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The Oregon Administrative Rules contain OARs filed through August 15, 2014
 
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OREGON HEALTH AUTHORITY,
PUBLIC HEALTH DIVISION

 

DIVISION 4

OREGON CONTRACEPTIVE CARE

333-004-0000

Description of OregonContraceptiveCare

OregonContraceptiveCare (CCare) is a Medicaid waiver demonstration project approved by the Centers for Medicare and Medicaid Services (CMS) to provide comprehensive contraceptive management services to eligible low-income Oregon residents statewide. OregonContraceptiveCare extends Medicaid coverage for contraceptive management services to Oregon residents with family incomes at or below 250 percent of the Federal Poverty Level (FPL) through a contract network of qualified agencies. The administrative rules set forth for this project apply only to agencies with an approved medical services agreement (MSA) to provide contraceptive management services through this project. Other reproductive health services and reimbursement covered by Medicaid are governed by the Oregon Health Authority, Division of Medical Assistance Program's administrative rules and federal guidelines.

Stat. Auth.: ORS 413.042
Stats. Implemented: ORS 413.032
Hist.: PH 4-2005, f. & cert. ef. 2-18-05; PH 5-2007, f. 4-9-07, cert. ef. 4-23-07; PH 19-2012, f. & cert. ef. 12-26-12

333-004-0010

Definitions

(1) “Acquisition cost” means the net amount paid per invoice line item to a pharmaceutical manufacturer, supplier or distributor for a contraceptive supply, plus any shipping and handling that is supported by the invoice.

(2) “Agency” means an entity enrolled by the Reproductive Health Program (RH) to provide CCare covered services at clinic site(s) to clients.

(3) “Authority” means the Oregon Health Authority.

(4) “CCare Eligibility Database” means the web-based database designed and managed by the Center for Prevention and Health Promotion (Center) for the statewide collection, tracking and storage of CCare client eligibility information.

(5) “Center” means the Center for Prevention and Health Promotion, within the Public Health Division of the Oregon Health Authority.

(6) “Citizenship verification” means confirming a client’s claim of U.S. citizenship through documentation of a certified birth record, passport or other document(s) deemed acceptable proof of U.S. citizenship verification by the federal government.

(7) “CLIA” means the Clinical Laboratory Improvement Amendments of 1988, which establishes quality standards for all laboratory testing to ensure the accuracy, reliability and timeliness of patient test results, and allows for certification of clinical laboratories operating in accordance with these federal amendments.

(8) “Client” means a person of any age or gender who is enrolled in and receives contraceptive management services from CCare.

(9) “Clinic” means a site within an agency that provides CCare billable services to eligible clients.

(10) “Clinic Visit Record” or “CVR” means the form or set of information that is completed for each client visit, and that is used as a data collection instrument and a billing claim form for CCare.

(11) “CMS” means the Centers for Medicare and Medicaid Services, located within the federal Department of Health and Human Services.

(12) “Contraceptive management” means a limited scope of reproductive health services as described in OAR 333-004-0040.

(13) “Established client,” for the purpose of mail ordered supplies, means a person who has been obtaining contraceptive services/supplies from the prescribing clinic for a minimum of three consecutive months.

(14) “FPL” means the federal poverty level guidelines established each year by the Department of Health and Human Services, used to determine eligibility for CCare other federally funded programs.

(15) “Individual” means a person who has applied for CCare, but has not yet been verified as eligible for services.

(16) "Lawful Permanent Resident" or “LPR” means a person who, notwithstanding other eligibility requirements, is a qualified non-citizen as described in OAR 461-120-0125(14).

(17) “Medical Services Agreement” or “MSA” means an agreement that sets forth the relationship between the Center and the enrolling agency regarding payment by the Center for contraceptive management services, supplies, or devices.

(18) “Nationally-recognized standard of care” means a diagnostic, screening, or treatment process recognized by a national organization, including but not limited to the American Cancer Society (ACS), American College of Obstetrics and Gynecologists (ACOG), U.S. Preventative Services Task Force (USPSTF), or the U.S. Medical Eligibility Criteria (USMEC).

(19) “OregonContraceptiveCare” or “CCare” means the Medicaid waiver program that provides statewide reproductive health services to eligible clients that is administered by the Reproductive Health Program within the Authority.

(20) “Project number” means the administrative number assigned by the RH to an agency.

(21) “Provider” means a licensed health care professional operating within a scope of practice, who works for an agency that is authorized by the Authority to bill for contraceptive management services for eligible CCare clients.

(22) “Refugee/Asylee” means a person admitted to the United States because of a well-founded fear of persecution in their homeland due to race, religion or political opinion, as determined by the United States Citizenship and Immigration Services.

(23) “Reproductive Health Program” or “RH” means the program within the Center for Prevention and Health Promotion that administers CCare.

(24) “Reproductive health services” means comprehensive family planning and related preventive health services provided to clients, including but not limited to:

(a) Patient education and counseling;

(b) Breast and pelvic examinations;

(c) Breast and cervical cancer screening;

(d) Sexually transmitted disease (STD) prevention education, counseling, testing and referral; and

(e) Pregnancy diagnosis and counseling.

(25) “RH program manual” means the reference guide provided by RH to agencies, outlining the scope and policies of the CCare program. This manual is available online by selecting “Program Manuals” at www.healthoregon.org/rhmaterials.

(26) “School-Based Health Center” means a health center certified by the School-Based Health Center Program located within the Center for Prevention and Health Promotion.

(27) "Site number" means the administrative number assigned by RH to each clinic within a participating CCare agency.

Stat. Auth.: ORS 413.042
Stats. Implemented: ORS 413.032
Hist.: PH 4-2005, f. & cert. ef. 2-18-05; PH 3-2007(Temp), f. 2-23-07, cert. ef. 4-1-07 thru 9-28-07; PH 5-2007, f. 4-9-07, cert. ef. 4-23-07; PH 2-2009, f. & cert. ef. 3-2-09; PH 10-2010, f. & cert. ef. 6-30-10; PH 5-2011(Temp), f. & cert. ef. 7-1-11 thru 12-27-11; PH 11-2011, f. & cert. ef. 10-27-11; PH 19-2012, f. & cert. ef. 12-26-12

333-004-0020

Client Eligibility

(1) In order to be eligible for CCare, an individual must:

(a) Have a household income and size at or below 250 percent of the FPL;

(b) Reside in Oregon;

(c) Not be sterile, have an unconfirmed sterilization status, or have been sterilized less than six months prior to eligibility determination;

(d) If female, be less than 60 years of age;

(e) Provide a valid Social Security Number (SSN) as required by 42 USC 1320b-7; and

(f) Be a citizen of the United States, with acceptable proof of citizenship verification and identity; or

(g) Meet the definition of Lawful Permanent Resident as described in OAR 333-004-0010; or

(h) Meet the definition of refugee/asylee as described in OAR 333-004-0010 and provide acceptable proof of refugee/asylee status.

(2) An individual who is in the custody of a law enforcement agency or is an inmate of a public institution, including a juvenile detention facility, is not eligible for CCare.

(3) An individual who receives or who is eligible for the Citizen/Alien-Waived Emergency Medical benefit package under Title XIX is not eligible for CCare.

(4) An individual enrolled in another Medicaid program that provides family planning benefits is not eligible for CCare.

(5) Eligibility for CCare does not constitute eligibility for any other medical assistance program. Eligibility for reproductive health services, including contraceptive management, as part of any other medical program is determined by the eligibility requirements for that specific program.

