Or. Admin. Code § 410-120-1260 - Provider Enrollment
(1) This
rule applies to providers requesting enrollment, currently enrolled, and
previously enrolled with the Oregon Health Authority (Authority), Health
Systems Division (Division).
(2)
Providers signing the Provider Enrollment Agreement constitute agreement to
comply with all applicable Authority provider rules, Oregon Department of Human
Services (ODHS) provider rules, and federal and state laws and regulations
applicable to Medicaid payments.
(3) Authority review of a provider
application for enrollment, material change in a provider's enrollment
information, and any documentation received in response to an Authority
re-validation request is based on a categorical risk level of limited,
moderate, or high. If a provider falls within more than one risk level
described in 42 CFR
455.450, the highest level of review is
conducted by Authority. Authority will assign a risk level which meets or
exceeds federal requirement and reserves the right to adjust provider risk
level at any time when:
(a) Authority imposes
a payment suspension, in accordance with OAR
410-120-1400, on a provider
based on credible allegation of fraud, waste or abuse;
(b) The provider has an existing Medicaid
overpayment which, including all outstanding depts and interest, is $1,500 or
greater and all of the following:
(A) Is more
than 30 calendar days old;
(B) Has
not been repaid at the time the application for enrollment is filed;
(C) Is not currently being appealed;
and
(D) Is not part of an Authority
approved extended repayment schedule for the entire outstanding
overpayment.
(c) The
provider has been excluded by the Office of Inspector General (OIG) or another
state's Medicaid program within the previous 10 years; or
(d) Authority or CMS in the previous six (6)
months lifted a temporary moratorium for the particular provider type, in
compliance with 42 CFR
455.470 and
42 CFR
424.570, and a provider that was prevented
from enrolling based on the moratorium applies for enrollment as a provider at
any time within six (6) months from the date the moratorium was
lifted.
(4) Authority,
CMS, its agents, or its designated contractors may, in accordance with
42 CFR
455.432, conduct pre- and post-enrollment
on-site visits and unannounced inspections of any and all provider locations at
any time, for all provider types.
(5) Providers enrolled by the Authority
include:
(a) A non-billing provider, meaning a
provider who is issued a provider number for purposes of screening, data
collection or non-claims-use such as, but not limited to:
(A) Ordering or referring providers, required
by 42 CFR
455.410, whose only relationship with the
Authority is to order, refer, or prescribe services for Authority
members;
(B) A billing agent or
billing service submitting claims or providing other business services on
behalf of a provider but not receiving payment in the name of or on behalf of
the provider;
(C) An encounter only
provider contracted with and credentialed by a MCE, as required by OAR
410-141-3510.
(b) A payable provider, meaning a
provider who is issued a provider number for submitting health care claims for
reimbursement from the Authority. A payable provider may be:
(A) The rendering provider;
(B) An individual, agent, business,
corporation, clinic, group, institution, or other entity that in connection
with the submission of claims or encounters receives or directs the payment on
behalf of a rendering provider.
(6) When a payable provider is receiving or
directing payment on behalf of the rendering provider, the payable provider
must:
(a) Meet one of the following standards:
(A) Have a relationship with the rendering
provider described in 42 CFR
447.10(g) and have the
authority to submit the rendering provider enrollment application and
supporting documentation on behalf of the rendering provider; and
(B) Is a contracted billing agent or billing
service enrolled with the Oregon Health Authority to provide services with the
submission of claims and to receive or direct payment in the name of the
rendering provider pursuant to
42 CFR
447.10(f).
(b) Maintain and provide to the
Authority upon request records indicating the billing provider's relationship
with the rendering provider. This includes:
(A) Identifying all rendering providers for
whom they bill or receive or direct payments at the time of
enrollment;
(B) Notifying the
Authority within 30 days using Authority forms of a change to the rendering
provider's enrollment record such as name, date of birth, address, Authority
assigned provider numbers, National Provider Identification Numbers (NPI),
Social Security Number (SSN), or the Employer Identification Number (EIN);
and
(C) The authorization to direct
payment, signed by the rendering provider.
