Or. Admin. Code § 333-004-3110

Current through Register Vol. 63, No. 11, November 1, 2024

Section 333-004-3110 - RH Access Fund Billing and Claims

(1) Only agencies providing services pursuant to an approved MSA, and who have been assigned a project number and site number may submit claims for reproductive health or abortion services.

(2) An agency may bill for reproductive health or abortion services by submitting appropriate CVR data to the RH Program via the RH Program's contracted data and claims processor. A claim is considered valid only if all required data are submitted.

(3) An agency may bill the RH Program for supplies at acquisition cost through the CVR.

(a) Reimbursement for supplies billed by RHCare and CCare Clinics will be based on 340B program pricing if the agency is eligible to purchase supplies under 340B pricing. Otherwise, reimbursement for supplies will be based on acquisition cost.

(b) Reimbursement for supplies billed by AbortionCare Clinics will be based on acquisition cost.

(4) All billings for reproductive health services must be coded with International Classification of Diseases, 10th Revision (ICD-10). Up to six diagnosis codes (one primary and five secondary) may be included. Billings for abortion services do not require any codes from the International Classification of Diseases.

(a) Title X: All claims must be coded with a diagnosis code in either the Z30 Contraceptive Management series, the Z31 Procreative Management series, or Z32.0 Pregnancy Testing series, with the exception of STI treatment and rescreening and stand-alone repeat Pap testing that is pursuant to a previous family planning visit.

(b) CCare: All claims must be coded with a diagnosis code in the Z30 Contraceptive Management series. The Z30 code must be the primary diagnosis code for all claims with the exception of a comprehensive annual visit in which the Z30 code may be a secondary diagnosis code. Comprehensive annual visits may not be billed more frequently than once every eleven months and one day.

(c) RHEA: All claims must be coded with a diagnosis code that corresponds to one or more of the covered services listed under OAR 333-004-3070(4) (RH Access Fund Covered Services by Funding Source), and as listed in the Allowable Diagnosis Codes section of the RH Program's website.

(5) Laboratory services are included in the RH Access Fund reimbursement rates. The exception to this is the combined GC/CT test. 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) Language assistance provided shall be reimbursed separately from the fixed rate only if appropriately indicated on the CVR.

(7) Ultrasound services, sedation and anesthesia services, and certain other services associated with abortion are reimbursed separately from the bundled abortion procedure rates.

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

(9) Covered services provided by telehealth technology may be billed to the RH Program, as appropriate. The CVR must indicate that the visit was conducted via telehealth. All telehealth visits must adhere to applicable state and federal telehealth regulations.

(10) An agency certified with the RH Program must not seek payment from an enrollee, or from a financially responsible relative or representative of that enrollee, for any services covered by the RH Access Fund. The agency shall accept RH Access Fund reimbursement for any covered services as defined in OAR 333-004-3070 (RH Access Fund Covered Services by Funding Source), drugs, devices, or supplies as payment in full.

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

(b) An enrollee may be billed for services that are not covered by the RH Access Fund, unless the clinic misrepresented coverage of the service to the client.

(c) Enrollees must be informed prior to their visit that they may be billed for services not covered by the RH Access Fund.

(d) Agencies may not request a deposit from the enrollee in advance of services covered by the RH Access Fund.

(11) By submitting a claim to the RH Program for payment, the agency is attesting that it has complied with all rules of the RH Program and is certifying that the information is true, accurate, and complete.

(a) All billings must be for services provided within the agency and its provider's licensure or certification, with the following exceptions:

(A) Services performed by a CLIA certified laboratory outside of the clinic;

(B) Procedures performed by contracted vasectomy providers; or

(C) RH-approved procedures performed by contracted facilities.

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

(12) An agency may not submit to the RH Program:

(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 already been made by the RH Program or another source unless the amount paid is clearly entered on the claim form.

(d) Any claim or written orders contrary to generally accepted standards of medical practice;

(e) Any claim for services that exceed what has been requested or agreed to by the client or the responsible relative or guardian or requested by another medical practitioner;

(f) Any claim for services provided to persons who were not eligible;

(g) Any claim using procedure codes that overstate or misrepresent the level, amount or type of health care provided.

(13) 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 the RH Program.

(14) Third party resources. The following subsections apply only to enrollees with private insurance coverage.

(a) All reasonable efforts must be taken to ensure that the RH Program is the payor of last resort, unless an enrollee requests special confidentiality which must be documented on the RH Access Fund Enrollment Form. An enrollee's request for special confidentiality ensures that the agency must not bill third party resources, but instead must bill the RH Program directly. This option does not apply just to minors, nor is it to be used for all teens.

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

(A) Determining the existence of insurance or other coverage by asking the enrollee.

(B) Billing a third party resource when third party coverage is known to the agency, prior to billing the RH Program.

(c) If the enrollee has private insurance that has been billed for reproductive health or abortion services and the reimbursement from the insurance is less than the RH Program reimbursement rate, the balance may be billed to the RH Program

(d) An agency must report the reimbursement received from insurance, including services, drugs, devices, and supplies. The exact amount received from the insurance company for services, drugs, devices, and supplies must be reported in total.

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

(f) If third party payment is received after the RH Program 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 60 calendar days of the date the payment is received. Failure to submit a billing correction within 60 calendar 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.

(15) No agency shall submit claims for payment to the RH Program 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.

(16) 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 the RH Program, except those services or supplies provided prior to the date of suspension or termination.

(17) No agency shall submit claims that result in:

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

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

Or. Admin. Code § 333-004-3110

PH 84-2020, adopt filed 12/18/2020, effective 1/1/2021; PH 202-2022, amend filed 10/27/2022, effective 10/27/2022

Statutory/Other Authority: ORS 413.042, ORS 414.432, ORS 431.147, ORS 431.149 & OL 2022, ch. 45, sec 10

Statutes/Other Implemented: ORS 414.432, ORS 431.147, ORS 413.032 & OL 2022, ch. 45, sec 10