OAR 410-125-0640: Third Party Payers — Other Resources, Client Responsibility and Liability

(1) Medicare: Do not send claims to the Division of Medical Assistance Programs (Division) until they have been billed to and adjudicated by Medicare: (a) Exception: Take home drugs and other services, which are not covered by Medicare, may be billed directly to the Division without billing Medicare first; (b) See: billing instructions in the Hospital Services Supplemental Information on the Division’s website for additional information on billing Medicare claims. (2) Other Insurance. With the exception of services described in the General Rules, bill all other insurance first before billing the Division. Report the payments made by the other insurers. (3) Motor vehicle accident fund: (a) Enter 01 (Auto Accident) in the Occurrence Code Block and give the date of the accident; (b) For all other clients, bill all other resources before billing the Division. Do not bill the Motor Vehicle Accident Fund. (4) Employment Related Injuries: Enter 04 (Employment Related Accident) in the Occurrence Code Block and give the date of the injury. (5) Liability: (a) Liability refers to insurance that provides payment based on legal liability for injuries or illness or damages to property. It includes, but is not limited to, automobile liability insurance, uninsured and underinsured motorist insurance, homeowners' liability insurance, malpractice insurance, product liability insurance and general casualty insurance. It also includes payments under state "wrongful death" statutes that provide payment for medical damages; (b) The provider may bill the insurer for liability prior to billing the Division. The provider may not bill both the Division and the insurer; (c) The provider may bill the Division after receiving a payment denial from the insurer; however, the Division billing must be within 12 months of date of service. Payment accepted from Division is payment in full; (d) The provider may bill the Division without billing the liability insurer. However, payment accepted from the Division is payment in full. The payment made by the Division may not later be returned in order to pursue payment from the liability insurer. When the provider bills the Division, the provider agrees not to place any lien against the client's liability settlement; (e) The provider has 12 months from the date of service to bill the Division. No payment will be made by Division under any circumstances once the one year limit has passed if no billing has been received within that time. (6) Adoption agreements. Adopting parents and/or an adoption agency may be considered a prior resource. In some instances, the Division makes reimbursement to hospitals and other providers for services provided to a mother whose baby is to be adopted. The Division may also make reimbursement for services provided to the infant. Some adoption agreements, however, stipulate that the adoptive parents will make payment for part or all of the medical costs for the mother and/or the child. In these instances, the adoptive parent(s) and/or agency are a third party resource and should be billed before billing the Division for this service. (7) Veteran's Administration benefits: (a) Some clients have limited benefits through the Veterans' Administration. Hospitals must bill the Veterans' Administration for VA covered services before billing the Division; (b) The Veterans' Administration requires notification within 72 hours of an emergency admission to a non-VA hospital. (8) Trust funds. Some individuals will have trust funds that will pay for medical expenses. Occasionally a special trust fund will be set up to pay for extraordinary medical expenses, such as a transplant. These, and other trusts which pay medical expenses, are considered a prior resource. Bill the trust fund prior to billing the Division for services that are covered by the trust fund. (9) Billing the client. A provider may bill the client or any financially responsible relative or representative of that individual only as allowed in OAR 410-120-1280. (10) The hospital may not bill the client under the following circumstances: (a) For services which are covered by the Division; (b) For services for which the Division has made payment; (c) For services billed to the Division for which no payment is made because third party reimbursement exceeds the Division maximum allowed amount; (d) For any deductible, coinsurance or co-pay amount; (e) For services for which the Division has denied payment to the hospital as a result of one of the following: (A) The hospital failed to supply the correct information to the Division to allow processing of the claim in a timely manner as described in these rules and the General Rules; (B) The hospital failed to obtain prior authorization as described in these rules; (C) The service provided by the hospital was determined by or the Division not to be medically appropriate; or (D) The service provided by the hospital was determined by the QIO not to be medically appropriate, necessary, or reasonable.