(c) Prior to submission of any claims or
receipt or direction of any payment from the Authority, obtain signed
confirmation from the rendering provider that the billing entity or provider is
authorized by the rendering provider to submit claims or receive or direct
payment on behalf of the rendering provider. This authorization, and any
limitations or termination of such authorization, must be signed by the
rendering provider and maintained in the provider's files for at least seven
(7) years following the submission of claims or receipt or direction of funds
from the Authority.
(7)
To facilitate timely claims and encounter processing and payment consistent
with applicable privacy and security requirements for providers:
(a) The Authority requires all non-billing
and payable providers to be enrolled consistent with the provider enrollment
process described in this rule;
(b)
If the provider uses electronic media to conduct transactions with the
Authority or authorizes a non-billing provider, e.g. billing service or billing
agent, to conduct such electronic transactions, the rendering provider must
comply with the Authority Electronic Data Interchange (EDI) rules, OAR
943-120-0100 through
943-120-0200. Enrollment as a
payable or non-billing provider is a necessary requirement for submitting
electronic claims, but the provider must also register as an EDI trading
partner and identify the EDI submitter in order to submit electronic claims;
and
(c) The claims and encounters
submitted to the Authority must include an NPI for each provider subject to the
NPI requirements in 45 CFR Part 162 Subpart D. Rendering and referring
providers may not have the same NPI listed on the claim or encounter. Billing
and rendering providers may not have the same NPI listed on the claim or
encounter.
(8) To be
enrolled and able to bill and receive payment as a provider, an individual or
organization must:
(a) Meet applicable
licensing and regulatory requirements set forth by federal and state statutes,
regulations, and rules. The provider's license must be active. Authority may
deny enrollment, re-enrollment or revalidation when a provider's licensing body
has placed limitations on the provider's license or an action that created a
limitation on the provider's license impacts the quality or safety of services
provided to OHP members. The Authority may request additional documentation
from the provider or the licensing body or require additional
screening.
(b) Comply with all
Oregon statutes and regulations for provision of Medicaid and CHIP services.
This includes meeting all applicable national and state licensure and
certification requirements for all employees, subcontractors, vendors or other
third parties providing services to Medicaid members for which the enrolled
provider is receiving reimbursement from Authority;
(c) If providing services within Oregon, 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; and
(d) Comply with all
requests from Oregon Department of Justice (DOJ) Medicaid Fraud Control Unit
(MFCU) for records and information when MFCU determines it is necessary to
carry out its responsibilities. The records and information must be provided
without charge and in the form requested by MFCU. A provider must comply with a
request from MFCU for access to any records and information kept by providers
to which OHA, ODHS, MCEs and MFCUs are authorized access by 42 CFR s431.107,
including, but not limited to, any records necessary to disclose the extent of
services provided to beneficiaries and any information regarding payments
claimed by the provider for furnishing said services. The records and
information must be provided without charge and in the form requested by MFCU.
When a MFCU request for access is made in person such access must be granted
immediately. A provider must make available to MFCU, copies of all procedural
and policy statements, directives, and proposed or adopted regulations
concerning the Medicaid program, and any other information relevant to the work
of MFCU. Providers shall disclose protected health care information to the MFCU
for oversight activities as authorized by 45 CFR s164.512(d).
(9) An Indian Health Service
facility meeting enrollment requirements shall be enrolled on the same basis as
any other qualified provider. However, when state licensure is normally
required, the facility need not obtain a license but must meet all applicable
standards for licensure.
(10) A
provider that is currently subject to sanction by the Authority or the
provider, a person with ownership or control of the provider, or a provider's
managing employee is excluded, sanctioned or suspended by the federal
government or another state from Medicare or Medicaid participation the
provider is not eligible for enrollment, consistent with OAR
410-120-1400, except when the
Agency determines good cause exists, in accordance with
42 CFR
455.23;
(11) All providers listed in section (5) of
this rule must provide the following information before the Authority may
enroll and issue or revalidate an Authority assigned provider number.
