Current through Register Vol. 63, No. 9, September 1, 2024
(1) The following applies to the rate the
Oregon Health Authority (Authority) pays brokerages:
(a) The Authority shall calculate and pay a
brokerage a fixed rate for rides based on the following formula: Direct costs
plus indirect costs divided by the number of projected monthly rides. "Direct
costs" are transportation costs plus administrative costs;
(b) The Authority shall notify the brokerages
of their specific ride rates; and
(c) The Authority shall assess any needed
modifications to this rate:
(A)
Quarterly;
(B) When the Authority
changes any program affecting eligibility or scope; or
(C) If other factors impact the brokerage's
cost of delivering service.
(2) Brokerages shall account for costs and
expenses of non-emergent medical transportation (NEMT) services to Oregon
Health Plan (OHP) Fee For Service (FFS) clients separate from any other
services the brokerage provides. Brokerages shall require all subcontractors to
account for costs and expense for NEMT services separate from any other
services the subcontractors provide. Brokerages shall use and require all
subcontractors to adopt generally accepted accounting principles or accounting
standards or cost principles required by federal or state laws, rules, or
regulations.
(3) The Authority
shall reimburse brokerages for valid claims submitted to the Authority, using
the standardized electronic billing format prescribed by the Authority. All
brokerages' professional claims for transportation services shall include a
HIPAA-compliant, the Centers for Medicare and Medicaid Services (CMS)-defined
2- digit POS code to indicate the type of transportation service used and have
the required combination of modifier and procedure code. All required billing
information must be included on the claim for the additional client. Medicaid
is always the payer of last resort. If a client has Medicare or third-party
insurance, the brokerages shall bill these insurers before billing the
Authority.
(4) The Authority shall
conduct an annual cost settlement to review brokerages costs and expenses and
determine any overpayment or underpayment for costs the brokerage incurred for
covered NEMT services for eligible clients. The following applies to the
Authority's cost settlement process:
(a) The
Authority shall request cost and expense settlement information from the
brokerages 6 months after the end of the fiscal year. The request shall include
file(s) detailing the brokerages claims, a template for the brokerages to
submit their cost and expenses information and instructions for completing the
template. The Authority uses the Oregon Medicaid Management Information System
(MMIS) to create file(s) detailing the brokerages claims data for the
applicable procedure codes per NEMT provider;
(b) Brokerages shall submit the requested
information, certified by a Certified Public Accountant, and complete the
template provided by the Authority within 90 days of receiving the Authority's
request;
(c) The Authority shall
verify the reported costs and expenses and notify the brokerages in writing of
the Authority's determination;
(d)
Brokerages shall comply with the allowable cost requirements established by the
Authority;
(e) If the Authority's
determination results in an adjustment, the brokerages may request an appeal
pursuant to OAR 410-120-1560 through
410-120-1600, pertaining to
provider appeals.
(f) The brokerage
shall refund the amount of the overpayment determined by the Authority within
60 days or as specified by the Authority in its written notice to the
brokerage.
(g) Payment by the
Authority does not restrict or limit the Authority or any state or federal
oversight entity's right to review or audit before or after the payment is made
to a brokerage. Payments may be denied or subject to recovery by the Authority
if medical review, audit, or other post-payment review of the supplemental
payment or the claim upon the basis a supplemental payment was issued
determines the service was not provided in accordance with applicable rules, by
an eligible NEMT provider, or does not meet the criteria for quality of care or
medical appropriateness of the care or payment.
(5) To be eligible for payment brokerages and
subcontractors must meet all of the requirements in Chapter 410 division 136
rules and Chapter 410 division 120 rules. The Authority shall pay for covered
services the brokerage authorized and provided in good faith, including mailing
transit passes to clients. The Authority shall use the rate in effect on the
day of the transport or the mailing date of the transit passes. For the purpose
of this rule "Good faith" means:
(a) The
brokerage verified client eligibility on the date of service or the date of
mailing the transit passes, using the Authority's eligibility information;
or
(b) The client eligibility
information was inconsistent or not available, and the brokerage used the most
recent client information available immediately before the time of service or
mailing of transit passes.
(6) Each brokerage may establish a working
capital reserve with funds the Authority provides. The following applies to any
established working capital reserve:
(a) The
working capital reserve shall represent 30 days of cash expenses for normal
operating purposes. The Authority may base the reserve on a time other than 30
days if circumstances warrant the change;
(b) The Authority shall calculate the reserve
amount as part of the annual cost settlement for the most recent past fiscal
year;
(c) The Authority shall base
the reserve amount on an average of six months of operating expenses that the
brokerage reports in its monthly NEMT financial reports. However, the Authority
may base the reserve amount on more or less than six months of expenses when a
six-month average does not reflect an accurate accounting of
expenses;
(d) Brokerages shall
maintain a separate account for the reserve funds; and
(e) The Authority may require the brokerage
to return any funds in excess of the amount the Authority calculated, or the
Authority may decrease the ride rate to reduce the reserves. If the Authority
requires the brokerage to return the excess funds, the brokerage shall do so
within 45 days of receipt of the Authority notification.
Statutory/Other Authority: ORS
413.042
Statutes/Other Implemented: ORS
414.065
