OAR 410-120-1395
Program Integrity

(1)

The Oregon Health Authority (Authority) uses several approaches to promote program integrity. These rules describe program integrity actions related to provider payments. Our program integrity goal is to pay the correct amount to a properly enrolled provider for covered, medically appropriate services provided to an eligible client according to the client’s benefit package of health care services in effect on the date of service. Types of program integrity activities include but are not limited to the following activities:

(a)

Medical review and prior authorization processes, including all actions taken to determine the medical appropriateness of services or items;

(b)

Provider obligations to submit correct claims;

(c)

Onsite visits to verify compliance with standards;

(d)

Implementation of Health Insurance Portability and Accountability Act (HIPAA) electronic transaction standards to improve accuracy and timeliness of claims processing and encounter reporting;

(e)

Provider credentialing activities;

(f)

Accessing federal Department of Health and Human Services database (exclusions);

(g)

Quality improvement activities;

(h)

Cost report settlement processes;

(i)

Audits;

(j)

Investigation of fraud or prohibited kickback relationships;

(k)

Coordination with the Department of Justice Medicaid Fraud Control Unit (MFCU) and other health oversight authorities.

(2)

Providers must maintain clinical, financial and other records, capable of being audited or reviewed, consistent with the requirements of OAR 410-120-1360 (Requirements for Financial, Clinical and Other Records), Requirements for Financial, Clinical and Other Records, in the General Rules Program, the Oregon Health Plan administrative rules, and the rules applicable to the service or item.

(3)

The following people may review a request for services or items, or audit a claim for care, services or items, before or after payment, for assurance that the specific care, item or service was provided in accordance with the Division of Medical Assistance Program’s (Division) rules and the generally accepted standards of a provider’s field of practice or specialty:

(a)

Authority, Department staff or designee; or

(b)

Medical utilization and review contractor; or

(c)

Dental utilization and review contractor; or

(d)

Federal or state oversight authority.

(4)

Payment may be denied or subject to recovery if the review or audit determines the care, service or item was not provided in accordance with Division rules or does not meet the criteria for quality or medical appropriateness of the care, service or item or payment. Related provider and Hospital billings will also be denied or subject to recovery.

(5)

When the Authority determines that an overpayment has been made to a provider, the amount of overpayment is subject to recovery.

(6)

The Authority may communicate with and coordinate any program integrity actions with the MFCU, DHHS, and other federal and state oversight authorities.

(7)

The Authority must notify HHS-OIG within 20 working days of any disclosures from the date it receives the information, or takes any adverse action to limit the ability of an individual or entity to participate in its program as provided in 42 CFR 1002.3(b). This includes, but is not limited to, suspension, denials, terminations, settlement agreements and situations where an individual or entity voluntarily with draws from the program to avoid a formal sanction.

(8)

When the Authority initiates an exclusion under § 1002.210, it must notify the individual or entity subject to the exclusion and other state agencies, the state medical licensing board, the public, beneficiaries, and others as provided in § 1001.2005 and § 1001.2006.

Source: Rule 410-120-1395 — Program Integrity, https://secure.­sos.­state.­or.­us/oard/view.­action?ruleNumber=410-120-1395.

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 410-120-1395’s source at or​.us