Information disclosed by the provider is subject to verification by Authority
and all providers must provide documentation at any time upon written request
by the Authority:
(a) The provider must
disclose to the Authority the name, federal Tax Identification Number (TIN),
date of birth, primary business address, every business location and P.O Box
address of the provider and, as applicable, for the following:
(A) Each person who has a direct or indirect
ownership or control interest in the provider, is an agent or is a managing
employee of the provider, regardless of whether that person is an individual or
corporate entity;
(B) Each person
who has a direct or indirect ownership or control interest in the provider, is
an agent or is a managing employee of the provider who has been convicted of a
criminal offense related to that person's involvement in any program under
Medicare, Medicaid, or the CHIP program in the last ten years;
(C) Any subcontractor in which the provider
has a direct or indirect ownership interest of five (5) percent or
more.
(D) For the purpose of this
rule, a person with direct or indirect ownership or control interest is defined
in 42 CFR
455.101 and Authority calculates ownership
and control percentage as required by
42 CFR
455.102.
(E) When disclosing tax identification
numbers:
(i) For corporations, use the
federal TIN;
(ii) For individuals
use the Social Security Number (SSN);
(iii) All other providers use the
EIN;
(iv) The SSN or EIN of the
rendering provider may not be the same as the Tax Identification Number of the
billing provider;
(v) Pursuant to
42 CFR
433.37, including federal tax laws at
26 USC
6041, SSN and EIN provided are used for the
administration of federal, state, and local tax laws and the administration of
this program for internal verification and administrative purposes including
but not limited to identifying the provider for payment and collection
activities.
(F) Whether
any of the persons so named with an ownership or control interest in the
provider requesting enrollment:
(i) Is
related to another person with ownership or controlling interest in the
provider requesting enrollment as a spouse, parent, child, sibling, or other
family members by marriage or otherwise; and
(ii) The name of any other current or former
Medicaid providers in which an owner of the provider requesting enrollment has
an ownership or control interest.
(G) A provider shall submit, within 35
calendar days of the date of a request by the Authority full and complete
information about:
(i) the ownership of any
subcontractor with whom the provider has had business transactions totaling
more than $25,000 during the 12-month period ending on the date of the request;
and
(ii) any significant business
transactions between the provider and any wholly owned supplier, or between the
provider and any subcontractor, during the five-year period ending on the date
of the request.
(H)
Failure to disclose or submit required information: Authority may not reimburse
a provider for services furnished in the period beginning the day following the
date the information was due to the Authority and ending on the day before the
date on which the information was supplied. Authority will suspend or terminate
the provider's enrollment and Authority assigned provider number, in accordance
with 42 CFR
455.104.
(b) The provider must submit required
information to the Authority:
(A) Provider
enrollment application based on the type of provider, Provider Enrollment
Agreement, Provider Disclosure Statement, and all Attachments. Authority only
accepts current versions of enrollment forms. All required forms are available
at all times on OHA's Provider Enrollment website;
(B) Application fee if required under
42 CFR
455.460;
(C) Consent to criminal background check to
complete Authority established screening process and comply with
42 CFR §
455.410 and §
455.450 requirements for provider
categories which pose increased financial risk of fraud, waste or abuse to the
Medicaid program, 42 CFR
§
455.434 when required;
(D) The Authority may use Medicare provider
enrollment data to satisfy the requirement of (11)(b)(C), in this rule;
and
(E) Copy of provider's license,
certification, or both.
(12) Authority may screen providers and
validate information disclosed by providers as required under
42 CFR
455.436. Authority reserves the right to
conduct and review providers requesting enrollment or revalidation in a more
stringent manner than Medicare or other state Medicaid programs, conduct
additional screening, or impose additional requirements on providers, or all
three, for a provider or a group of providers identified by the Authority as at
increased risk for fraud, waste or abuse.
