OAR 333-010-0160
Requirements for Financial, Clinical and Other Records


(1)

The Center is responsible for analyzing and monitoring the operation of ScreenWise BCC and for auditing and verifying the accuracy and appropriateness of payment, utilization of services, the quality of care, and access to care. The provider shall:

(a)

Develop and maintain adequate financial and clinical records and other documentation which supports the services for which payment has been requested. Payment will be made only for services that are adequately documented.

(b)

All medical records must document the service provided, primary diagnosis code for the services, the date on which the service was provided, and the individual who provided the services. Patient account and financial records must also include documentation of charges, identify other payment resources pursued, indicate the date and amount of all debit or credit billing actions, and support the appropriateness of the amount billed and paid. The records must be accurate and in sufficient detail to substantiate the data reported.

(2)

Clinical records must sufficiently document that the client’s services were primarily for breast or cervical cancer screening or diagnosis of breast or cervical cancer. The client’s record must be annotated each time a service is provided and signed or initialed by the individual who provided the service or must clearly indicate the individual who provided the service. Information contained in the record must meet the standards of care for breast and cervical cancer screening and diagnosis, and must be appropriate in quality and quantity to meet the professional standards applicable to the provider or practitioner and any additional standards for documentation set forth in this rule.

(3)

The provider must have policies and procedures to ensure the maintenance of the confidentiality of medical record information. These procedures ensure that the provider may release such information in accordance with federal and state statutes, ORS 179.505 (Disclosure of written accounts by health care services provider), 411.320 (Disclosure and use of records limited to purposes connected to administration of public assistance programs), 45 CFR 205.50.

(4)

The provider must retain clinical, financial and other records described in this rule for at least four years from the date of last activity.

(5)

Upon written request from the Center, the Authority, the Oregon Department of Justice Medicaid Fraud Unit, the Oregon Secretary of State, or their authorized representatives (Requestor), the provider must furnish requested documentation, without charge, immediately or within the time-frame specified in the written request. Copies of the documents may be furnished unless the originals are requested. At their discretion, representatives of the Requestor may review and copy the original documentation in the provider’s place of business. Upon the written request of the provider, the Requestor may, at their sole discretion, modify or extend the time for provision of such records if, in the opinion of the Center, good cause for such extension is shown. Factors used in determining whether good cause exists include:

(a)

Whether the written request was made in advance of the deadline for production;

(b)

If the written request is made after the deadline for production, the amount of time elapsed since that deadline;

(c)

The efforts already made to comply with the request;

(d)

The reasons the deadline cannot be met;

(e)

The degree of control that the provider had over its ability to produce the records prior to the deadline; and

(f)

Other extenuating factors.

(6)

Access to records, inclusive of medical charts and financial records, does not require authorization or release from the client if the purpose of such access is to:

(a)

Perform billing review activities;

(b)

Perform utilization review activities;

(c)

Review quality, quantity and services provided;

(d)

Facilitate payment authorization and related services;

(e)

Investigate a client’s fair hearing request;

(f)

Facilitate investigation by the Authority;

(g)

Where review of records is necessary to the operation of the program.

(7)

Failure to comply with requests for documents and within the specified time-frames means that the records subject to the request may be deemed by the Authority not to exist for purposes of verifying appropriateness of payment, medical appropriateness, the quality of care, and the access to care in an audit or overpayment determination, and accordingly subjects the provider to possible denial or recovery of payments made by the Authority, or to sanctions.

Source: Rule 333-010-0160 — Requirements for Financial, Clinical and Other Records, https://secure.­sos.­state.­or.­us/oard/view.­action?ruleNumber=333-010-0160.

