OAR 410-125-0640
Third Party Payers — Other Resources, Client Responsibility and Liability


(1)

Medicare: Do not send claims to the Division of Medical Assistance Programs (Division) until they have been billed to and adjudicated by Medicare:

(a)

Exception: Take home drugs and other services, which are not covered by Medicare, may be billed directly to the Division without billing Medicare first;

(b)

See: billing instructions in the Hospital Services Supplemental Information on the Division’s website for additional information on billing Medicare claims.

(2)

Other Insurance. With the exception of services described in the General Rules, bill all other insurance first before billing the Division. Report the payments made by the other insurers.

(3)

Motor vehicle accident fund:

(a)

Enter 01 (Auto Accident) in the Occurrence Code Block and give the date of the accident;

(b)

For all other clients, bill all other resources before billing the Division. Do not bill the Motor Vehicle Accident Fund.

(4)

Employment Related Injuries: Enter 04 (Employment Related Accident) in the Occurrence Code Block and give the date of the injury.

(5)

Liability:

(a)

Liability refers to insurance that provides payment based on legal liability for injuries or illness or damages to property. It includes, but is not limited to, automobile liability insurance, uninsured and underinsured motorist insurance, homeowners’ liability insurance, malpractice insurance, product liability insurance and general casualty insurance. It also includes payments under state “wrongful death” statutes that provide payment for medical damages;

(b)

The provider may bill the insurer for liability prior to billing the Division. The provider may not bill both the Division and the insurer;

(c)

The provider may bill the Division after receiving a payment denial from the insurer; however, the Division billing must be within 12 months of date of service. Payment accepted from Division is payment in full;

(d)

The provider may bill the Division without billing the liability insurer. However, payment accepted from the Division is payment in full. The payment made by the Division may not later be returned in order to pursue payment from the liability insurer. When the provider bills the Division, the provider agrees not to place any lien against the client’s liability settlement;

(e)

The provider has 12 months from the date of service to bill the Division. No payment will be made by Division under any circumstances once the one year limit has passed if no billing has been received within that time.

(6)

Adoption agreements. Adopting parents and/or an adoption agency may be considered a prior resource. In some instances, the Division makes reimbursement to hospitals and other providers for services provided to a mother whose baby is to be adopted. The Division may also make reimbursement for services provided to the infant. Some adoption agreements, however, stipulate that the adoptive parents will make payment for part or all of the medical costs for the mother and/or the child. In these instances, the adoptive parent(s) and/or agency are a third party resource and should be billed before billing the Division for this service.

(7)

Veteran’s Administration benefits:

(a)

Some clients have limited benefits through the Veterans’ Administration. Hospitals must bill the Veterans’ Administration for VA covered services before billing the Division;

(b)

The Veterans’ Administration requires notification within 72 hours of an emergency admission to a non-VA hospital.

(8)

Trust funds. Some individuals will have trust funds that will pay for medical expenses. Occasionally a special trust fund will be set up to pay for extraordinary medical expenses, such as a transplant. These, and other trusts which pay medical expenses, are considered a prior resource. Bill the trust fund prior to billing the Division for services that are covered by the trust fund.

(9)

Billing the client. A provider may bill the client or any financially responsible relative or representative of that individual only as allowed in OAR 410-120-1280 (Billing).

(10)

The hospital may not bill the client under the following circumstances:

(a)

For services which are covered by the Division;

(b)

For services for which the Division has made payment;

(c)

For services billed to the Division for which no payment is made because third party reimbursement exceeds the Division maximum allowed amount;

(d)

For any deductible, coinsurance or co-pay amount;

(e)

For services for which the Division has denied payment to the hospital as a result of one of the following:

(A)

The hospital failed to supply the correct information to the Division to allow processing of the claim in a timely manner as described in these rules and the General Rules;

(B)

The hospital failed to obtain prior authorization as described in these rules;

(C)

The service provided by the hospital was determined by or the Division not to be medically appropriate; or

(D)

The service provided by the hospital was determined by the QIO not to be medically appropriate, necessary, or reasonable.

