OAR 410-133-0140
School Medical Provider Enrollment Provisions
(1)
This rule applies only to providers seeking reimbursement from the Division, except as otherwise provided in OAR 410-120-1295 (Non-Participating Provider).(2)
Only Educational Agency (EA) providers of SBHS that meet the criteria for the provision of special education programs approved by the State Superintendent of Public Instruction qualifying such programs for state reimbursement under OAR 581-015-2005 (Criteria for Approving School District Special Education Programs) will be enrolled with the Division as school medical (SM) providers allowed to seek reimbursement for the provision of covered health services pursuant to a Medicaid eligible child’s Individualized Education Program (IEP) or Individualized Family Service Plan (IFSP).(3)
The provider enrollment process will consist of: The completion and submission of the School Medical (SM) provider enrollment application and the required attachments, disclosure documents, and provider agreement with the Division of Medical Assistance Programs.(4)
An approved enrollment application by the Division or the Authority unit responsible for enrolling the SM provider is a contractual agreement that binds the SM provider to comply with the Authority administrative rules OAR 943-120-0300 (Definitions) through 943-120-0380, the Division General Rules 410-120-1260 (Provider Enrollment) and School-Based Health Services (SBHS) rules.(5)
Signing the SM provider agreement enclosed in the application package constitutes agreement by performing, and billing providers for provision of SBHS to comply with all applicable rules of the Medical Assistance Program and federal and state laws and regulations.(6)
An SM provider is a performing provider. A performing provider is the provider of a service or item. A billing provider is an individual, agent, business, corporation, clinic, group, institution, or other entity who in connection with the submission of claims to the Authority, receives or directs the payment (either in the name of the performing provider or the name of the billing provider) from the Authority, on behalf of a performing provider and has been delegated the authority to obligate or act on behalf of the performing provider (See OAR 410-120-1260 (Provider Enrollment)):(a)
A billing provider is responsible for identifying to the Division and keeping current the identification of all performing providers for whom they bill, or receive or direct payments. This identification must include the providers’ names, Authority provider numbers, NPIs, and either the performing provider’s Social Security Number (SSN) or Employer Identification Number (EIN). The SSN or EIN of the performing provider cannot be the same as the Tax Identification Number (TIN) of the billing provider. In order to facilitate timely claims processing and claims payment consistent with applicable privacy and security requirements, the Authority requires billing providers to be enrolled consistent with the provider enrollment process described in OAR 410-120-1260 (Provider Enrollment)(7);(b)
If the SM performing provider uses electronic media to conduct transactions with the Authority, or authorizes a billing provider to conduct such electronic transactions, the SM performing provider must comply with the Electronic Data Interchange (EDI). Enrollment as a SM performing provider or billing provider is a necessary requirement for submitting electronic claims, but the provider must also register as a trading partner and identify the EDI Submitter;(c)
A school medical (SM) performing provider that uses electronic media to conduct transaction with the Authority or authorizes a billing provider to conduct such electronic transactions, must comply with the electronic data interchange (EDI). Enrollment as an SM performing provider or billing provider is a necessary requirement for submitting electronic claims. If the SM provider intends to use an electronic data interchange (EDI) submitter, the SM performing provider must register with the Authority as a trading partner and shall complete the “Trading Partner Authorization of EDI Submitter” and the EDI submitter information required in the application in compliance with the trading partner requirements of identifying the authority of the EDI submitter to submit claims on its behalf. The EDI submitter must sign the EDI certification and meet other Authority EDI submission requirements pursuant to the EDI rules, before the Authority may accept an electronic submission from the EDI submitter on behalf of the performing provider. Information about the EDI transaction requirements is available on the Authority’s web site.(7)
To be enrolled and able to bill as an SM provider, an EA, must meet applicable licensing and regulatory requirements set forth by federal and state statutes, regulations, and rules and must comply with all Oregon statutes and regulations for provision of Medicaid and State Children’s Health Insurance program (SCHIP) services. In addition, all providers of services within the State of Oregon must have a valid Oregon business license if such a license is a requirement of the state, federal, county or city government to operate a business or to provide services.(8)
An EA, individual, or organization that is currently subject to sanction by the Medical Assistance Program or Federal government is not eligible for enrollment.(9)
The Authority requires compliance with the National Provider Identification (NPI) requirements in 45 CFR Part 142. Providers that obtain an NPI should update their records with the Division Provider Enrollment. Provider applicants that have been issued an NPI must include that NPI number with the Division provider enrollment application.(10)
A performing provider number will be issued to an EA providing covered health care services or items upon:(a)
