OAR 410-125-1060
Fiscal Audits


(1)

Year-end fiscal audits will include retrospective examination and verification of claims and the determination of allowable charges and costs of hospital services provided to Division clients.

(2)

The principal source document for the fiscal audit of Title XIX/Title XXI and General Assistance patient billings and payments for a given fiscal period is the Division’s data processing printout. This printout includes all transactions for the audit period. Using gross totals from this printout and applying other information from Division records, information received from the hospital, and other sources, the Division will compile detailed schedules of adjustments and revise the gross totals. A revised Calculation of Reasonable Cost Statement (DMAP 42) will be prepared using revised totals and information from the Medicare report.

(3)

Cost Settlements: The Division will send the hospital a letter stating the amount of underpayment or overpayment calculated by the Division for the fiscal year examined. The letter will also state the hospital’s inpatient/outpatient interim reimbursement rate for the period from the effective date of the change until the next fiscal year’s audit is completed. Payment of the cost-settlement amount is due and payable within 30 days from the date of the letter.

(4)

The Division, at its discretion, may grant a thirty-day (30) extension for the purpose of reviewing the cost settlement upon a written request by the hospital. If a thirty-day (30) extension is granted, payment of the cost settlement amount is due within sixty (60) days from the date of the letter. If the provider chooses to appeal the decision or rate, a written request for an administrative review, or contested case must be received by the Division within thirty (30) days of the date of the letter notifying the hospital of the settlement amount and interim rate, or within sixty (60) days if the Division has granted a thirty (30) day extension, not withstanding the time limits in OAR 410-120-1580 (Provider Appeals — Administrative Review)(3) or 410-120-1660(1). Upon receipt of the request, the Division will attempt to resolve any differences informally with the provider before scheduling the administrative review or hearing.

(5)

Under extraordinary circumstances, the Division, at its discretion, may negotiate a repayment schedule with a hospital. The hospital may be required to submit additional information to support the hospital’s request for a repayment schedule. The hospital will be required to pay interest associated with extended payments granted by the Division.

(6)

The revised Calculation of Reasonable Cost, copies of adjustment schedules, and a copy of the printout are available to the hospital upon request. For Type A rural hospitals the Calculation of Reasonable Cost Statement will reflect the difference between payment at 100% of costs and payment for dates-of-services on or after January 1, 2006 under the fee schedule for clinical laboratory services provided by the hospital. An adjustment to the Cost Settlement will be made to reimburse a Type A hospital at 100% of costs for laboratory and radiology services provided to Medical Assistance Program clients during the period the hospital was designated a Type A hospital. Settlements to Type B and Critical Access hospitals will be made within the legislative appropriation.

(7)

The adjusted Professional Component Cost-to-Charge ratio(s) will be applied to all corresponding revenue code charges as listed on the Hospital Claim Detail Reports for cost settlements finalized on or after October 1, 1999.

(8)

Hospital Based Rural Health Clinics shall be subject to the rules in the Hospital Services for the Oregon Health Plan Guide for Type A and B Hospitals. Hospital Based Rural Health Clinics cost settlements for dates of service from January 1, 2001 shall be finalized to cost.

(9)

No interim settlements will be made. No settlements will be made until after receipt and review of the audited Medicare cost report.
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 410-125-1060’s source at or​.us