Or. Admin. R. 333-010-0140

Current through Register Vol. 63, No. 8, August 1, 2024

Section 333-010-0140 - Billing

(1) Only clinics providing breast and cervical cancer screening and diagnostic services pursuant to an approved medical services agreement, and who have been assigned an agency number may submit claims for ScreenWise BCC services.

(2) All services must be billed by submitting claim information in the method specified by the ScreenWise BCC.

(3) A primary diagnosis code is required on all claims. All billings must be coded with the most current and appropriate International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM), incorporated by reference and the most appropriate Current Procedural Terminology (CPT) codes. Information regarding CPT code lists, including required notice to providers regarding CPT code list revisions, may be found in the provider's Medical Services Agreement. Claims including primary diagnosis codes that are not listed on the approved CPT code list will not be paid without program approval.

(4) The provider must use CLIA certified laboratories for all tests whether done at the clinic site or by an outside clinic.

(5) Enrolled providers with ScreenWise BCC must not seek payment from an eligible client, or from a financially responsible relative or representative of that individual, for any services covered by ScreenWise BCC.

(a) A client may be billed for services that are not covered by ScreenWise BCC. However, the provider must inform the client in advance of receiving the specific service that it is not covered, the estimated cost of the service, and that the client or client's representative is financially responsible for payment for the specific service. Providers must document in writing that the client was provided this information and the client knowingly and voluntarily agreed to be responsible for payment. The client or client's representative must sign the documentation.

(b) Services not covered by ScreenWise BCC are those outside of the scope of standard breast and cervical cancer screening and diagnosis, or those not included in the ICD-10 list, incorporated by reference and approved CPT code lists.

(6) Prior to submission of a claim to the Center for payment, an approved provider agreement must be in place.

(7) All claims must be submitted with data, as described in the claims section of the rules.

(a) Except for services performed by a CLIA certified laboratory outside of the clinic, all billings must be for services provided within the provider's licensure or certification.

(b) Providers must submit true and accurate information when billing the Center.

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

(8) Diagnosis Code Requirement:

(a) A primary diagnosis code is required on all claims.

(b) Use the highest degree of specificity within the diagnosis codes listed in the ICD-10-CM codes, incorporated by reference, for breast and cervical screening or diagnostic testing.

(9) No provider shall submit to the Center:

(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 been made by another source unless the amount paid is clearly entered on the claim form;

(10) The provider must submit a billing error edit correction, or refund the amount of the overpayment, on any claim where the provider identifies an overpayment made by the Center.

(11) A provider who, after having been previously warned in writing by the Authority or the Department of Justice about improper billing practices, is found to have continued such improper billing practices and has had an opportunity for a contested case hearing, shall be liable to the Center for up to triple the amount of the established overpayment received as a result of such violation.

(12) Third Party Resources:

(a) Providers must make all reasonable efforts to ensure that ScreenWise BCC will be the payor of last resort with the exception of clinic or offices operated by the Indian Health Service (IHS) or individual American Indian tribes;

(b) Providers must make all reasonable efforts to obtain payment first from other resources. For the purposes of this rule reasonable efforts include:

(A) Determining the existence of insurance coverage or other resource by asking the client;

(B) Except in the case of the underinsured, when third party coverage is known to the provider, by any other means available:

(i) The provider must bill the third party resource;

(ii) Comply with the insurer's billing and authorization requirements.

(C) Providers are required to submit a billing error edit correction showing the amount of the third party payment or to refund the amount received from another source within 30 days of the date the payment is received. Failure to submit a billing error edit correction within 30 days of receipt of the third party payment or to refund the appropriate amount within this time frame is considered concealment of material facts and grounds for recovery or sanction.

Or. Admin. R. 333-010-0140

PH 9-2008, f. & cert. ef. 6-16-08; PH 17-2015, f. 9-30-15, cert. ef. 10/1/2015; PH 11-2016, f. & cert. ef. 4/1/2016

Stat. Auth.: ORS 413.042

Stats. Implemented: ORS 413.042