1. (1) The enrolled school medical provider must:

   1. (a) Bill the Authority in compliance with OARs 410-120-1280 and 943-120-0330;
   2. (b) Bill services using a professional claim format (i.e., paper CMS-1500 or electronic equivalent to the CMS-1500 form).
   3. (c) Include a procedure code, a diagnosis code, a modifier, and a referring provider ID (Medicaid ID or NPI) for each service billed.
   4. (d) Submit timely claims. The Authority shall accept a claim up to 12 months from the date of service. Once a service has been submitted on a claim within the 12-month timely filing limit, the school medical provider has an additional six months to resubmit the denied claim or adjust the paid claim.

2. (2) Duplicate billing:

   1. (a) Occurs when a claim is submitted for a specific service when the same service is provided and billed for on the same date of service.
   2. (b) Reimbursement made because of duplicate billing shall be recovered.
   3. (c) The billing provider is subject to OARs 410-120-1400 and 410-120-1510.

Statutory/Other Authority

ORS 413.042 & 414.065

Statutes/Other Implemented

ORS 414.065

History

DMAP 65-2025, amend filed 08/29/2025, effective 08/29/2025
DMAP 121-2024, amend filed 09/06/2024, effective 09/06/2024
DMAP 56-2020, amend filed 10/02/2020, effective 10/05/2020
DMAP 19-2020, temporary amend filed 04/09/2020, effective 04/09/2020 through 10/05/2020
DMAP 19-2009, f. 6-12-09, cert. ef. 7-1-09
DMAP 43-2008, f. 12-17-08, cert. ef. 12-28-08
DMAP 32-2008(Temp), f. & cert. ef. 10-2-08 thru 3-27-09
DMAP 28-2008(Temp), f. 6-30-08, cert. ef. 7-1-08 thru 12-28-08
OMAP 53-2005, f. 9-30-05, cert. ef. 10-1-05
OMAP 24-2005(Temp), f. & cert. ef. 4-5-05 thru 10-1-05
OMAP 53-2003, f. 8-13-03 cert. ef. 9-1-03
OMAP 31-2003, f. & cert. ef. 4-1-03
HR 39-1991, f. & cert. ef. 9-16-91