1. (1) In order to be reimbursed for services rendered, providers must comply with the following:

   1. (a) Medicaid fee-for-service only claims must be filed within 12 months of the date of service. The date of service for an inpatient hospital stay is considered the date of discharge;
   2. (b) Claims for recipients that have Medicare and Medicaid coverage must be filed with the Medicare fiscal intermediary within 12 months of the date of service to meet the Division’s timely filing rule;
   3. (c) Claims that fail to cross over electronically from Medicare must be submitted hard copy to the Division within six months from the date on the Medicare Explanation of Medicare Benefits (EOMB), provided they are filed with Medicare within one year from the date of service;
   4. (d) Claims for CCO enrolled members must comply with Oregon Administrative Rule 410-141-3565.

2. (2) A claim submitted within 12 months of the date of service but is denied may be resubmitted within 18 months of the date of service. These claims must be submitted to the Health Systems Division (Division) at the address listed in the provider contacts document. The provider must present documentation acceptable to the Division verifying the claim was originally submitted within 12 months of the date of service, unless otherwise stated in individual provider rules. Acceptable documentation is:

   1. (a) A remittance advice from the Division that shows the claim was submitted before the claim was one year old;
   2. (b) A copy of a billing record or ledger showing dates of submission to the Division.

3. (3) Exceptions to the 12-month requirement that may be submitted to the Division are as follows:

   1. (a) When the Department, Division, or the client's branch office makes an error that causes the provider not to be able to bill within 12 months of the date of service, the claim may be filed up to six months after the error is discovered. The Division must confirm the error;
   2. (b) When a court or an Administrative Law Judge orders the Division to make payment;
   3. (c) When the Division determines a client is retroactively eligible for Division medical coverage and more than 12 months passes between the date of service and the determination of the client's eligibility.

Statutory/Other Authority

ORS 413.042

Statutes/Other Implemented

ORS 414.025 & 414.065

History

DMAP 23-2023, minor correction filed 03/31/2023, effective 03/31/2023
DMAP 78-2018, amend filed 06/27/2018, effective 07/01/2018
OMAP 39-2005, f. 9-2-05, cert. ef. 10-1-05
OMAP 20-1998, f. & cert. ef. 7-1-98
HR 5-1997, f. 1-31-97, cert. ef. 2-1-97
HR 31-1994, f. & cert. ef. 11-1-94
HR 32-1993, f. & cert. ef. 11-1-93, Renumbered from 410-120-0340
HR 41-1991, f. & cert. ef. 10-1-91
HR 19-1990, f. & cert. ef. 7-9-90
HR 2-1990, f. 12-12-90, cert. ef. 3-1-90, Renumbered from 461-013-0145
AFS 55-1987, f. 10-29-87, cert. ef. 11-1-87
AFS 17-1985, f. 3-27-85, cert. ef. 5-1-85
AFS 117-1982, f. 12-30-82, cert. ef. 1-1-83
AFS 103-1982, f. & cert. ef. 11-1-82
AFS 52-1982, f. 5-28-82, cert. ef. 6-30-82
Renumbered from 461-013-0080, AFS 47-1982, f. 4-30-82, cert. ef. 5-1-82
AFS 5-1981, f. 1-23-81, cert. ef. 3-1-81
AFS 46-1980, f. & cert. ef. 8-1-80
PWC 812, f. & cert. ef. 10-1-76
PWC 803(Temp), f. & cert. ef. 7-1-76
PWC 683, f. 7-198-74, cert. ef. 8-11-74