(13) Authority may at its sole discretion
require providers to enroll as a Medicare provider prior to enrolling in
Oregon's Medicaid program.
(14)
Authority may implement 180-day moratoriums on the enrollment of providers in a
specific service category, on a statewide basis, or within a specific Oregon
geographic area, when the Authority determines the action is necessary to
safeguard public funds or to maintain the fiscal integrity of the Oregon
Medicaid program.
(15) Provider
enrollment and the signed Provider Enrollment Agreement expires five (5) years
from the date of enrollment. Authority will revalidate all enrolled providers
at least every five (5) years, compliant with
42 CFR §
455.414. Authority reserves the right to
revalidate more frequently, at its discretion. Failure of a provider to respond
to Authority notice or failure to return requested information for revalidation
will result in termination of the provider enrollment agreement and Authority
assigned provider number.
(16)
Enrolled providers shall notify the Authority in writing using Authority forms
within 35 calendar days of a material change in any status or condition that
relates to their qualifications or eligibility to provide medical assistance
services including, but not limited to, those listed in this subsection:
(a) Changes in federal TIN, SSN or EIN.
Failure to notify the Authority of a change of Federal TIN for entities or a
SSN, or EIN for individual providers may result in the imposition of a $50 fine
per incident:
(b) Changes in
business service location, affiliation, ownership, NPI, ownership and control
information, or criminal convictions. The provider must notify the Authority
using Agency provided forms;
(c)
Providers who have more than one (1) NPI or receive a new NPI after enrolling
with the Authority must complete a separate enrollment with the Authority for
each NPI prior rendering services or listing the NPI on claims or encounters
submitted to Authority.
(d)
Bankruptcy proceedings, the provider shall immediately notify the Authority
Provider Enrollment Unit in writing;
(e) Claims submitted by or payments made to
providers who have not furnished the notification required by this rule or to a
provider that fails to submit a new application as required by the Division
under this rule may be denied or recovered.
(17) If Authority notifies the provider of an
error in the federal TIN, the provider must supply the appropriate valid
federal TIN within 35 calendar days of the date of Authority's notice. Failure
to comply with this requirement may result in Authority imposing a fine of $50
for each such notice. Federal TIN requirements described in this rule refer to
any such requirements established by the Internal Revenue Service.
(18) Providers upon request may be enrolled
by Authority up to 12 months prior to the date application for enrollment is
received by the Authority only if:
(a) The
provider is appropriately licensed, certified, and otherwise meets all federal
and Authority requirements for providers at the time services are
provided;
(b) The MCE submits to
the Authority all required documentation to enroll the provider as an encounter
only provider and that provider has an executed contract with and has
successfully completed a credentialing process with the MCE;
(c) Upon request, the provider or MCE must
submit to Authority a clear written statement as to why retro-enrollment is
necessary to increase access to care and advance the triple aim.
(19) The Authority requires two
types of provider numbers:
(a) The Authority
issued Oregon Medicaid provider number which establishes an individual or
organization's enrollment as an Oregon Medicaid provider:
(A) The Provider Enrollment Agreement and the
provider's enrollment as an Oregon Medicaid provider is specific to the
provider type and specialty type listed on the application for enrollment and
constitutes a contractual relationship with the Authority. This Authority
assigned number designates the specific categories of services covered by the
Authority Provider Enrollment Agreement. For example, a pharmacy provider
number applies to pharmacy services and cannot be used by the provider provide
or bill for durable medical equipment.
(B) A provider seeking to render services or
bill as more than one provider type shall complete a separate provider
application and establish a separate Oregon Medicaid provider number;
(C) For providers not subject to NPI
requirements, this Authority issued number is the provider identifier for
billing the Authority.
