OAR 410-120-1285
Recoupment and Data Sharing with Third-Party Insurers

(1) The Oregon Health Authority (Authority) delegates to the Department of Human Services (Department), Office of Payment Accuracy and Recovery (OPAR) authority to administer Third-Party Liability programs required by federal law to reduce medical expenditures. This includes the following programs:
(a) The Data Match Unit;
(b) The Health Insurance Group;
(c) The Medical Payment Recovery Unit; and
(d) The Personal Injury Liens Unit.
(2) For this rule, an “insurer” means an employee benefit plan, self-insured plan, managed care organization or group health plan, a third-party administrator, fiscal intermediary or pharmacy benefit manager of the plan or organization, or other party that is by statute, contract, or agreement legally responsible for payment of a claim for a health care item or service.
(3) “OPAR” means the Office of Payment Accuracy and Recovery, Department of Human Services, and subunits.
(4) For this rule “subscriber” means an individual who is eligible for coverage on their behalf and not because of dependent status.
(5) An insurer shall provide to OPAR, a CCO, or a Managed Care Organization, upon request, within 30 calendar days, the following information:
(a) The period during which a recipient, a spouse, partner or dependents are covered by the insurer;
(b) The nature of coverage that is provided by the insurer; for example, medical, prescription drug, dental, vision, motor vehicle personal injury protection, or workers compensation;
(c) The name, claim submission address, and identifying numbers of the plan; for example, group and policy numbers;
(d) The name of the subscriber, if any, and the date of birth and social security number;
(e) The amount of any copay, coinsurance, or deductible required by the insurer.
(6) An insurer may not deny a claim submitted by OPAR, a managed care organization, or a CCO, based on the date of submission of the claim, the type or format of the claim form, or a failure to present proper documentation at the point of sale that is the basis of the claim if:
(a) The claim is submitted within the three-year period beginning on the date on which the health care item or service was furnished; and
(b) Any action to enforce the claim is commenced within six years of submission of the claim.
(7) If an insurer denies a claim or does not pay the claim in full, the insurer shall provide a detailed explanation for its action, including citation to applicable contractual or statutory authority for the action. If the insurer cites a contractual provision, the insurer shall provide a copy of the applicable contractual provision on request.
(8) An insurer, when requsted by OPAR, shall provide OPAR an electronic file of all insured or subscribed individuals residing in Oregon to assist OPAR to do a data match with recipient records to determine if any Medicaid recipient has coverage through the insurer. The electronic file shall be delivered to OPAR every 30 days, unless otherwise agreed. The Authority may enter into a trading partner agreement with the insurer to permit the exchange of information via “ASC X 12N 270⁄271 Health Benefit Inquiry and Response” transactions or other HIPAA compliant secure transaction methods in the event 270⁄271 transactions are not available. The insurer shall include the following information in the electronic file:
(a) The period during which a subscriber or insured, the spouse, partner or dependents are covered by the plan;
(b) The nature of coverage that is provided by the plan; for example, medical, prescription, dental, vision, or automotive personal injury protection, and workers compensation;
(c) The name, claim submission address, and identifying numbers of the plan; for example, group and policy numbers;
(d) The name of the subscriber, if any, and date of birth and social security number;
(e) The amount of any copay, coinsurance, or deductible required by the insurer.
(9) An insurer may not charge a fee for sharing data with the Authority, OPAR, a managed care organization, or CCO or for processing claims submitted by OPAR, a managed care organization, or a CCO.
(10) In the event a claim submitted to an insurer by OPAR, a managed care organization, or a CCO is paid all or in part to a third party, the insurer shall within 14 calendar days give the name and address of the payee, the check number, date and amount of the check or electronic payment, and a copy of the check or electronic payment to the claimant on request.

Source: Rule 410-120-1285 — Recoupment and Data Sharing with Third-Party Insurers, https://secure.­sos.­state.­or.­us/oard/view.­action?ruleNumber=410-120-1285.

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 410-120-1285’s source at or​.us