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.
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 410-120-1395’s source at or​.us