Or. Admin. Code § 333-004-4060

Current through Register Vol. 63, No. 10, October 1, 2024

Section 333-004-4060 - Abortion Access Plan Billing and Claims

(1) An authorized agency or authorized provider shall complete all required fields on the Abortion Access Plan claims form prior to submission to the RH Program.

(2) An authorized agency or authorized provider must not seek payment from an eligible client, or from a financially responsible relative or representative of that eligible client, for any services covered by the Abortion Access Plan. The authorized agency or authorized provider shall accept reimbursement from the RH Program for any covered services as defined in OAR 333-004-4020 (Covered Services) as payment in full.

(a) An eligible client may be billed for services that are not covered by Abortion Access Plan, unless the authorized agency or provider misrepresented coverage of the service to the eligible client.

(b) Eligible clients must be informed by the authorized agency or authorized provider prior to their visit that they may be billed for services not covered by the Abortion Access Plan.

(c) Authorized agencies or authorized providers may not request a deposit from the eligible client in advance of services covered by the Abortion Access Plan.

(3) By submitting a claim to the RH Program for payment, the authorized agency or authorized provider is certifying that the information is true, accurate, and complete.

(a) All billings must be for services provided within the agency's and provider's licensure or certification.

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

(4) An authorized agency or authorized provider 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.

(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 eligible 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 that overstate or misrepresent the level, amount or type of health care provided.

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

(6) No authorized agency or authorized provider shall submit claims that result in:

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

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

Or. Admin. Code § 333-004-4060

PH 47-2023, adopt filed 09/28/2023, effective 10/1/2023

Statutory/Other Authority: ORS 413.042 & OL 2022, Ch. 435 (HB 4034, Section 10)

Statutes/Other Implemented: ORS 413.032 & OL 2022, Ch. 435 (HB 4034, Section 10)