Source: Rule 410-125-0640 — Third Party Payers — Other Resources, Client Responsibility and Liability, https://secure.­sos.­state.­or.­us/oard/view.­action?ruleNumber=410-125-0640.

410‑125‑0000
Determining When the Patient Has Medical Assistance
410‑125‑0020
Retroactive Eligibility
410‑125‑0030
Hospital Hold
410‑125‑0040
Title XIX/Title XXI Clients
410‑125‑0041
Non-Title XIX/XXI Clients
410‑125‑0045
Coverage and Limitations
410‑125‑0050
Client Copayments
410‑125‑0080
Inpatient Services
410‑125‑0085
Outpatient Services
410‑125‑0086
Prior Authorization for FCHP/MHO Clients
410‑125‑0090
Inpatient Rate Calculations — Type A, Type B, and Critical Access Oregon Hospitals
410‑125‑0095
Hospitals Providing Specialized Inpatient Services
410‑125‑0101
Hospital-Based Nursing Facilities and Medicaid Swing Beds
410‑125‑0102
Medically Needy Clients
410‑125‑0103
Medicare Clients
410‑125‑0115
Non-Contiguous Area Out-of-State Hospitals — Effective for services rendered on or after October 1, 2003
410‑125‑0120
Transportation To and From Medical Services
410‑125‑0121
Contiguous Area Out-of-State Hospitals — Effective for services rendered on or after October 1, 2003
410‑125‑0124
Retroactive Authorization
410‑125‑0125
Free-Standing Inpatient Psychiatric Facilities
410‑125‑0140
Prior Authorization Does Not Guarantee Payment
410‑125‑0141
DRG Rate Methodology
410‑125‑0142
Graduate Medical Education Reimbursement for Public Teaching Hospitals
410‑125‑0146
Supplemental Reimbursement for Public Academic Teaching University Medical Practitioners
410‑125‑0150
Disproportionate Share
410‑125‑0155
Upper Limits on Payment of Hospital Claims
410‑125‑0162
Hospital Transformation Performance Program
410‑125‑0165
Transfers and Reimbursement
410‑125‑0170
Death Occurring on Day of Admission
410‑125‑0175
Hospitals Providing Specialized Outpatient Services
410‑125‑0180
Public Rates
410‑125‑0181
Non-Contiguous and Contiguous Area Out-of-State Hospitals — Outpatient Services
410‑125‑0190
Outpatient Rate Calculations — Type A, Type B, and Critical Access Oregon Hospitals
410‑125‑0195
Outpatient Services In-State DRG Hospitals
410‑125‑0200
Time Limitation for Submission of Claims
410‑125‑0201
Independent ESRD Facilities
410‑125‑0210
Third Party Resources and Reimbursement
410‑125‑0220
Services Billed on the Electronic 837I or on the Paper UB-04 and Other Claim Forms
410‑125‑0221
Payment in Full
410‑125‑0230
Qualified Directed Payments
410‑125‑0360
Definitions and Billing Requirements
410‑125‑0400
Discharge
410‑125‑0401
Definitions: Emergent, Urgent, and Elective Admissions
410‑125‑0410
Readmission
410‑125‑0450
Provider Preventable Conditions
410‑125‑0550
X-Ray or EKG Procedures Furnished in Emergency Room
410‑125‑0600
Non-Contiguous Out-of-State Hospital Services
410‑125‑0620
Special Reports and Exams and Medical Records
410‑125‑0640
Third Party Payers — Other Resources, Client Responsibility and Liability
410‑125‑0641
Medicare
410‑125‑0720
Adjustment Requests
410‑125‑1020
Filing of Cost Statement
410‑125‑1040
Accounting and Record Keeping
410‑125‑1060
Fiscal Audits
410‑125‑1070
Type A and Type B Hospitals
410‑125‑1080
Documentation
410‑125‑2000
Access to Records
410‑125‑2020
Post Payment Review
410‑125‑2030
Recovery of Payments
410‑125‑2040
Provider Appeals — Administrative Review
410‑125‑2060
Provider Appeals — Hearing Request
410‑125‑2080
Administrative Errors
Last Updated

Jun. 8, 2021

Rule 410-125-0640’s source at or​.us