OAR 410-120-1295
Non-Participating Provider

(1) For purposes of this rule, a provider enrolled with the Division of Medical Assistance Programs (Division) that does not have a contract with a Division-contracted Managed Care Entity (MCE) is referred to as a non-participating provider.
(2) For covered services that are subject to reimbursement from the CCO or PHP, a non-participating provider, other than a hospital governed by (3) below, must accept from the Division-contracted MCE, as payment in full, the amount that the provider would be paid from the Division if the client was fee-for-service (FFS).
(3) For covered services provided on and after October 1, 2011, the Division-contracted MCE that does not have a contract with a hospital, is required to reimburse, and hospitals are required to accept as payment in full, the following reimbursement:
(a) Non-participating Type A and Type B hospital: The MCE shall reimburse a non-participating Type A and Type B hospital fully for the cost of covered services based on the cost-to-charge ratio used for each hospital in setting the global payments to the MCE for the contract period. (ORS 414.727);
(b) Hospitals (not designated as a rural access or Type A and Type B hospital): As specified in ORS 414.743 (Payment to noncontracting hospital by coordinated care organization), the MCE shall reimburse inpatient and outpatient services using a Medicare payment methodology at a specified percentage point less than the percentage of Medicare costs used by the Oregon Health Authority (Authority) when calculating the base hospital capitation payment to the MCE excluding any supplemental payments.
(A) Effective for services on or after October 1, 2011, for a hospital providing 10 percent or more of the hospital admissions and outpatient hospital services to enrollees of the plan, the percentage of the Medicare reimbursement shall be equal to 64 percent;
(B) Effective for services on or after October 1, 2011, for a hospital providing less than 10 percent of the hospital admissions and outpatient hospital services to enrollees of the plan, the percentage of the Medicare reimbursement shall be equal to 66 percent.
(C) Effective for services on or after January 1, 2020 for a hospital providing 10 percent or more of the hospital admissions and outpatient hospital services to enrollees of the plan, the percentage of the Medicare reimbursement shall be equal to 76 percent.
(D) Effective for services on or after January 1, 2020 for a hospital providing less than 10 percent of the hospital admissions and outpatient hospital services to enrollees of the plan, the percentage of the Medicare reimbursement shall be equal to 78 percent.
(4) A non-participating hospital must notify the MCE within 2 business days of an MCE patient admission when the MCE is the primary payer. Failure to notify does not, in and of itself, result in denial for payment. The CCO or FCHP is required to review the hospital claim for:
(a) Medical appropriateness;
(b) Compliance with emergency admission or prior authorization policies;
(c) Member’s benefit package;
(d) The MCE contract and the Division’s administrative rules.
(5) After notification from the non-participating hospital, the MCE may:
(a) Arrange for a transfer to a contracted facility, if the patient is medically stable and the MCE has secured another facility to accept the patient;
(b) Perform concurrent review; and/or
(c) Perform case management activities.
(6) In the event of a disagreement between the MCE and hospital, the provider may appeal the decision by asking for an administrative review as specified in OAR 410-120-1580 (Provider Appeals — Administrative Review).

Source: Rule 410-120-1295 — Non-Participating Provider, https://secure.­sos.­state.­or.­us/oard/view.­action?ruleNumber=410-120-1295.

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
Telehealth
Last Updated

Jun. 8, 2021

Rule 410-120-1295’s source at or​.us