333‑010‑0000
Cancer Reporting Regulations: Definitions
333‑010‑0020
Cancer Reporting Regulations: Reporting Requirements for Health Care Facilities
333‑010‑0030
Cancer Reporting Regulations: Reporting Requirements for Practitioners
333‑010‑0032
Cancer Reporting Regulations: Reporting Requirements for Clinical Laboratories
333‑010‑0035
Cancer Reporting Regulations: Patient Notification Requirement
333‑010‑0040
Cancer Reporting Regulations: Quality Standards
333‑010‑0050
Cancer Reporting Regulations: Confidentiality and Access to Data
333‑010‑0055
Cancer Reporting Regulations: Research Studies
333‑010‑0060
Cancer Reporting Regulations: Special Studies
333‑010‑0070
Cancer Reporting Regulations: Advisory Committee
333‑010‑0080
Cancer Reporting Regulations: Training and Consultation
333‑010‑0090
Cancer Reporting Regulations: Fees
333‑010‑0100
ScreenWise Breast and Cervical Cancer Program: Description of the ScreenWise Breast and Cervical Cancer Program
333‑010‑0105
Definitions
333‑010‑0110
Client Eligibility
333‑010‑0115
Client Enrollment
333‑010‑0120
Covered Services
333‑010‑0125
Excluded Services
333‑010‑0130
Standards of Care for Breast and Cervical Cancer Screening and Diagnostic Services
333‑010‑0135
Provider Enrollment
333‑010‑0140
Billing
333‑010‑0145
Claims and Data Submission
333‑010‑0150
Timely Submission of Claims and Data
333‑010‑0155
Payment
333‑010‑0160
Requirements for Financial, Clinical and Other Records
333‑010‑0165
Compliance with Federal and State Statutes
333‑010‑0170
Denial or Recovery of Reimbursement Resulting from Review or Audit
333‑010‑0175
Recovery of Overpayments to Providers Resulting from Review or Audit
333‑010‑0180
Provider Sanctions
333‑010‑0185
Provider Appeals
333‑010‑0190
Provider Appeals (Level 1) — Claims Reconsideration
333‑010‑0195
Provider Appeals (Level 2) — Contested Case Hearing
333‑010‑0197
Presumptive Eligibility for BCCTP
333‑010‑0200
ScreenWise WISEWOMAN Program: Description of the WISEWOMAN Program
333‑010‑0205
Definitions
333‑010‑0210
Client Eligibility
333‑010‑0215
Client Enrollment
333‑010‑0220
Provider Enrollment
333‑010‑0225
Standards of Care for WISEWOMAN Program Screening and Services
333‑010‑0230
Submission of Information by Ancillary Providers
333‑010‑0235
Covered Services
333‑010‑0240
Excluded Services
333‑010‑0245
Claims and Billing
333‑010‑0250
Payment
333‑010‑0255
Denial or Recovery of Reimbursement Resulting from Review or Audit
333‑010‑0260
Recovery of Overpayments to Providers Resulting from Review or Audit
333‑010‑0265
Client Data Submission
333‑010‑0270
Requirements for Financial, Clinical and Other Records
333‑010‑0275
Compliance with Federal and State Statutes
333‑010‑0280
Provider Sanctions
333‑010‑0285
Provider Appeals (Level 1) — Claims Reconsideration
333‑010‑0290
Provider Appeals (Level 2) — Contested Case Hearing
333‑010‑0300
Tobacco Prevention and Education Program: Definitions
333‑010‑0310
Tobacco Prevention and Education Program: Purpose and Intent
333‑010‑0320
Tobacco Prevention and Education Program: Framework for Grant Awards
333‑010‑0330
Tobacco Prevention and Education Program: Local Coalitions and Community-Based Programs
333‑010‑0350
Tobacco Prevention and Education Program: Statewide Public Awareness and Education Programs
333‑010‑0360
Tobacco Prevention and Education Program: Statewide and Regional Projects Programs
333‑010‑0370
Tobacco Prevention and Education Program: Reporting
333‑010‑0600
Childhood Diabetes Database: Definitions
333‑010‑0610
Childhood Diabetes Database: General Authority and Purpose
333‑010‑0620
Childhood Diabetes Database: Reporting Requirements for Schools
333‑010‑0630
Childhood Diabetes Database: Reporting Requirements for Practitioners
333‑010‑0640
Childhood Diabetes Database: Confidentiality and Access to Data
333‑010‑0650
Childhood Diabetes Database: Research Studies
333‑010‑0660
Childhood Diabetes Database: Advisory Committee
333‑010‑0700
Dental Pilot Projects: Purpose
333‑010‑0710
Dental Pilot Projects: Definitions
333‑010‑0720
Dental Pilot Projects: Application Procedure
333‑010‑0730
Dental Pilot Projects: Application Review Process
333‑010‑0740
Dental Pilot Projects: Project Application Provisional Approval or Denial
333‑010‑0750
Dental Pilot Projects: Provisional Approval
333‑010‑0760
Dental Pilot Projects: Minimum Standards
333‑010‑0770
Dental Pilot Projects: Informed Consent
333‑010‑0780
Dental Pilot Projects: Pilot Project Evaluation and Monitoring by Sponsor
333‑010‑0790
Dental Pilot Projects: Authority Responsibilities
333‑010‑0800
Dental Pilot Projects: Project Modifications
333‑010‑0810
Dental Pilot Projects: Discontinuation or Completion of Project
333‑010‑0820
Dental Pilot Projects: Suspension, Denial or Termination of Project
Last Updated

Jun. 8, 2021

Rule 333-010-0160’s source at or​.us