Oregon Administrative Rules|Section 410-133-0220 - Billing and Payment

                                                
Current through Register Vol. 60, No. 12, December 1, 2021 
(1) The School Medical (SM) provider must bill the Oregon Health Authority (Authority), also termed Department, in accordance with OAR 410-120-0035; and must bill at a cost rate no greater than the education agency's cost rate for the applicable discipline reviewed and accepted by the Authority based on the cost determination process described in OAR 410-133-0245.
 
(2) Services must be billed on a CMS-1500 or by electronic media claims (EMC) submission using only those procedure codes and modifiers specified for the School-Based Health Services (SBHS) program. If the SM provider submits their claims electronically, the SM provider must become a trading partner with the Authority and comply with the requirements for Electronic Data Interchange (EDI) pursuant to Chapter 943 Division 120 rules and Chapter 410 Division 120 rules.
 
(3) The Authority will accept a claim up to 12 months from the date of service. See Department Provider Rules 943-120-0340 Claim and PHP Encounter Submission and General Rules 410-120-1300 Timely Submission of Claims.
 
(4) Third party liability. In general, the Medicaid program is the payor of last resort and a provider is required to bill other resources before submitting the claim to Medicaid. This requirement means that other payment sources, including other federal or state funding sources, must be used first before the Authority can be billed for covered health services. However, the following exceptions apply to the requirement to pursue third party resources: 
(a) For health services provided under the Individuals with Disabilities Education Act (IDEA), Medicaid pays before Oregon Department of Education (ODE) or the Educational Agency (EA), to the extent the health service is a covered service provided to a Medicaid-eligible student documented as required under these rules, and subject to the applicable reimbursement rate;
 
(b) If School-Based Health Services (SBHS) are provided under Title V of the Social Security Act (Maternal and Child Health Services Block Grant), Medicaid-covered Health Services provided by a Title V grantee are paid by Medicaid before the Title V funds;
 
(c) The Centers for Medicare and Medicaid Services (CMS) recognize that while schools are legally liable to provide IDEA-related health services at no cost to the eligible students, Medicaid reimbursement is available for these services because section 1903(c) of the ACT requires Medicaid to be primary to the U.S. Department of Education for payment of the health-related services provided under IDEA.
 
 
Or. Admin. R. 410-133-0220
HR 39-1991, f. & cert. ef. 9-16-91; OMAP 31-2003, f. & cert. ef. 4-1-03; OMAP 31-2003, f. & cert. ef. 4-1-03; OMAP 53-2003, f. 8-13-03 cert. ef. 9-1-03; OMAP 24-2005(Temp), f. & cert. ef. 4-5-05 thru 10-1-05; OMAP 53-2005, f. 9-30-05, cert. ef. 10-1-05; DMAP 28-2008(Temp), f. 6-30-08, cert. ef. 7-1-08 thru 12-28-08; DMAP 32-2008(Temp), f. & cert. ef. 10-2-08 thru 3-27-09; DMAP 43-2008, f. 12-17-08, cert. ef. 12-28-08; DMAP 19-2009, f. 6-12-09, cert.ef. 7-1-09; DMAP 19-2020, temporary amend filed 04/09/2020, effective 04/09/2020 through 10/05/2020; DMAP 56-2020, amend filed 10/02/2020, effective 10/5/2020
Statutory/Other Authority:ORS 413.042 & 414.065
 
Statutes/Other Implemented:ORS 414.065
This section was updated on 11/10/2020 by overlay.