Stat. Auth.: ORS 413.042
Stats. Implemented: ORS 413.032
Hist.: PH 4-2005, f. & cert. ef. 2-18-05; PH 5-2007, f. 4-9-07, cert. ef. 4-23-07; PH 2-2009, f. & cert. ef. 3-2-09; PH 19-2012, f. & cert. ef. 12-26-12

333-004-0030

Client Enrollment

(1) An individual is considered eligible for CCare upon submission of the following items to the CCare agency:

(a) A signed, completed, and dated CCare enrollment form that includes SSN and appropriate residency and income information; applicants under age 20 can be enrolled based on their own income, whether living at home or on their own; and

(b) If the individual claims U.S. citizenship, acceptable proof of U.S. citizenship verification and identity.

(2) All CCare client eligibility information must be recorded in the CCare Eligibility Database by the enrolling CCare agency.

(3) Final determination of eligibility and enrollment into CCare is made by RH based on the information recorded in the CCare Eligibility Database.

(a) An individual’s enrollment in CCare shall be suspended by RH if it determines that the individual’s SSN is invalid or income is above the eligibility threshold.

(b) An individual shall have 45 days to submit a valid SSN and income information to the CCare agency or the individual’s enrollment in CCare shall be terminated by RH.

(4) An enrolling CCare agency must retain a current, signed enrollment form and a copy of any citizenship and identity documents provided by the client as described in OAR 333-004-0120(3).

(5) If a CCare agency enrolls an individual who is deemed ineligible by RH, the individual’s eligibility shall be terminated by RH.

(6) A client’s eligibility is effective for one year from the date of enrollment. The date of enrollment must be on or before the first date of service.

(7) CCare enrollment forms may not be backdated. An individual or enrolling agency that backdates a form shall be considered by RH to have committed fraud.

(8) An individual who meets all eligibility criteria apart from acceptable proof of U.S. citizenship verification may be granted by RH a reasonable opportunity period (ROP) of 45 days during which time the individual may receive services. An individual must have U.S. citizenship verified before he or she can be enrolled in CCare.

Stat. Auth.: ORS 413.042
Stats. Implemented: ORS 413.032
Hist.: PH 4-2005, f. & cert. ef. 2-18-05; PH 5-2007, f. 4-9-07, cert. ef. 4-23-07; PH 2-2009, f. & cert. ef. 3-2-09; PH 19-2012, f. & cert. ef. 12-26-12

333-004-0040

Covered Services

(1) CCare covers contraceptive management services that are a limited scope of reproductive health services directly related to initiating or obtaining a contraceptive method and maintaining effective use of that method. CCare agencies shall only be reimbursed for visits at which the primary service is contraceptive initiation or management, and not for excluded services described in OAR 333-004-0050.

(2) Contraceptive management services based on a nationally-recognized standard of care include:

(a) An annual exam payable once each year;

(b) Clinically indicated follow-up visits to evaluate effectiveness of a contraceptive method;

(c) Management of side effects related to a contraceptive method;

(d) Changing a contraceptive method if medically necessary or requested by the client;

(e) Reproductive health counseling and education; and

(f) Laboratory tests, medical procedures (including vasectomy), and pharmaceutical supplies and devices directly related to contraceptive management as documented in clinic protocol.

(3) Each client may receive up to a one-year supply of contraceptives from the CCare agency.

Stat. Auth.: ORS 413.042
Stats. Implemented: ORS 413.032
Hist.: PH 4-2005, f. & cert. ef. 2-18-05; PH 5-2007, f. 4-9-07, cert. ef. 4-23-07; PH 2-2009, f. & cert. ef. 3-2-09; PH 19-2012, f. & cert. ef. 12-26-12

333-004-0050

Excluded Services

(1) Services and laboratory tests not described in OAR 333-004-0040 are not covered by CCare for any eligible client. If a client accepts financial responsibility for a non-covered service that is received during a visit, payment arrangements are between the agency and the client.

(2) RH shall not pay for any expense incurred for any of the following services or items:

(a) Sterilizations for female clients;

(b) Treatment for infections;

(c) Prenatal care, including pregnancy confirmations;

(d) Repeat pap smears not associated with contraceptive management services;

(e) Hysterectomies or abortions;

(f) Transportation to or from a clinic appointment;

(g) Procedures performed for medical reasons, whether or not the procedure results in preventing or delaying pregnancy or restoring fertility;

(h) Any other medical service or laboratory test that is not described in OAR 333-004-0060(6) and whose primary purpose is other than contraceptive management; and

(i) A clinic visit that has the purpose of ensuring or reinforcing the client’s effective use of a contraceptive method and where no medical decision-making is required (behavior modification visit).

Stat. Auth.: ORS 413.042
Stats. Implemented: ORS 413.032
Hist.: PH 4-2005, f. & cert. ef. 2-18-05; PH 5-2007, f. 4-9-07, cert. ef. 4-23-07; PH 2-2009, f. & cert. ef. 3-2-09; PH 19-2012, f. & cert. ef. 12-26-12

333-004-0060

Standards of Care for Contraceptive Management Services

Participating CCare agencies shall provide contraceptive management services according to the following standards.

(1) Informed Consent. The client's decision to participate in and consent to receive contraceptive management services must be voluntary and without bias or coercion.

(a) The informed consent process, provided verbally and supplemented with written materials, must be presented in a language the client understands.

(b) A signed consent must be obtained from the client receiving contraceptive management services.

(c) A separate, signed contraceptive method-specific consent must be obtained from the client for each prescription contraceptive method received.

(2) Confidentiality. Services must be provided in a manner that respects the client’s privacy and dignity in accordance with OAR 333-004-0060(7)(b).

(a) Clients must be assured of the confidentiality of services and of their medical and legal records.

(b) Records cannot be released without written client consent, except as may be required by law, or otherwise permitted by the Health Insurance Portability and Accountability Act (HIPAA).

(3) Availability of Contraceptive Services. A broad range of Federal Drug Administration (FDA)-approved contraceptive methods and their applications, consistent with recognized medical practice standards, as well as fertility awareness methods must be available on-site at the clinic for dispensing to the client at the time of the visit.

(a) If the agency’s clinical staff lack the specialized skills to provide vasectomies, intra-uterine devices (IUDs) or subdermal contraceptives, or if there is insufficient volume to ensure and maintain high skill level for these procedures, clients must be referred to another qualified provider for these procedures.

(b) Clients shall be able to get their first choice of contraceptive method during their visits unless there are specific contraindications.

(c) Contraceptive methods, including emergency contraception, must be available at the clinic site and available to the client at the time of service, except as provided in OAR 333-004-0060(8)(a).

(4) Linguistic and Cultural Competence. All services, support and other assistance must be provided in a manner that is responsive to the beliefs, interpersonal styles, attitudes, language and behaviors of the client receiving services, and in a manner that has the greatest likelihood of ensuring maximum program participation.

(a) The agency shall employ bilingual or bicultural staff, personnel or volunteers skilled or certified in the provision of medical and clinical interpretation during all clinic encounters for clients with limited English proficiency or who otherwise need this level of assistance. All persons providing interpretation services must adhere to confidentiality guidelines.

(b) The agency must assure the competency of language assistance provided to limited English proficiency clients by interpreters and bilingual staff. Family and friends shall not be used to provide interpretation services, unless requested by the client.

(c) The agency must make interpretation services available to all clients needing or requesting such assistance at no cost to the client. The agency must notify clients in need of interpretation services of the availability of such services in accordance with the Civil Rights Act of 1964.