(b) The Authority requires a National
Provider Identification (NPI) in compliance with 45 CFR Part 162 Subpart D, for
providers subject to NPI and Taxonomy requirements, as enumerated by the
National Plan and Provider Enumeration System (NPPES). A provider must obtain
an NPI and Taxonomy code prior to requesting enrollment and include these
numbers in the application to request enrollment. The NPPES NPI information and
provider applications are available at all times online:
https://nppes.cms.hhs.gov/#/.
For providers subject to NPI requirements:
(A)
The NPI is the provider identifier for billing the Authority. The Provider
Enrollment Agreement and the provider's enrollment as an Oregon Medicaid
provider is specific to the NPI listed on the application for enrollment and
constitutes a contractual relationship with the Authority;
(B) Providers currently enrolled that obtain
a new or additional NPI shall complete a new application for provider
enrollment with the Division's Provider Enrollment Unit and the application
must be approved by the Authority prior to the provider rendering or billing
for services associated with that NPI;
(20) Enrolled providers are required to check
the Prescription Drug Monitoring Program (PDMP) as defined in ORS 431A,655
before prescribing a schedule II-controlled substance pursuant to
42 U.S.C
1396w-3a.
(a) The PDMP check does not apply to clients
in exempt populations:
(A) Individuals
receiving hospice;
(B) Individuals
receiving palliative care;
(C)
Individuals receiving cancer treatment;
(D) Individuals with sickle cell disease;
and
(E) Residents of a long-term
care facility, of a facility described in
42 U.S.C.
1396d, or of another facility for which
frequently abused drugs are dispensed for residents through a contract with a
single pharmacy in accordance with
42 U.S.C.
1396w-3a(h)(2)(B);
and
(F) Individuals admitted to an
inpatient hospital facility. This exemption shall only apply to schedule II
controlled substances provided or administered to the individual admitted to
the inpatient hospital facility.
(21) Providers of services outside
of Oregon shall be enrolled as a provider if they comply with the requirements
in OAR 410-120-1260 and under the
following conditions:
(a) The provider is
appropriately licensed or certified in the state in which the provider is
located and meets standards for participation in the Medicaid program.
Disenrollment or sanction from other states' Medicaid programs or exclusion
from any other federal or state health care program is a basis for
disenrollment, termination, or suspension from participation as a provider in
Oregon's medical assistance programs;
(b) The provider bills only for services
provided within the provider's scope of licensure or certification;
(c) For noncontiguous out-of-state providers,
the services provided must be authorized in the manner required under OAR Ch
410 and Ch 309 rules specific to the service, OAR
410-120-1180 and these rule for
out-of-state services:
(A) The services
provided are for a specific Oregon Medicaid member who is temporarily outside
Oregon or the contiguous area of Oregon;
(B) Services provided are for foster care or
subsidized adoption children placed out of state; or
(C) The provider is seeking Medicare
deductible or coinsurance coverage for Oregon Qualified Medicare Beneficiaries
(QMB) members; or
(D) The services
for which the provider bills are covered services under the Oregon Health Plan
(OHP) and follow Authority requirements for prior authorization, when
applicable.
(d)
Facilities including but not restricted to hospitals, rehabilitative
facilities, institutions for care of individuals with mental retardation,
psychiatric hospitals, and residential care facilities shall be enrolled as
providers only if the facility is enrolled as a Medicaid provider in the state
in which the facility is located or is licensed as a facility provider of
services by Oregon;
(e)
Out-of-state providers may provide contracted services per OAR
410-120-1880; and
(f) Out-of-state entities seeking to enroll,
or enrolled, as a billing provider shall register with the Secretary of State
and the Department of Revenue to transact business in Oregon pursuant to ORS
63.701 and OAR
410-120-1260.