Completion of the application and submission of the required School-Based Health Services SM Provider Attachment, disclosure documents, and provider agreement;(b)
The signing of the SM provider application by the authorized representative for the EA to bind the EA SM provider to compliance with these rules;(c)
Verification of licensing or certification. Loss of the appropriate licensure or certification or failure to meet the criteria for the provision of special education programs approved by the State Superintendent of Public Instruction qualifying such programs for state reimbursement under OAR 581-015-2005 (Criteria for Approving School District Special Education Programs) will result in immediate dis-enrollment of the provider and recovery of payments made subsequent to the loss of licensure or certification;(d)
Approval of the application and required documentation for an SM provider by the Division or the Division responsible for enrolling the provider.(11)
An SM performing provider may be enrolled retroactive to the date services were provided to a medical assistance client/child if:(a)
The SM provider met the criteria for the provision of special education programs approved by the State Superintendent of Public Instruction qualifying such programs for state reimbursement under OAR 581-015-2005 (Criteria for Approving School District Special Education Programs), was appropriately licensed, certified, and otherwise met all Medical Assistance Program requirements at the time services were provided; and(b)
Services were provided less than 12 months prior to the date of application for medical assistance provider status as evidenced by the first date stamped on the paper claims(s) submitted with application materials for those services either manually or electronically; or(c)
Extenuating circumstances existed outside the control of the EA SM provider consistent with federal Medicaid regulations, with approval of the Division’s Provider Services Unit Manager.(12)
Issuance of an Authority-assigned SM provider number establishes enrollment of an EA as a provider for limited categories of services for the Medical Assistance Program applicable to the provision of Medicaid covered School-Based Health Services (SBHS).(13)
An SM provider is required for providing and continuing to provide to the Authority accurate, complete and truthful information regarding their qualification for enrollment. The SM provider is responsible for notifying the Division in writing of a material change in any status or condition that relates to their qualifications or eligibility to provide SBHS including but not limited to change in any of the following information: changes address, business affiliation, licensure, ownership, certification, NPI, billing agents or Federal Tax Identification Number (TIN), change in status for meeting the criteria for the provision of special education programs approved by the State Superintendent of Public Instruction qualifying the EA’s programs for state reimbursement under OAR 581-015-2005 (Criteria for Approving School District Special Education Programs), if the SM provider or a person with an ownership or control interest, or an agent or managing employee of the SM provider has been convicted of a criminal offense related to that person’s involvement in any program under Medicare, Medicaid, or Title XX services program, the SM provider must notify the Division in writing within 30 calendar days of the change:(a)
Failure to notify the Division of a change of federal tax identification number (TIN) may result in the imposing of a $50 fine;(b)
Changes in business affiliation, ownership and control of information, criminal convictions, NPI, or federal tax identification number may require the submission of a new application;(c)
Payments made to providers who have not furnished such notification as required by this rule or to a provider that has failed to submit a new application as required by this rule and OAR 410-120-1260 (Provider Enrollment) may be denied or recovered.(14)
For information regarding enrollment of Billing Providers (BP) and issuance of an Authority assigned BP Provider ID in compliance with Provider Rules see OAR 943-120-0300 (Definitions) through 943-120-1505 (Audits and Overpayment Recovery), 410-120-1260 (Provider Enrollment) and 943-120-0100 (Definitions) through 943-120-0200 (Authority System Administration).(15)
Provider termination:(a)
The SM provider may terminate enrollment at any time. The request must be in writing, via certified mail, return receipt requested. The notice shall specify the provider number to be terminated and the effective date of termination. Termination of the SM provider enrollment does not terminate any obligations of the SM provider for dates of services during which the enrollment was in effect;(b)
The Division provider terminations or suspensions may be for, but are not limited to the following:(A)
Breaches of provider agreement;(B)
Failure to comply with the statutes, regulations and policies of the Authority, Federal and State regulations that are applicable to the provider;(C)
When no claims have been submitted in an 18-month period. The provider must reapply for enrollment.(16)
When one or more of the requirements governing a provider’s participation in the medical assistance program are no longer met, the provider’s medical assistance program provider number may be immediately suspended. The provider is entitled to a contested case hearing as outlined in 410-120-1600 (Provider Appeals — Contested Case Hearings) to determine whether the provider’s medical assistance program number will be revoked.
Source:
Rule 410-133-0140 — School Medical Provider Enrollment Provisions, https://secure.sos.state.or.us/oard/view.action?ruleNumber=410-133-0140.