(d) The agency shall make easily understandable print materials available to clients and post signage in the languages of groups represented or commonly encountered in the service area.

(e) All print, electronic and audiovisual materials shall be appropriate in terms of the client's language and literacy level. A client's need for alternate formats must be accommodated.

(5) Access to Care. Services covered by CCare must be provided without cost to eligible clients. Clients must be informed of the scope of services available through the program.

(a) Appointments for established clients shall be available within a reasonable time period, generally less than two weeks. New clients who cannot be seen within this time period shall be referred to other qualified provider agencies in the area.

(b) Clinics with the appropriate license from the Oregon Board of Pharmacy may offer established clients the option of receiving their contraceptive methods by mail.

(A) Use of this option is at the discretion of the client; it cannot be offered as the only way in which to receive contraceptive methods.

(B) Contraceptive methods that require a written prescription may only be mailed to established clients who have been using the method(s) for at least three months, with no problems or contraindications.

(C) Non-prescription methods may be mailed to any established client, regardless of the client’s previous use of the method(s).

(D) Clients must not incur any cost for the option of receiving contraceptive methods through the mail.

(E) Clinics must package and mail supplies in a manner that ensures the integrity of contraceptive packaging and effectiveness of the method upon delivery.

(c) Although not covered by CCare, treatment and supplies for sexually transmitted infections must be available at the clinic site, or by referral.

(d) Clients in need of additional medical or psychosocial services beyond the scope of the agency must be provided with information about available local resources, including domestic violence and substance abuse related services. Clients must also be given a brochure listing locations of free or low-cost primary care services in the area.

(e) All services must be provided to eligible clients without regard to age, marital status, race, parity, disability, gender identity, or sexual orientation.

(f) All counseling and referral-to-care options appropriate to a positive or negative pregnancy test result during authorized contraceptive services must be provided in an unbiased manner, allowing the client full freedom of choice between prenatal care, adoption counseling or pregnancy termination services.

(6) Clinical and Preventive Services.

(a) The scope of contraceptive management services offered to women and female-bodied clients at each CCare clinic site must include:

(A) A comprehensive health history, including health risk behaviors and a complete obstetrical, gynecological, contraceptive, personal and family medical history; and a sexual health history, in conjunction with contraceptive counseling;

(B) An initial physical examination including cervical cancer screening as indicated, that follows a nationally-recognized standard of care.

(C) Routine laboratory tests related to the decision-making process for contraceptive choices;

(D) Provision of a broad range of FDA-approved contraceptive methods, devices, supplies, and procedures, including emergency contraception;

(E) Follow-up care for maintenance of a client's contraceptive method or for change of method;

(F) Information about providers available for meeting primary care needs and direct referral for needed medical services not covered by CCare, including management of high-risk conditions and specialty consultation if needed; and

(G) Preventive and control services for communicable diseases, provided within the context of a contraceptive management visit, including:

(i) Testing and diagnosis for sexually transmitted infections (STIs) as indicated; and

(ii) Reporting of STIs, as required, to appropriate public health agencies for contact management, prevention, and control.

(b) The scope of contraceptive management and clinical preventative services offered to men and male-bodied clients must include:

(A) A health history, including health risk behaviors and a sexual health history, in conjunction with contraceptive counseling and provision of contraceptive barrier methods;

(B) Vasectomy or referral for vasectomy, as appropriate;

(C) Vasectomy counseling, including a comprehensive health history that includes health risk behaviors and a complete contraceptive, personal and family medical history; and a sexual health history;

(D) Physical examination if indicated within the context of a contraceptive management visit;

(E) Information about providers available for meeting primary care needs and direct referral for needed medical services not covered by CCare, including management of high-risk conditions and specialty consultation if needed; and

(F) Preventive and control services for communicable diseases, provided within the context of a contraceptive management visit, including:

(i) Testing and diagnosis for sexually transmitted infections (STIs) as indicated; and

(ii) Reporting of sexually transmitted infections (STI), as required, to appropriate public health agencies for contact management, prevention, and control.

(c) All services must be documented in the client’s medical record.

(7) Education and Counseling Services. The following elements comprise the required education and counseling services that must be provided to all contraceptive management clients:

(a) Initial clinical assessment and re-assessment as needed, of the client's contraceptive management educational needs and knowledge about reproductive health, including:

(A) Counseling and education about a broad range of FDA-approved contraceptive methods, devices, supplies, and procedures, including emergency contraception;

(B) A description of services and clinic procedures;

(C) Relevant reproductive anatomy and physiology;

(D) Preventive health care, nutrition, preconception health maintenance, pregnancy plans, and STI and Human Immunodeficiency Virus (HIV) prevention;

(E) Psychosocial issues, such as partner relationship and communication, risk-taking, and decision-making; and

(F) An explanation of how to locate and access primary care services not covered by CCare.

(b) Initial and all subsequent education and counseling sessions must be provided in a way that is understandable to the client and conducted in a manner that respects the dignity and privacy of the client and facilitates the client's ability to make informed decisions about reproductive health behaviors and goals, and must include:

(A) An explanation of the results of the physical examination and the laboratory tests;

(B) Information on where to obtain 24-hour emergency care services;

(C) The option of including a client's partner in the education/counseling session, and other services at the client's discretion; and

(D) Effective educational information that takes into account diverse cultural and socioeconomic factors of the client and the psychosocial aspects of reproductive health.

(c) Each client must be provided with adequate information to make an informed choice about contraceptive management methods, including:

(A) A general verbal or written review of all FDA-approved contraceptive methods, including sterilizations and emergency contraception, along with the opportunity for the client to ask questions. Documentation of this method education must be maintained in the client record;

(B) A description of the implications and consequences of sterilization procedures, if provided;

(C) Specific instructions for care, use, and possible danger signs for the selected method. Documentation of method-specific information must be maintained in the client record;

(D) The opportunity for questions concerning procedures or methods; and

(E) Written information about how to obtain services for contraceptive management related complications or emergencies.

(d) Clinicians and other agency staff persons providing education and counseling must be knowledgeable about the psychosocial and medical aspects of reproductive health, and trained in client-centered counseling techniques. Agency staff must make referrals for more intensive counseling as indicated.

(8) Exceptions:

(a) School-Based Health Centers are exempt from the requirement to make contraceptive methods available for on-site dispensing described in section (3) and subsection (5)(b) of this rule. Because some school boards prohibit dispensing contraceptives on school grounds, School-Based Health Centers may offer contraceptive methods to clients either on-site or by referral. When offered by referral, School-Based Health Centers must have an established referral agreement in place, preferably with another CCare clinic. RH must be notified of the parties involved in order to ensure proper billing and audit practices. When the referral clinic participates in CCare, that clinic may submit claims directly to CCare for reimbursement of the dispensed supplies. When referral clinics do not participate in CCare, payment arrangements must be made between the referring and receiving clinics. Dispensing by any provider must not result in a charge to the client.

(b) Non-School-Based Health Center sites:

(A) Agencies may bill CCare for client counseling and education services conducted at a school site, grade 12 and under, if the site meets the following criteria:

(i) The school site must have no established School-Based Health Center;

(ii) The school site must be within a RH-approved distance from the enrolled CCare agency to ensure adequate access to client contraceptive method of choice; and

(iii) The school site must have a dedicated, private room(s) for services to be conducted.

