Provider Announcement

REQUIREMENTS: - Immediately: Billing team and claims processing staff must audit current practices against the regulatory hierarchy (CFR > OAR > Contract). Review claims payment notice procedures and discontinue sending notices for approved claims; send notices ONLY for denied claims per OAR 410-141-3565(8)(c). - Immediately: Update encounter data submission workflows to comply with OAR 410-141-3570(4): submit encounter data within 45 days of claim adjudication, not monthly. Update any automated submission systems and calendar reminders. - Immediately: Verify member disenrollment procedures align with OAR 410-141-3810(1)(b)(A) for all valid reasons to disenroll without cause. Update member communication templates and eligibility system rules. - Within 1 week: Providers performing hysterectomy or sterilization procedures must update consent form submission procedures: submit forms to OHA within 30 days from date of service (not prior to procedure) per OAR 410-141-3570(6). Audit pending procedures for compliance. - Within 1 week: Billing team must verify NEMT attendant policies reflect OAR 410-141-3935 requirement: attendants required for members age 12 and under only (not all members under 18). - Within 1 week: Appeals/continued benefits team must ensure duration of continued benefits during appeals/contested case hearings follows 42 CFR 438.420(c) and remove contract language referencing authorization expiration as a stopping condition. - Ongoing: Designate staff member to report any newly discovered discrepancies between contract, OAR, and CFR to Cheryl Henning, CCO Contracts Administrator (Cheryl.L.Henning@dhsoha.state.or.us). Non-compliance may result in claim denials, member service failures, and OHA sanctions.