(g) The Authority shall enroll an
out-of-state noncontiguous pharmacy as a provider only when enrollment is
necessary to meet a need that cannot be met by an in-state pharmacy. The
pharmacy is required to be licensed in the state where the member filled the
prescription (i.e. state where medication is dispensed) and must be enrolled
with the Authority as a Medicaid provider in order to submit claims or
encounters to Authority. Identified needs include but are not limited to the
following:
(A) Enrollment is necessary to
reimburse an out-of-state pharmacy for services rendered to a member that
travels out of Oregon and is unable to use a pharmacy licensed in Oregon. The
out-of-state pharmacy must be licensed in the state where the services are
rendered;
(B) Enrollment is
necessary to ensure the Authority is the payer of last resort, OAR
410-120-1280, such as when a
member's TPL payer requires use of an out-of-state mail order
pharmacy;
(C) Enrollment is
necessary to ensure access to covered pharmacy services that are not otherwise
generally available either through the Authority's contracted mail order
pharmacy or through enrolled in-state pharmacies; or
(D) Enrollment is necessary to ensure access
to covered pharmacy services provided to members residing in a licensed
in-state facility, such as a long-term care facility. The out-of-state pharmacy
and the enrollment is limited to services provided to residents of the in-state
facility.
(22) Termination of provider enrollment and
the Authority assigned provider number:
(a)
The provider may terminate enrollment at any time. The request shall be in
writing and signed by the provider. The notice shall specify the Authority
assigned provider number to be terminated and the effective date of
termination. Termination or deactivation of the provider enrollment does not
terminate any obligations of the provider for dates of services during which
the enrollment was in effect;
(b)
The Authority may deny enrollment, revalidation, or re-enrollment, or sanction
and suspend or terminate a provider at any time including but not limited to
any of the reasons listed in OAR410-120-1400; and
(c) Authority will send written notice to the
provider when a provider's application for enrollment, revalidation or
re-enrollment is denied, enrollment is terminated or suspended, or a sanction
is imposed by Authority under OAR
410-120-1400, regardless of
whether the provider is continuously enrolled, or the provider number is active
at the time notice is issued. Authority notice will state the effective date of
the Action.
(23) A
provider may appeal a termination, suspension or other sanction. If a
provider's enrollment, revalidation, or re-enrollment is denied, enrollment is
suspended, terminated or any sanction is imposed by the Authority under this
rule, the provider may request a contested case hearing pursuant to OAR
410-120-1400,
410-120-1460,
410-120-1600 and
410-120-1860.
(24) If a provider's enrollment is suspended
or terminated, the Authority may notify board of registration or licensure,
federal or other state Medicaid agencies, MCEs and the National Practitioner
Data Base of the finding(s) and the sanction(s) imposed.
(25) If a provider's enrollment has been
deactivated, terminated or suspended for any reason the provider must complete
a new application for enrollment, including all required documentation, and
submit it to the Authority. To re-enroll the provider, Authority review is
contingent upon the risk-based screening in section (3) of this rule. A
re-enrollment by Authority has the same requirements and process as a new
enrollment.
(26) Authority may deny
enrollment, revalidation or re-enrollment request (for encounter purposes) to
an encounter only provider, or sanction and suspend or terminate an enrolled
encounter only provider, for any of the reasons in OAR
410-120-1400:
(a) Authority will notify the encounter only
provider and the MCE. Authority notice will state the effective date of the
Action;
(b) Authority may recoup
any overpayments in accordance with OAR Ch 410, Div. 120, CH 410 Div. 141, and
the contract between the MCE and the Authority; and
(c) The MCE must adjust encounter claims in
accordance with OAR 410-141-3570 and recoup
overpayments from the provider in accordance with OAR
410-141-3510.
(27) The provision of health care
services or items to Authority members is a voluntary action on the part of the
provider. Providers are not required to serve all Authority members seeking
service.
(28) Providers seeking to
enroll in the Authority must be a provider type established in the State Plan
as approved for Medicaid reimbursement.
Notes
Publications referenced are available from the agency.
Statutory/Other Authority: ORS 413.042, 414.615, 414.625, 414.635 & 414.651
Statutes/Other Implemented: ORS 414.610 - 414.685
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