(B) Agencies that wish to bill CCare for client counseling and education services conducted at secondary school sites must adhere to the following standards:

(i) The agency must notify RH of the school site to be enrolled and must request from RH a unique site number for the school site;

(ii) The agency must receive written approval from the school site to conduct services;

(iii) For newly enrolling clients, the agency must ensure that clients meet all eligibility criteria described in OAR 333-004-0020 and are enrolled according to 333-004-0030 at the school site;

(iv) For clients already enrolled in CCare, the agency must ensure that clients have active eligibility;

(v) The agency must follow all standards of care for contraceptive management services described in OAR 333-004-0060 with the exception of 333-004-0060(3) (supplies dispensed on-site) and 333-004-0060(6) (clinical and preventive services);

(vi) The agency must offer clients a written referral to the enrolled CCare clinic for supply pick-up and full array of clinical services; and

(vii) The agency must submit claims for services conducted at the school site using the assigned project and site number of the school site.

Stat. Auth.: ORS 413.042
Stats. Implemented: ORS 413.032
Hist.: PH 4-2005, f. & cert. ef. 2-18-05; PH 5-2007, f. 4-9-07, cert. ef. 4-23-07; PH 2-2009, f. & cert. ef. 3-2-09; PH 10-2010, f. & cert. ef. 6-30-10; PH 19-2012, f. & cert. ef. 12-26-12

333-004-0070

Provider Enrollment

(1) An agency and its providers must meet applicable licensing or regulatory requirements set forth by federal and state statutes, regulations, and rules to be enrolled and to bill as an agency. In addition, all agencies and its providers 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.

(2) Signing a MSA constitutes agreement by agencies to comply with all applicable rules of RH, the Division of Medical Assistance Programs, and federal and state laws and regulations.

(3) Signing a MSA constitutes agreement by agencies to serve both CCare and Oregon Health Plan covered clients.

(4) An agency or any of its providers that are currently subject to sanctions by the Authority or the federal government is not eligible for enrollment as a CCare agency.

(5) A CCare project number and site number shall be issued to an agency and any applicable clinics upon:

(a) Completion of the MSA and submission of the required documents;

(b) The signing of the MSA and related forms by the person authorized by the agency to bind the agency and its providers to compliance with these rules;

(c) Verification of licensing or certification; and

(d) Approval of the application by RH and the Division of Medical Assistance Programs.

(6) An agency must notify RH within 30 days of a change in address, business affiliation, licensure, ownership, certification, billing agents or Federal Tax Identification Number (TIN). Failure to notify RH of a change of Federal Tax Identification Number may result in a sanction. Changes in business affiliation, ownership, and Federal Tax Identification Number may require the submission of a new application. In the event of bankruptcy proceedings, the agency must immediately notify RH in writing. RH may recover payments made to agencies who have not notified RH of changes as required by this section.

(7) Agencies outside the state of Oregon may be enrolled under the following conditions:

(a) The agency is appropriately licensed or certified and meets standards established within the provider's state for participation in Medicaid; and

(b) The agency is located in a state contiguous to Oregon, and is within 75 miles of the Oregon border.

(8) Agency termination:

(a) An agency may terminate enrollment at any time. The notice must be made to RH 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 agency enrollment does not terminate any obligations of the agency for dates of services during which the enrollment was in effect.

(b) RH may terminate CCare agency enrollment due to inactivity. After 12 months of no claims activity, agencies may be contacted by RH with a written notice by certified mail, return-receipt requested, regarding inactivity and pending termination of agency enrollment. The notice shall specify the effective date of termination unless the agency notifies RH within 30 days upon receipt of notice of intention to resume claims activity.

(9) Agency responsibilities:

(a) An agency performs all services, or provides all items, as an independent contractor. The agency is not an officer, employee, or agent of RH.

(b) The agency is responsible for its employees, and for providing employment-related benefits and deductions that are required by law. The agency is solely responsible for its acts or omissions, including the acts or omissions of its own officers, employees or agents. RH’s responsibility is limited to its authorization and payment obligations for covered services or items provided in accordance with OAR 333-004-0000 through 333-004-0230.

Stat. Auth.: ORS 413.042
Stats. Implemented: ORS 413.032
Hist.: PH 4-2005, f. & cert. ef. 2-18-05; PH 5-2007, f. 4-9-07, cert. ef. 4-23-07; PH 2-2009, f. & cert. ef. 3-2-09; PH 10-2010, f. & cert. ef. 6-30-10; PH 19-2012, f. & cert. ef. 12-26-12

333-004-0080

Billing and Claims

(1) Only clinics providing contraceptive management services pursuant to an approved MSA, and who have been assigned a project number and site number may submit claims for CCare services.

(2) An agency may bill for contraceptive management services by submitting CVR data or by submitting the CVR form to RH. A claim is considered valid only if all required data are submitted.

(3) An agency may bill RH for supplies through the CVR at actual acquisition cost; that is, the amount or unit cost of the contraceptive supply the agency actually pays to the pharmaceutical manufacturer, supplier or distributor for the contraceptive supplies, after applying any discounts, promotions or other reductions. Shipping and handling may be included in the acquisition cost only if supported by an invoice.

(4) An agency shall include a primary diagnosis code on all claims. All billings must be coded with the most recent and appropriate International Classification of Diseases. All billings must be coded with the diagnosis codes in the V25 Contraceptive Management series to the highest level of specificity. No other primary diagnosis code can be billed.

(5) An agency may bill RH for laboratory services related to contraceptive management through a fixed rate that includes clinical and laboratory services. The exception to this is the combined gonorrhea/Chlamydia (GC/CT) test occurring in the context of a CCare contraceptive initiation management visit. The combined GC/CT test shall be reimbursed separately from the fixed rate only if the appropriate medical service is indicated on the CVR.

(6) Birth control supplies billable to CCare must be approved by the Authority, be FDA approved, and may include intrauterine devices, cervical caps, oral contraceptives, subdermal implants, condoms, diaphragms, spermicides, patches, rings, injectibles, and emergency contraception.

(7) An agency must ensure that all laboratory tests done at the clinic site or by an outside clinic are conducted by CLIA certified laboratories.

(8) An agency enrolled with CCare must not seek payment from an eligible client, or from a financially responsible relative or representative of that client, for any services covered by CCare. The agency shall accept RH reimbursement for any CCare-covered services, pharmaceuticals, devices, or supplies as payment in full.

(a) If an agency has misrepresented client eligibility for services, the agency must assume responsibility for the full cost of services provided.

(b) A client may be billed for services that are not covered by CCare as outlined in the CCare enrollment form.

(9) Upon submission of a claim to RH for payment, the agency attests that it has complied with all rules of CCare.

(a) Except for services performed by a CLIA certified laboratory outside of the clinic, all billings must be for services provided within the agency and its provider’s licensure or certification.

(b) It is the responsibility of an agency to submit true and accurate information when billing CCare.

(c) A claim may not be submitted prior to providing services.

(10) No agency shall submit to RH:

(a) Any false claim for payment;

(b) Any claim altered in such a way as to result in a payment for a service that has already been paid; or

(c) Any claim upon which payment has been made by another source unless the amount paid is clearly entered on the claim form.

(11) An agency is required to correct the billing error or to refund the amount of the overpayment, on any claim where the agency identifies an overpayment made by RH.

(12) An agency that, after having been previously warned in writing by the Authority or the Department of Justice regarding findings of improper billing practices as described in OAR 333-004-0140, is found to have continued such improper billing practices and has had an opportunity for a contested case hearing, shall be liable to RH for up to triple the amount of the established overpayment received as a result of such violation.

(13) Third Party Resources. The following subsections apply only to clients with private insurance coverage.

