OAR 410-120-1140
Verification of Eligibility and Coverage

(1)

To ensure Division reimbursement of services, providers are responsible to verify the following before rendering services:

(a)

Client eligibility: That the person is an eligible Oregon Health Plan (OHP) client on the date(s) services are rendered; and

(b)

Benefit coverage: That the person is enrolled in an OHP benefit package that covers the services they plan to render. See OAR 410-120-1210 (Medical Assistance Benefit Packages and Delivery System) for services covered under each Division benefit package.

(2)

Providers who do not verify eligibility and benefit coverage with the Division before serving a person shall assume full financial responsibility in serving that person.

(3)

The following types of client identification (ID) only list the client’s name, Oregon Medicaid ID number (prime number), and the date the ID was issued. They do not guarantee client eligibility or benefit coverage:

(a)

The standard ID (called the Oregon Health ID, formerly the DHS Medical Care ID) printed on perforated paper the size of a business card;

(b)

Replacement IDs (printed on regular printer paper in case of misplaced originals).

(4)

When a person presents a standard or replacement ID, providers must verify client eligibility and benefit coverage through one of the following (For instructions see the Division General Rules Supplemental Information available on the web at http:/­/­www.oregon.gov/­OHA/­HSD/­OHP/­Pages/­Policy-General-Rules.aspx:

(a)

The Division’s Medicaid Management Information System (MMIS) Provider Web portal;

(b)

The Automated Voice Response (AVR) telephone system;

(c)

Batch or real-time electronic data interchange (EDI) eligibility inquiry (270) and response (271) transactions;

(5)

The client may also present one of the following Temporary Oregon Health IDs; both are full-page forms:

(a)

DMAP form 1086: This document guarantees eligibility and benefit coverage for seven days from the beginning dates of coverage entered in Part 1 of the form. This temporary ID is issued only if the client needs immediate care but their eligibility and coverage information is not yet available for verification as described in part (4) of this rule. Providers must honor the Temporary Oregon Health ID when presented within seven (7) days of the beginning date of coverage entered on the form;

(b)

OHP 3263A: Approval Notice for Hospital Presumptive Eligibility for Medical Coverage: This ID is issued for those who are “presumed” eligible based on certain information and authorizes benefit coverage only on a temporary basis. The OHP 3263A informs the client of the exact date by which the Division must receive their full Medicaid application so that they may be evaluated for ongoing eligibility.

Source: Rule 410-120-1140 — Verification of Eligibility and Coverage, https://secure.­sos.­state.­or.­us/oard/view.­action?ruleNumber=410-120-1140.

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 410-120-1140’s source at or​.us