The department's Medical Payment Recovery Unit is responsible for recovering Medicaid funds that have been expended on behalf of a Medicaid eligible client where other insurance coverage should have been the primary source for payment.
If you have questions about a request to refund a provider payment made to you for Medicaid services, contact Medical Payment Recovery (MPR) at 503-378-2005 (fax 503-391-2360). Please specify if it is a medical claim or a prescription claim.
If you have questions about billing, adjustments, or other claim-related questions, contact DMAP. Go to the Oregon Health Plan's contacts webpage for more information.
About Medical Payment Recovery
With some specific exceptions, providers are required to bill Third Party Liability (TPL) resources prior to billing Medicaid for the purpose of coordination of benefits. If, after 30 days, the third party resource doesn't respond, the provider can bill Medicaid.
The Medical Payment Recovery Unit works with insurance carriers, medical providers, clients and other state agencies to ensure appropriate payments are made by the primary payer.
Frequently Asked Questions
Is Medicaid an insurance company?
No. Medicaid is a benefit the state provides for eligible clients under the Oregon Health Plan (OHP). If the client has private health insurance, and Medicaid has already paid the claims, the department then bills the third party insurance for reimbursement. When a Medicaid client has third party insurance providers are required to bill the private insurance carrier before billing the state because Medicaid is always the payer of last resort.
If an OHP (Medicaid) client has a third party insurance (TPI) and it is not showing in MMIS, who do I contact?
Providers are required to report third party insurance on the Insurance Notification Form (DHS 8708). Once completed, fax it to the Health Insurance Group (HIG) at 503-373-0358 or mail to HIG, PO Box 14023, Salem, Oregon 97309.
I am treating an OHP (Medicaid) patient for a vehicle- or work-related injury. Who do I contact?
If Medicaid has paid medical bills related to that injury, the client must file a claim against the liable third party. Contact Personal Injury Liens at 503-378-4514 or 1-800-377-3841 or e-mail email@example.com. The client must complete and submit to DHS either the:
I need to send in a refund check. What do I need to include with it?
You will need a copy of the Remittance Advice (RA) indicating the claim and the amount that is being refunded for each claim. If you are refunding because other insurance has paid, please enclose a copy of the insurance Explanation of Benefits (EOB).
If you do not have a copy of the Remittance Advice you will need to send:
Provider NPI number
Claim date(s) of service
Recipient name and case number
Claim ICN (internal control number)
The amount you are refunding for each claim
The reason for the refund
Why is it necessary to get a prior authorization (PA) for a service that has already been denied?
A prior authorization needs to be in place before the carrier will pay the claim and frequently can be approved and used retroactively for recovery purposes.
Does a physician need to do a PA when MPR sends them a request?
Yes. Providers are required to comply with the request.
If a provider's claim did not process correctly who should they contact?
For any claims processing questions you can refer them to the DMAP Provider Services Unit (PSU) at 800-336-6016.
Who should I refer a provider to if they have questions about DMAP policies or billing practices?
Refer them to DMAP Provider Services at 800-336-6016 or OHP Tools for Providers for other resources.
There was an adjustment that took back a claim payment. How can I find out why this happened?
For information regarding claim adjustments you can contact the Provider Services Unit at 800-336-6016.