(a) Federal law requires that all reasonable efforts be taken to ensure that CCare is the payor of last resort, unless a client requests special confidentiality which must be documented on the CCare enrollment form. A client’s request for special confidentiality ensures that the agency must not bill third party resources, but instead must bill CCare directly.

(b) An agency must make reasonable efforts to obtain payment from other resources before billing CCare. For the purposes of this rule "reasonable efforts" include:

(A) Determining the existence of insurance or other resource by asking the client.

(B) When third party coverage is known to the agency, prior to billing CCare:

(i) The agency must bill the third party resource; and

(ii) Resubmit a denied claim when the service is payable in whole or in part by an insurer.

(c) If the client has private insurance that has been billed for CCare services and the reimbursement from the insurance does not cover the entire cost of the services, the balance may be billed to CCare.

(d) An agency must report the reimbursement received from insurance, including both services and supplies, on box 17A, 2 of the CVR. The exact amount received from the insurance company must be reported in total.

(e) The CCare payment to the agency after the agency has received third party payment may not exceed the total of what CCare would pay for both services and supplies. The total amount of service and supply minus the amount paid by the primary insurance is the amount the agency shall be reimbursed.

(f) If third-party payment is received after CCare has been billed, agencies are required to submit a billing correction showing the amount of the third party payment or to refund the amount received from another source within 30 days of the date the payment is received. Failure to submit a billing correction within 30 days of receipt of the third party payment or to refund the appropriate amount within this time frame is considered concealment of material facts and grounds for recovery or sanction.

Stat. Auth.: ORS 413.042
Stats. Implemented: ORS 413.032
Hist.: PH 4-2005, f. & cert. ef. 2-18-05; PH 3-2007(Temp), f. 2-23-07, cert. ef. 4-1-07 thru 9-28-07; PH 5-2007, f. 4-9-07, cert. ef. 4-23-07; PH 2-2009, f. & cert. ef. 3-2-09; PH 19-2012, f. & cert. ef. 12-26-12

333-004-0100

Timely Submission of Claims

(1) CCare claims are processed once a month, on or near the 15th of the month. To be included in a given month’s processing, an agency must submit a claim to RH and RH must receive the claim by the Thursday before the 15th of each month.

(2) RH shall pay CCare claims within 12 months of the date of service. Claims submitted more than 12 months after the date of service shall be rejected.

(3) Errors causing rejection of any claim must be resolved by the agency within 12 months of the date of service. Claims older than 12 months submitted by the agency to RH shall not be paid, except when RH has made an error that caused the agency not to be able to bill within 12 months of the date of service. The error must be confirmed by RH before the claim shall be paid.

(4) Client data not related to payment of the claim may be corrected by the agency at any time after the date of service.

Stat. Auth.: ORS 413.042
Stats. Implemented: ORS 413.032
Hist.: PH 4-2005, f. & cert. ef. 2-18-05; PH 5-2007, f. 4-9-07, cert. ef. 4-23-07; PH 2-2009, f. & cert. ef. 3-2-09; PH 19-2012, f. & cert. ef. 12-26-12

333-004-0110

Payment

(1) RH shall make payment only to an enrolled agency that actually performs the services for eligible clients.

(2) The reimbursement rates for CCare visits are set by RH and are available online at www.healthoregon.org/rhmaterials by selecting “Program Manuals,” and then selecting “Section C, Exhibit 8.” Claims are reimbursed at the rates in effect on the date of service.

(3) Contraceptive pharmaceuticals, devices and supplies are separately reimbursed at acquisition cost as described in OAR 333-004-0080(3), up to a set maximum amount, and are available online at www.healthoregon.org/rhmaterials by selecting “Program Manuals,” and then selecting “Section C, Exhibit 8.”

(4) The combined gonorrhea/Chlamydia test is reimbursed separately from the visit.

(5) RH may not make payment on claims that have been assigned, sold, or otherwise transferred, or on which an agency of billing services receives a percentage of the amount billed or payment authorized. This includes, but is not limited to, transfer to a collection agency or party who advances money to an agency for accounts receivable.

(6) RH shall only pay for services that are adequately documented and for contraceptive supply costs that are supported by invoice.

Stat. Auth.: ORS 413.042
Stats. Implemented: ORS 413.032
Hist.: PH 4-2005, f. & cert. ef. 2-18-05; PH 3-2007(Temp), f. 2-23-07, cert. ef. 4-1-07 thru 9-28-07; PH 5-2007, f. 4-9-07, cert. ef. 4-23-07; PH 2-2009, f. & cert. ef. 3-2-09; PH 19-2012, f. & cert. ef. 12-26-12

333-004-0120

Requirements for Financial, Clinical and Other Records

(1) RH is responsible for analyzing and monitoring the operation of CCare and for auditing and verifying the accuracy and appropriateness of payment, utilization of services, the quality of care, and access to care. An agency shall:

(a) Develop and maintain adequate financial and clinical records and other documentation that supports the services for which payment has been requested.

(b) Document the service provided, primary diagnosis code for the services, the date on which the service was provided, and the agency staff who provided the services in every medical record. Client account and financial records must also include documentation of charges, identification of other payment resources pursued, the date and amount of all debit or credit billing actions, and support the appropriateness of the amount billed and paid. The records must be accurate and in sufficient detail to substantiate the data reported.

(c) Sufficiently document that the client's purpose of visit was primarily for contraceptive management services. The client's record must be annotated each time a service is provided and signed or initialed by the agency staff that provided the service or must clearly indicate the agency staff that provided the service. Information contained in the record must meet the standards of care for contraceptive management services as described in OAR 333-004-0060, and must be appropriate in quality and quantity to meet the professional standards applicable to the provider and any additional standards for documentation found in this rule.

(2) An agency must have policies and procedures to ensure the maintenance of the confidentiality of medical record information. These procedures must ensure that the agency may release such information in accordance with federal and state statutes, including but not limited to ORS 179.505 through 179.507, 413.175, 42 CFR part 2, if applicable, 42 CFR subpart F, and ORS 433.045 with respect to HIV test information.

(3) An agency must retain clinical records for seven years and financial and other records described in this rule for at least five years from the date of service. Original enrollment records must be retained for seven years.

(4) Upon written request from RH, the Division of Medical Assistance Programs, the Authority, the Oregon Department of Justice Medicaid Fraud Unit, the Oregon Secretary of State or their authorized representatives (requestor), an agency must furnish requested documentation, without charge, immediately or within the time-frame specified in the written request.

(5) If an agency fails to comply with requests for records within the specified timeframes it may result in the Authority deeming those records not to exist for purposes of verifying appropriateness of payment, medical appropriateness, the quality of care, and the access to care in an audit or overpayment determination, and accordingly subjects the agency to possible denial or recovery of payments made by the Authority, or to sanctions.

(6) The agency, and any officers, employees, agents, and subcontractors of the agency shall comply with the following requirements for the CCare Eligibility Database:

(a) Implement security measures that reasonably and appropriately provide administrative, physical and technical safeguards that protect the confidentiality, integrity and availability of the CCare Eligibility Database. The agency’s security measures must be documented in writing and be available for review by RH upon request. RH review of the reasonableness of security measures, as well as the agency’s compliance with RH assigned access control or security requirements, shall take into account the agency’s physical, administrative, and technical capabilities related to security measures and the potential risk of unauthorized use or disclosure of the CCare Eligibility Database by the agency, its officers, employees, agents or subcontractors;

(b) Prevent any unauthorized access to or disclosure of information from the CCare Eligibility Database;

(c) Take necessary actions to comply with RH determinations of the level of access that may be granted, as well as changes in level of access, or suspension or termination of access as determined by RH;

(d) Keep any RH-assigned access control requirements such as identification of authorized user(s) and access-control information in a secure location until access is terminated; monitor and securely maintain access by the agency and its agents or subcontractors in accordance with security requirements or access controls assigned by RH; and make available to RH upon request all information about the agency’s use or application of the CCare Eligibility Database.

