OAR 410-136-3200: Reimbursement and Accounting for all Modes of Transports

(1) The following applies to the rate the Oregon Health Authority (Authority) pays brokerages: (a) The Authority shall calculate and pay a brokerage a fixed rate for rides based on the following formula: Direct costs plus indirect costs divided by the number of projected monthly rides. “Direct costs” are transportation costs plus administrative costs; (b) The Authority shall notify the brokerages of their specific ride rates; and (c) The Authority shall assess any needed modifications to this rate: (A) Quarterly; (B) When the Authority changes any program affecting eligibility or scope; or (C) If other factors impact the brokerage’s cost of delivering service. (2) Brokerages shall account for costs and expenses of non-emergent medical transportation (NEMT) services to Oregon Health Plan (OHP) Fee For Service (FFS) clients and RHAF clients separate from any other services the brokerage provides. Brokerages shall require all subcontractors to account for costs and expense for NEMT services separate from any other services the subcontractors provide. Brokerages shall use and require all subcontractors to adopt generally accepted accounting principles or accounting standards or cost principles required by federal or state laws, rules, or regulations. (3) The Authority shall reimburse brokerages for valid claims submitted to the Authority, using the standardized electronic billing format prescribed by the Authority for OHP clients and the specified billing format prescribed by the Authority for RHAF clients. All brokerages’ professional claims for transportation services shall include a HIPAA-compliant, the Centers for Medicare and Medicaid Services (CMS)-defined 2- digit POS code to indicate the type of transportation service used and have the required combination of modifier and procedure code. All required billing information must be included on the claim for the additional client. Medicaid is always the payer of last resort. If a client has Medicare or third-party insurance, the brokerages shall bill these insurers before billing the Authority. (4) The Authority shall conduct an annual cost settlement to review brokerages costs and expenses and determine any overpayment or underpayment for costs the brokerage incurred for covered NEMT services for eligible clients. The following applies to the Authority’s cost settlement process: (a) The Authority shall request cost and expense settlement information from the brokerages 6 months after the end of the fiscal year. The request shall include file(s) detailing the brokerages claims, a template for the brokerages to submit their cost and expenses information and instructions for completing the template. The Authority uses the Oregon Medicaid Management Information System (MMIS) to create file(s) detailing the brokerages claims data for the applicable procedure codes per NEMT provider; (b) Brokerages shall submit the requested information, certified by a Certified Public Accountant, and complete the template provided by the Authority within 90 days of receiving the Authority’s request; (c) The Authority shall verify the reported costs and expenses and notify the brokerages in writing of the Authority’s determination; (d) Brokerages shall comply with the allowable cost requirements established by the Authority; (e) If the Authority’s determination results in an adjustment, the brokerages may request an appeal pursuant to OAR 410-120-1560 through 410-120-1600, pertaining to provider appeals. (f) The brokerage shall refund the amount of the overpayment determined by the Authority within sixty (60) days or as specified by the Authority in its written notice to the brokerage. (g) Payment by the Authority does not restrict or limit the Authority or any state or federal oversight entity’s right to review or audit before or after the payment is made to a brokerage. Payments may be denied or subject to recovery by the Authority if medical review, audit, or other post-payment review of the supplemental payment or the claim upon the basis a supplemental payment was issued determines the service was not provided in accordance with applicable rules, by an eligible NEMT provider, or does not meet the criteria for quality of care or medical appropriateness of the care or payment. (5) To be eligible for payment brokerages and subcontractors must meet all of the requirements in chapter 410 division 136 rules and chapter 410 division 120 rules. The Authority shall pay for covered services the brokerage authorized and provided in good faith, including mailing transit passes to clients. The Authority shall use the rate in effect on the day of the transport or the mailing date of the transit passes. For the purpose of this rule “Good faith” means: (a) The brokerage verified client eligibility on the date of service or the date of mailing the transit passes, using the Authority’s eligibility information; or (b) The client eligibility information was inconsistent or not available, and the brokerage used the most recent client information available immediately before the time of service or mailing of transit passes. (6) Each brokerage may establish a working capital reserve with funds the Authority provides. The following applies to any established working capital reserve: (a) The working capital reserve shall represent thirty (30) days of cash expenses for normal operating purposes. The Authority may base the reserve on a time other than thirty (30) days if circumstances warrant the change; (b) The Authority shall calculate the reserve amount as part of the annual cost settlement for the most recent past fiscal year; (c) The Authority shall base the reserve amount on an average of six (6) months of operating expenses that the brokerage reports in its monthly NEMT financial reports. However, the Authority may base the reserve amount on more or less than six (6) months of expenses when a six-month average does not reflect an accurate accounting of expenses; (d) Brokerages shall maintain a separate account for the reserve funds; and (e) The Authority may require the brokerage to return any funds in excess of the amount the Authority calculated, or the Authority may decrease the ride rate to reduce the reserves. If the Authority requires the brokerage to return the excess funds, the brokerage shall do so within fourty-five (45) days of receipt of the Authority notification.