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Billing of PacificSource Community Solutions Members

A provider rendering services to a PacificSource Community Solutions member may not bill the member or a financially responsible relative/representative for any Medicaid-covered services, except in the following situations:

  • The member did not inform the provider of his enrollment with the plan at the time of service, and as a result, the provider was unable to bill the plan for any reason--including submitting a timely claim or lacking a pre-approval (the provider must have documentation of attempts to obtain eligibility/enrollment information)
  • The member received services prior to enrolling in the plan. He/she was retro-actively enrolled with the plan to be effective on the date of service, but upon retro-active review, did not meet established criteria for coverage of the service provided
  • The member does not have full OHP benefits. For example, members with limited coverage (such as Standard members) may be billed for services that are not benefits of those programs. However, in order to bill the member under these circumstances, the provider must document that the member was informed in advance of receiving the specific service that 1) it is not covered, 2) the estimated cost of the service, 3) that the member/representative is financially responsible for payment of the specific service. The provider must document this in writing and the member/representative must have signed it to knowingly and voluntarily agree to be responsible for payment. Follow this link for an OHP Patient Responsibility Form.

A provider rendering services to a PacificSource Community Solutions member may not bill the member or a financially responsible relative/representative for non-covered services except in the following situation:

  • The service is not covered/has been denied by the plan, and the member was informed in advance of receiving the specific service that 1) it is not covered, 2) the estimated cost of the service, 3) that the member/representative is financially responsible for payment of the specific service. The provider must document this in writing, and the member/representative must have signed it to knowingly and voluntarily agree to be responsible for payment. Follow this link for an OHP Patient Responsibility Form.

A provider MAY NOT bill a plan member/representative for:

  • Services that have been denied by the plan due to provider error (for example, required documentation not submitted, pre-approval not obtained, etc);
  • Missed appointments.

Reference: Oregon Administrative Rule 410-120-1280