(e) Report any privacy or security incidents by the agency, its officers, employees, agents or subcontractors that compromise, damage, or cause a loss of protection to the CCare Eligibility Database, as follows:

(A) Report to RH in writing within five business days of the date on which the agency becomes aware of such incident; and

(B) Provide RH the results of the incident assessment findings and resolution strategies.

(7) The agency must comply with RH requests for corrective action concerning a privacy or security incident, and with laws requiring mitigation of harm caused by the unauthorized use or disclosure of confidential information, if any.

(8) If RH determines that the agency’s security measures or actions required under section (7) of this rule are inadequate to address the security requirements, RH shall notify the agency. RH and the agency may meet to discuss appropriate security measures or action. If security measures or corrective actions acceptable to RH cannot be agreed upon, RH reserves the right to take such actions as it determines appropriate under the circumstances. Actions may include, but are not limited to, restricting access, or amending or terminating the agency agreement.

(9) RH reserves the right to request additional information from the agency related to security measures, and to change, suspend or terminate access to or use of the CCare Eligibility Database by the agency, its officers, employees, agents or subcontractors.

(10) Wrongful use or disclosure of the CCare Eligibility Database by the agency, officers, its employees, agents or its subcontractors may cause the immediate suspension or revocation of any access granted, in the sole discretion of RH. RH may also pursue any other legal remedies provided under the law.

Stat. Auth.: ORS 413.042
Stats. Implemented: ORS 413.032
Hist.: PH 4-2005, f. & cert. ef. 2-18-05; PH 5-2007, f. 4-9-07, cert. ef. 4-23-07; PH 2-2009, f. & cert. ef. 3-2-09; PH 19-2012, f. & cert. ef. 12-26-12

333-004-0130

Compliance with Federal and State Statutes

(1) Submission of a claim for medical services or supplies provided to a CCare client shall be deemed a representation by the agency to RH of the agency’s compliance with the applicable sections of the federal and state statutes referenced in this rule:

(a) 45 CFR Part 84 that implements Title V, Section 504 of the Rehabilitation Act of 1973;

(b) Title II and Title III of the Americans with Disabilities Act of 1991;

(c) Title VI of the Civil Rights Act of 1964; and

(d) 42 CFR Part 493 Laboratory Requirements and ORS Chapter 438 (Clinical Laboratories).

(2) Agencies are required to comply with the "Health Insurance Portability and Accountability Act" (HIPAA) regarding the confidentiality of client records.

(3) Providers described in ORS Chapter 419B are required to report suspected child abuse to their local child welfare office of the Department of Human Services or police, in the manner described in ORS Chapter 419B.

(4) The Clinical Laboratory Improvement Act (CLIA), requires all entities that perform even one laboratory test, including waived tests on, "materials derived from the human body for the purpose of providing information for the diagnosis, prevention or treatment of any disease or impairment of, or the assessment of the health of, human beings" to meet certain federal requirements. If an entity performs tests for these purposes, it is considered under CLIA to be a laboratory.

(5) Clinics that dispense contraceptive methods on-site must be licensed by the Oregon Board of Pharmacy as described in OAR 855-043-0001 through 855-043-0310.

Stat. Auth.: ORS 413.042
Stats. Implemented: ORS 413.032
Hist.: PH 4-2005, f. & cert. ef. 2-18-05; PH 5-2007, f. 4-9-07, cert. ef. 4-23-07; PH 19-2012, f. & cert. ef. 12-26-12

333-004-0140

Review or Audit of Claims

(1) RH staff, contractor or auditor may review a claim for assurance that the specific medical service or contraceptive device or supply was provided by an agency in accordance with OAR 333-004-0000 through 333-004-0230 and the Standards of Care for Contraceptive Management Services set forth in 333-004-0060.

(2) To determine the number of inappropriate claims, and subsequently the overpayment amount, RH may review a statistically valid random sample of claims with sufficient sample size for a confidence interval of 95 percent.

(3) RH may deny payment or seek recovery or payment if a review or audit determines the service does not meet RH rules or the Standards of Care for Contraceptive Management Services set forth in OAR 333-004-0060.

(4) RH shall notify the agency, in writing, of the improper billing findings and subsequent actions to be taken by the agency to correct the identified findings and any sanctions that may be imposed by RH.

Stat. Auth.: ORS 413.042
Stats. Implemented: ORS 413.042
Hist.: PH 4-2005, f. & cert. ef. 2-18-05; PH 5-2007, f. 4-9-07, cert. ef. 4-23-07; PH 2-2009, f. & cert. ef. 3-2-09; PH 19-2012, f. & cert. ef. 12-26-12

333-004-0150

Recovery of Overpayments to Providers Resulting from Review or Audit

(1) When RH determines that an overpayment has been made to an agency, the amount of overpayment is subject to recovery.

(a) If RH determines an overpayment amount by the random sampling method set forth in OAR 333-004-0140(2), an agency may request a 100 percent audit of all billings submitted to CCare for contraceptive management services provided during the period in question.

(b) If an agency requests a 100 percent audit:

(A) The agency is responsible for payment and arrangement; and

(B) The audit must be conducted by a certified public accountant who is knowledgeable with the Oregon Administrative Rules covering the payments in question, and must be conducted within 120 calendar days of the request to use such audit in lieu of RH's random sample.

(2) The amount of the review or audit overpayment to be recovered:

(a) Is the entire amount determined by RH or the amount agreed to by RH and the agency;

(b) Is not limited to amounts determined by criminal or civil proceedings; and

(c) Includes interest charged at allowable state rates.

(3) RH shall deliver to an agency by registered or certified mail or in person a request for repayment of the overpayment and the documentation to support the overpayment amount.

(4) The overpayment is due and payable 30 calendar days from the date of the decision by RH:

(a) An agency may request an additional 30-day grace period from RH.

(b) A request for a hearing does not change the date the repayment of the overpayment is due.

(5) RH may extend the reimbursement period for an agency or accept an offer of repayment terms from an agency. Any change in reimbursement period or terms must be made in writing by the RH.

(6) If the agency refuses to reimburse the overpayment or does not adhere to an agreed upon payment schedule, RH may:

(a) Recoup future agency payments up to the amount of the overpayment;

(b) Suspend or terminate the agency’s enrollment in CCare; or

(c) Pursue civil action to recover the overpayment.

(7) RH may, at any time, change the amount of the overpayment upon receipt of additional information. RH shall notify an agency in writing of any changes. Any monies paid to RH by an agency that exceed an overpayment shall be refunded to the agency.

(8) If an agency is terminated or sanctioned for any reason, RH may pursue civil action to recover any amounts due and payable to CCare.

Stat. Auth.: ORS 413.042
Stats. Implemented: ORS 413.032
Hist.: PH 4-2005, f. & cert. ef. 2-18-05; PH 5-2007, f. 4-9-07, cert. ef. 4-23-07; PH 2-2009, f. & cert. ef. 3-2-09; PH 19-2012, f. & cert. ef. 12-26-12

333-004-0160

Provider Sanctions

The following are conditions that may result in the imposition of a sanction on an agency.

