OAR 411-370-0020: Provider Requirements

(1) These rules cover all programs and services of the Department’s community services programs for recipients with developmental disabilities (hereinafter referred to as community services programs). All providers seeking payment from the Department for the provision of covered services to eligible service recipients of community services programs must comply with these rules and the applicable rules, standards, and procedures of the specific programs or services defined as community services programs in OAR 411-370-0010. (2) COVERED PROVIDER AGREEMENTS. Agreements with providers for community services programs may include: (a) Direct contracts with the Department; (b) Contracts with Department designees, including Community Developmental Disabilities Programs; or (c) Provider enrollment agreements with the Department. (3) Covered services paid for with state, Medicaid (Title XIX), or other funds by the Department for community services programs are also subject to federal and state Medicaid rules and requirements. In interpreting these rules and program-specific rules, the Department shall construe them as much as possible in a manner that shall comply with federal and state laws and regulations, and the terms and conditions of federal waivers and the state plans. (4) A provider paid with state or Medicaid funds for community services programs must comply with all applicable federal and state laws and regulations pertaining to the provision of Medicaid services under the Medicaid Act, Title XIX, 42 United States Code (USC) 1396 et seq. (5) Payment for any service by a provider of community services programs may not be made by or through (directly or by power of attorney) any individual or organization, such as a collection agency or service bureau, that advances money to a provider for accounts receivable that the provider has assigned, sold, or transferred to the person or organization for an added fee or a deduction of a portion of the accounts receivable. (6) The Department shall make community services programs provider payments to only the following: (a) The provider who actually performed the service; (b) In accordance with a reassignment from the provider to a government agency or reassignment by a court order; or (c) To an enrolled billing provider, such as a billing service or an accounting firm that, in connection with the submission of claims, receives or directs payments in the name of the provider, if the billing provider’s compensation for this service is: (A) Related to the cost of processing the billing; and (B) Not related on percentage or other basis to the amount that is billed or collected and not dependent upon the collection of the payment. (7) Providers must comply with Third Party Resource (TPR) requirements in Department policies, program-specific rules, provider enrollment agreements, or contracts. (8) PROGRAM INTEGRITY. (a) The Department shall use several approaches to promote integrity of the community services programs. This section of the rule describes integrity actions related to: (A) Provider billings and payments, including actions and expectations contained within service element standards and procedures, program-specific rules, or contracts with Department representatives including Community Developmental Disabilities Programs or brokerages. The program integrity goal is to pay the correct amount to a properly enrolled provider for covered services provided to an eligible recipient according to these rules and the program-specific services in effect on the date of the service; and (B) Provider performance in the delivery of services to recipients as well as general program practices. The program integrity goal includes approaches to assure the provision of appropriate services for which payment is to be made as well as compliance with these rules, service element standards and procedures, program-specific rules, provider enrollment agreements, or contracts. (b) Program integrity activities include but are not limited to the following: (A) Review, including but not limited to the evaluation of services in accordance with appropriate service or process, error identification, and prior authorization processes including all actions taken to determine the provision of services in accordance with service element standards and procedures, program-specific rules, provider enrollment agreements, or contract; (B) Onsite visits to verify compliance with service element standards and procedures, program-specific rules, provider enrollment agreements, or contracts; (C) Quality improvement activities; (D) Coordination with the Department of Justice, Medicaid Fraud Control Unit and other oversight authorities including law enforcement; and (E) For provider billings and payments: (i) Implementation of transaction standards to improve accuracy and timeliness of claims processing; (ii) Cost report settlement processes; (iii) Audits; and (iv) Investigation of false claims, fraud, or prohibited business relationships. (F) For provider service delivery: (i) Provider licensing or certification required responsibilities and activities; and (ii) Specific service monitoring and evaluation activities provided in program-specific rules or Department policy. (G) For provider fiscal health: (i) Prior to receiving a Provider Enrollment Number, submit to the Department a revenue and expense forecast for two entire fiscal years. Existing agencies, submit to the Department a revenue and expense forecast for the next fiscal year upon request. (ii) Prior to receiving a Provider Enrollment Number and upon request, provide evidence to the Department of the financial ability to sustainably operate the agency and the ability to maintain sufficient cash or cash equivalent liquid resources. The liquid resources must be sufficient to pay the operating costs, including labor costs, wages, and benefits, for all programs for at least three months. The liquid resources must be continuously available and independent from any other person, agency, business, or entity; (iii) Copies of bank statements from the last three months demonstrating banking activity in both checking and savings accounts, as applicable, or demonstration of cash on hand, if requested. (c) The following may engage in program integrity activities including but not limited to general monitoring of the provider’s performance in service delivery, reviewing a request for services, or auditing a claim of services, before or after payment, for assurance that the specific care or service was provided in accordance with the program-specific rules and the generally accepted standards of performance: (A) Department staff or designees, including staff of a Community Developmental Disabilities Program or brokerage; and (B) Federal or state oversight authority. (d) Payment may be denied or may be subject to recovery if the review or audit determines the service was not provided in accordance with provider rules, program-specific rules, provider enrollment agreements or contracts, or does not meet the criteria for quality or appropriateness of the service or payment. (e) If the Department or other federal or state oversight authorities determine that an overpayment has been made to a provider, the amount of overpayment is subject to recovery. (f) The provider may face other sanctions or penalties, including termination of provider enrollment agreements or contracts as allowed by program-specific or Department rules. (g) The Department may communicate with and coordinate any program integrity actions with the Medicaid Fraud Control Unit, United States Department of Health and Human Services, other federal or state oversight authorities including law enforcement, or Department designees including Community Developmental Disabilities Programs and brokerages.