OAR 410-147-0080: Prepaid Health Plans (PHPs)

(1) Most Oregon Health Plan (OHP) clients have prepaid health services, contracted for by the Oregon Health Authority (Authority) through enrollment in a prepaid health plan (PHP). Clinics serving eligible OHP clients who are enrolled in a PHP must secure authorization from the PHP prior to providing PHP-covered services or case management services. Federally Qualified Health Centers (FQHC) and Rural Health Clinics (RHC) must request an authorization or referral from the PHP before providing any services to clients enrolled in a PHP unless the FQHC or RHC have contracted with the PHP to provide PHP-covered services. If an FQHC or RHC has an arrangement or contract with a PHP, the clinic is responsible to follow PHP rules and prior authorization requirements. See OAR 410 division 141 for OHP Program Rules and; 410-147-0060, Prior Authorization. (2) The Division of Medical Assistance Programs (Division) encourages FQHCs and RHCs to contact each PHP in their local service area for the purpose of requesting inclusion in their panel of providers. (3) PHPs contracting with FQHCs or RHCs, for the provision of providing services to their members, are required by 42 USC 1396b(m)(2)(A)(ix) to provide payment to the FQHC or RHC that is not less than the level and amount of payment which the PHP would make for services furnished by a non-FQHC/RHC provider. (4) Payment for services provided to PHP-enrolled clients (PHP members) is a matter between the FQHC or RHC and the PHP authorizing the services except as otherwise provided in OAR 410-141-0410, OHP primary care managers. If a PHP denies payment to an FQHC or RHC because arrangements were not made with the PHP prior to providing the service, Division will not reimburse the FQHC or RHC under the encounter rate, except as outlined in Section (5) of this rule (see OAR 410-141-0120, OHP PHP Provision of Health Care Services). (5) FQHCs and RHCs can provide family planning services or Human Immunodeficiency Virus and Acquired Immune deficiency Sydrome prevention services to eligible PHP members without authorization or a referral from the PHP. The FQHC and RHC must bill the PHP first. If the PHP will not reimburse for the service, then the clinic may bill Division. Refer to ORS 414.153, Authorization for payment for certain point of contact services. (6) PHPs will execute agreements with publicly funded providers, unless cause can be demonstrated to Division’s satisfaction why such an agreement is not feasible for authorization of payment for point of contact services in the following categories (refer to ORS 414.153): (a) Immunizations; (b) Sexually transmitted diseases; and (c) Other communicable diseases. (7) PHPs are responsible to ensure the provision of qualified sign language and oral interpreter services for covered medical, mental health or dental care visits, for their enrolled PHP Members with a hearing impairment or who are non-English speaking. Services must be sufficient for the FQHC or RHC provider to be able to understand the PHP Member's complaint; to make a diagnosis; respond to the PHP Member's questions and concerns; and to communicate instructions to the PHP Member. See OAR 410-141-0220(7), Oregon Health Plan prepaid health plan Accessibility. (8) The provider assumes full financial risk in serving a person not confirmed by Division as eligible on the date(s) of service. It is the responsibility of the provider to verify a client’s eligibility. Refer to OAR 410-120-1140 Verification of Eligibility: (a) That the individual receiving medical services is eligible on the date of service for the service provided; (b) Whether an OHP client receives services on a fee-for-service (open card) basis or is enrolled with a PHP; and (c) Whether the service is covered by a third party resource (TPR), a PHP, or if Division reimburses on a fee-for-service basis. (9) Division requires the following of a FQHC or RHC under contract with a PHP: (a) Clinic must maintain reimbursement and documentation records that will permit calculation of supplemental payments according to OAR 410-147-0460. According to OAR 410-141-0180, Oregon Health Plan prepaid health plan Record Keeping, a PHP’s participating providers shall maintain a clinical record keeping system with sufficient detail and clarity to permit internal and external clinical audit to validate encounter submissions and to assure Medically Appropriate services are provided consistent with the documented needs of the PHP Member. See also OAR 410-120-1360, Requirements for Financial, Clinical and Other Records; (b) Clinics are subject to ongoing performance review by the PHP. According to OAR 410-141-0200, Oregon Health Plan prepaid health plan Quality Improvement (QI) System, PHPs must maintain an effective process for monitoring, evaluating, and improving the access, quality and appropriateness of services provided to Division Members. The QI program must include QI projects that are designed to improve the access, quality and utilization of services; (c) Clinics are subject to program review by Division, the Department of Human Services’ Audit Unit, and the Department of Justice Medicaid Fraud Unit for the purposes of assuring program integrity and: (A) Compliance with Oregon Revised Statutes, Oregon Administrative Rules and Federal laws and regulations; (B) Use of accurate and complete encounter and fee-for-service claims data, and supporting clinical documentation, for calculating PHP supplemental payments and compensation for out-stationed outreach workers; (C) Adequate records maintenance for cost reimbursed services to thoroughly explain how the amounts reported on the cost statement were determined. The records must be accurate and in sufficient detail to substantiate the data reported.