(1) Basis for sanction:

(a) Conviction of a provider of a felony or misdemeanor related to a crime or violation of Title XVIII, XIX, or XX of the Social Security Act or related state laws (or entered a plea of nolo contendere);

(b) Conviction of fraud related to any federal, state, or locally financed health care program or commission of an act that is subject to criminal or civil penalties under Medicaid statutes;

(c) Conviction of interference with the investigation of health care fraud;

(d) Conviction of unlawfully manufacturing, distributing, prescribing, or dispensing a controlled substance;

(e) Failure to comply with the state and federal statutory requirements set forth in OAR 333-004-0130;

(f) An action by a state licensing authority relating to a provider's professional competence, professional conduct, or financial integrity, that results in the provider either:

(A) Having his or her license suspended or revoked; or

(B) Surrendering the license while a formal disciplinary proceeding was pending before a licensing authority.

(g) Suspension or exclusion from participation in a federal or state-administered health care program for reasons related to professional competence, professional performance, or other reason;

(h) Improper billing practices, including billing for excessive charges or visits, furnishing items or services substantially in excess of the patient's contraceptive management needs, or of a quality that fails to meet professionally recognized standards;

(i) Failure to furnish services as required by law or contract with the RH;

(j) Failure to supply requested information on subcontractors and suppliers of goods or services;

(k) Failure to supply requested payment information;

(l) Failure to grant access or to furnish as requested, records, or to grant access to facilities upon request of RH or a designated requestor;

(m) Receiving payments for services provided to persons who were not eligible;

(n) Establishing multiple claims using procedure codes that overstate or misrepresent the level, amount or type of health care provided;

(o) Failure to develop, maintain, and retain in accordance with relevant rules and standards adequate clinical or other records that document the medical appropriateness, nature, and extent of the health care provided;

(p) Failure to develop, maintain, and retain in accordance with relevant rules and standards adequate financial records that document charges incurred by a client and payments received from any source;

(q) Failure to follow generally accepted accounting principles or accounting standards or cost principles required by federal or state laws, rule, or regulation;

(r) Submission of claims or written orders contrary to generally accepted standards of medical practice;

(s) Submission of claims for services that exceed that requested or agreed to by the client or the responsible relative or guardian or requested by another medical practitioner;

(t) Breach of the terms of the medical services agreement;

(u) Failure to correct deficiencies in operations after receiving written notice of the deficiencies from RH;

(v) Submission of any claim for payment for which payment has already been made by RH;

(w) Provision of or billing for services provided by ineligible or unsupervised staff; or

(x) Alteration of clinical or billing records that have been requested by RH or a designated requestor.

(2) An agency or any of its providers who have been suspended, terminated, or excluded from participation in a federal or state-administered medical program, such as Medicare or Medicaid, or whose license to practice has been suspended or revoked by a state licensing board, shall not submit claims for payment, either personally or through claims submitted by any billing agency or other agency, for any services or supplies provided under CCare, except those services or supplies provided prior to the date of suspension or termination.

(3) No agency shall submit claims for payment to RH for any services or supplies provided by a person or agency that has been suspended or terminated from participation in a federal or state-administered medical program, such as Medicare or Medicaid, or whose license to practice has been suspended or revoked by a state licensing board, except for those services or supplies provided prior to the date of suspension or termination.

(4) When the provisions of sections (2) or (3) of this rule are violated, RH may suspend or terminate the agency who is responsible for the violation.

(5) Agency sanctions shall be imposed at the discretion of RH or the director of the office whose budget includes payment for the services involved. RH shall notify an agency in writing of any sanction proposed to be imposed that shall explain the agency’s appeal rights in accordance with OAR 333-004-0200 through 333-004-0230.

(6) RH shall consider the following factors in determining the sanction(s) to be imposed (this list includes but is not limited to these factors):

(a) Seriousness of the offenses(s);

(b) Extent of violations by the agency;

(c) History of prior violations by the agency;

(d) Prior imposition of sanctions;

(e) Prior agency education; and

(f) Agency willingness to comply with RH rules.

(7) The Division of Medical Assistance Programs shall be notified whenever a sanction is imposed on an agency.

Stat. Auth.: ORS 413.042
Stats. Implemented: ORS 413.032
Hist.: PH 4-2005, f. & cert. ef. 2-18-05; PH 5-2007, f. 4-9-07, cert. ef. 4-23-07; PH 2-2009, f. & cert. ef. 3-2-09; PH 19-2012, f. & cert. ef. 12-26-12

333-004-0200

Agency Appeals

(1) An agency may appeal a RH decision in which the agency is directly adversely affected such as the following:

(a) A denial or limitation of payment allowed for services or items provided;

(b) A denial of an application for new or continued participation in CCare;

(c) Sanctions imposed, or intended to be imposed, by RH on an agency; or

(d) RH overpayment determinations made under OAR 333-004-0150.

(2) An agency appeal is initiated by filing a timely request in writing for review with RH.

(a) An agency appeal request is not required to follow a specific format as long as it provides a clear written expression from an agency expressing disagreement with a RH decision.

(b) The request must identify the decision made by RH that is being appealed and the reason the agency disagrees with that decision.

(c) An agency appeal request is timely if it is received by RH within 60 calendar days of the date of RH’s decision.

(3) Types and methods for agency appeals are as follows:

(a) A RH denial of or limitation of payment allowed, RH claim decision, or RH overpayment determination for services or items provided to a client must be appealed as claim re-determinations under OAR 333-004-0210.

(b) A notice of sanctions imposed, or intended to be imposed, the effect of the notice of sanction is, or will be, to deny, suspend or revoke an agency’s project number necessary to participate in CCare is entitled to appeal under OAR 333-004-0230. An agency that is entitled to appeal a notice of sanction as a contested case may request administrative review instead of a contested case hearing if the agency submits a written request for administrative review of the notice of sanction and agrees in writing to waive the right to a contested case hearing, and RH agrees to review the appeal of the notice of sanction as an administrative review.

(c) All agency appeals of RH decisions not described in subsections (3)(a) or (b) of this rule are handled as administrative reviews in accordance with OAR 333-004-0220 unless RH issues an order granting a contested case hearing.

(4) In the event an agency’s request for appeal is not timely, RH shall determine whether the failure to file the request was caused by circumstances beyond the control of the agency. In determining whether to accept a late request for review, RH requires the request to be supported by a written statement that explains why the request for review is late. RH may conduct such further inquiry as RH deems appropriate. In determining timeliness of filing a request for review, the amount of time RH determines accounts for circumstances beyond the control of the provider is not counted.

(5) The burden of presenting evidence to support an agency appeal is on the agency.

(a) Consistent with OAR 333-004-0110, payment on a claim shall only be made for services that are adequately documented and billed in accordance with 333-004-0080 and all applicable administrative rules related to covered services for clients and establishing the conditions under which services, supplies or items are covered.

(b) Eligibility for enrollment and for continued enrollment is based on compliance with applicable rules, the information submitted or required to be submitted with the application for enrollment and the enrollment agreement, and the documentation required to be produced or maintained in accordance with OAR 333-004-0120.

(6) Agency appeal proceedings, if any, shall be held in Portland, unless otherwise stipulated to by all parties and agreed to by RH.

Stat. Auth.: ORS 413.042
Stats. Implemented: ORS 413.032
Hist.: PH 19-2012, f. & cert. ef. 12-26-12

333-004-0210

Claim Re-Determination

(1) If an agency disagrees with an initial claim determination, it may request a review for re-determination of the denied claim payment. The request to open an initial claim determination for a re-determination review must be made through RH in writing, within 60 days from the date of the RH original claim adjudication date.

