260
Provider Enrollment 410‑120‑1280
Billing 410‑120‑1285
Recoupment and Data Sharing with Third-Party Insurers 410‑120‑1295
Non-Participating Provider 410‑120‑1300
Timely Submission of Claims 410‑120‑1320
Authorization of Payment 410‑120‑1340
Payment 410‑120‑1350
Buying-Up 410‑120‑1360
Requirements for Financial, Clinical and Other Records 410‑120‑1380
Compliance with Federal and State Statutes 410‑120‑1385
Compliance with Public Meetings Law 410‑120‑1390
Premium Sponsorships 410‑120‑1395
Program Integrity 410‑120‑1396
Provider and Contractor Audits 410‑120‑1397
Recovery of Overpayments to Providers — Recoupments and Refunds 410‑120‑1400
Provider Sanctions 410‑120‑1460
Type and Conditions of Sanction 410‑120‑1510
Fraud and Abuse 410‑120‑1560
Provider Appeals 410‑120‑1570
Claim Re-Determinations 410‑120‑1580
Provider Appeals — Administrative Review 410‑120‑1600
Provider Appeals — Contested Case Hearings 410‑120‑1855
Client’s Rights and Responsibilities 410‑120‑1860
Contested Case Hearing Procedures 410‑120‑1865
Denial, Reduction, or Termination of Services 410‑120‑1870
Client Premium Payments 410‑120‑1875
Agency Hearing Representatives 410‑120‑1880
Contracted Services 410‑120‑1920
Institutional Reimbursement Changes 410‑120‑1940
Interest Payments on Overdue Claims 410‑120‑1960
Payment of Private Insurance Premiums 410‑120‑1980
Requests for Information and Public Records 410‑120‑1990
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Last Updated

Jun. 8, 2021

Rule 410-120-0025’s source at or​.us