OAR 410-141-3565
Managed Care Entity Billing
(1)
Providers shall submit all claims for MCE members in the following timeframes:(a)
Submit initial claims within no more than 120 days of the date of service for all cases, except as provided for in section (1)(b) of this rule. MCEs may negotiate terms within this timeframe agreeable to both parties;(b)
Submit initial claims within 365 days of the date of service in the following cases:(A)
Pregnancy;(B)
Eligibility issues such as retroactive deletions or retroactive enrollments;(C)
Medicare is the primary payer, except where the MCE is responsible for the Medicare reimbursement;(D)
Other cases that delay the initial claim to the MCE, not including failure of the provider to verify the member’s eligibility; or(E)
Third Party Liability (TPL). Pursuant to 42 CFR 136.61, subpart G: Indian Health Services and the amended Public Law 93-638 under the Memorandum of Agreement that Indian Health Service and 638 Tribal Facilities are the payers of last resort and are not considered an alternative liability or TPL.(c)
For initial claims submitted timely that need correction, have prompted a provider appeal as outlined in OAR 141-120-1560, or for a reason not included in (1)(b) of this rule that otherwise require a re-submission, MCEs shall establish a time-frame in their policies and procedures which allow a billing provider to make such re-submissions or appeals for a minimum of 180 days after the initial adjudication date.
Source:
Rule 410-141-3565 — Managed Care Entity Billing, https://secure.sos.state.or.us/oard/view.action?ruleNumber=410-141-3565
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