(2) All requests must contain a detailed letter of explanation identifying the specific re-determination denial issue and alleged error. This information must be submitted to RH at the time of the request.

(3) At the time the request for re-determination is made an agency is responsible for providing the information needed to adjudicate its claim, including relevant medical records and evidence-based practice data to support the position being asserted on review. RH may request additional information that it finds relevant to the review. An agency requesting a re-determination review must include the following:

(a) The specific service, supply or item being denied, and include all relevant codes and a detailed justification for the re-determination of the denied service;

(b) A copy of the original claim and a copy of the original denial notice or remittance advice that describes the basis for the claim denial under re-determination; and

(c) Any information or medical documentation pertinent to support the request and to obtain a resolution of the re-determination review dispute.

(4) A re-determination review is based on RH review of documentation and applicable law. RH does not provide a face-to-face meeting with an agency as part of the re-determination process.

(a) The agency is responsible for the timely submission of review request and all information pertinent to conducting the review and consistent with the requirements of this rule.

(b) RH shall notify an agency requesting review that the re-determination request has been denied if:

(A) The agency did not submit a timely request;

(B) The required information is not provided at the same time the request is submitted; or

(C) The agency fails to submit any additional requested information within 14 business days of request.

(5) RH’s final decision under this rule is the final decision on appeal. Under ORS 183.484, this decision is an order in other than a contested case. ORS 183.484 and the procedures in OAR 137-004-0080 through 137-004-0092 apply to RH’s final decision under this rule.

Stat. Auth.: ORS 413.042
Stats. Implemented: ORS 413.032
Hist.: PH 19-2012, f. & cert. ef. 12-26-12

333-004-0220

Agency Appeals — Administrative Review

(1) An administrative review is an agency appeal process that allows an opportunity for the Center administrator or designee to review a RH decision affecting the agency, where administrative review is appropriate and consistent with OAR 333-004-0200, Agency Appeals.

(2) Administrative review is an appeal process under OAR 333-004-0200 that addresses primarily legal or policy issues that may arise in the context of a RH decision that adversely affects the agency and that is not otherwise reviewed as a claim re-determination, a contested case, or client appeal.

(a) If RH finds that the appeal shall be handled as a different form of agency appeal the Center administrator or designee shall notify the agency of this determination.

(b) Within the time limits established by RH in the administrative review, the agency must provide RH with a copy of all relevant records, the RH decision, and other materials relevant to the appeal.

(3) If the Center administrator or designee decides that a meeting between the agency and RH staff shall assist the review, the Center administrator or designee shall notify the agency requesting the review of the date, time, and place the meeting is scheduled.

(4) The review meeting shall be conducted in the following manner:

(a) It shall be conducted by the Center administrator or designee;

(b) No minutes or transcript of the review shall be made;

(c) The agency requesting the review does not have to be represented by counsel during an administrative review meeting and shall be given ample opportunity to present relevant information;

(d) RH staff shall not be available for cross-examination but RH staff may attend and participate in the review meeting;

(e) Failure to appear without good cause constitutes acceptance of RH’s determination;

(f) The Center administrator may combine similar administrative review proceedings, including the meeting, if the Center administrator determines that joint proceedings may facilitate the review; and

(g) The Center administrator or designee may request the agency making the appeal to submit, in writing, new information that has been presented orally. In such an instance, a specific date for receiving such information shall be established.

(5) The results of the administrative review shall be sent to the agency, in writing, within 30 calendar days of the conclusion of the administrative review proceeding, or such time as may be agreed to by the agency and RH.

(6) RH’s final decision on administrative review is the final decision on appeal and binding on the parties. Under ORS 183.484, this decision is an order in other than a contested case. ORS 183.484 and the procedures in OAR 137-004-0080 through 137-004-0092 apply to the Authority’s final decision on administrative review.

Stat. Auth.: ORS 413.042
Stats. Implemented: ORS 413.032
Hist.: PH 19-2012, f. & cert. ef. 12-26-12

333-004-0230

Agency Appeals — Contested Case Hearings

(1) A contested case procedure is a hearing that is conducted by the Office of Administrative Hearings where a contested case is appropriate and consistent with OAR 333-004-0200, Agency Appeals. If the request for contested case hearing was timely filed but should have been filed as a claim re-determination, administrative review, or client appeal, RH shall refer the request to the proper appeal procedure and notify the agency.

(2) Contested case hearings are conducted in accordance with the Attorney General’s Model Rules, OAR 137-003-0501 through 137-003-0700.

(3) The party to an agency contested case hearing is the agency who requested the appeal. An agency that is a corporation may be represented by any of the persons identified in ORS 413.041.

(4) Informal conference. RH may notify the agency of the time and place of an informal conference, without the presence of the Administrative Law Judge (ALJ). The purposes of the informal conference are:

(a) To provide an opportunity to settle the matter;

(b) To make sure the agency and RH understand the specific reason for the action of the hearing request;

(c) To give the agency and RH an opportunity to review the information that is the basis for action; and

(d) To give the agency and RH the chance to correct any misunderstanding of the facts.

(5) The agency may, at any time prior to the hearing date, request an additional informal conference with RH that may be granted if RH finds, at its sole discretion, the additional informal conference shall facilitate the contested case hearing process or resolution of disputed issues.

(6) Contested case hearing. The ALJ shall conduct the contested case hearing using the Attorney General’s Model Rules, OAR 137-003-0501 through 137-003-0700.

(a) The burden of presenting evidence to support an agency appeal is on the agency that requested the appeal. Consistent with OAR 333-004-0110, payment on a claim shall only be made for services that are adequately documented and billed in accordance with OAR 333-004-0080 and all applicable administrative rules related to covered services for the client.

(b) Subject to RH approval under OAR 137-003-0525, the ALJ shall determine the location of the contested case hearings.

(7) Proposed and final orders. The ALJ is authorized to serve a proposed order on all parties and the RH unless, prior to the hearing, RH notifies the ALJ that a final order may be served by the ALJ.

(a) If the ALJ issues a proposed order, and the proposed order is adverse to a party, the party may file written exceptions to the proposed order to be considered by RH, or the ALJ when the ALJ is authorized to issue the final order. The exceptions must be in writing and received by RH or the ALJ, when the ALJ is authorized to issue the final order, not later than 10 calendar days after the date the proposed order is issued by the ALJ. No additional evidence may be submitted without prior approval of RH.

(b) The proposed order issued by the ALJ shall become a final order if no exceptions are filed within the time specified in subsection (a) of this section, unless RH notifies the parties and the ALJ that RH shall issue the final order. After receiving the exceptions or argument, if any, RH may adopt the proposed order as the final order or may prepare a new order. Prior to issuing the final order, RH may issue an amended proposed order.

(c) Procedures applicable to default orders for withdrawal of a hearing request, failure to timely request a hearing, failure to appear at a hearing, or other default, are governed by the Attorney General’s Model Rules, OAR 137-003-0670 through 137-003-0672.

(d) The final order is effective immediately upon being signed or as otherwise provided in the order.

(8) All contested case hearing decisions are subject to the procedures established in OAR 137-003-0675 through 137-003-0700 and to judicial review under ORS 183.482 in the Court of Appeals.

Stat. Auth.: ORS 413.042
Stats. Implemented: ORS 413.032
Hist.: PH 19-2012, f. & cert. ef. 12-26-12

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