|
OHP fee schedule for fee-for-service providers
Important note about fee schedules and rates: The fees and rates on these pages only apply to services or items provided to eligible fee-for-service DMAP clients by providers enrolled with DMAP, in compliance with applicable law.
The fee schedules are informational only; not a promise to pay the amount on the schedule. The information in the posted fee schedules does not affect claims processing in any way.
 Receive FFS Fee Schedule updates by email
For questions about the rates listed on the fee schedule, contact DMAP Provider Services at dmap.providerservices@state.or.us.
________________________________________________________________________________________________
About the FFS fee schedule
DMAP aims to update the fee schedule every other month. Fees may change without notice. While DMAP makes reasonable efforts to keep these schedules up-to-date, the actual payment amount, coverage and eligibility criteria in effect on the date of service will apply, regardless of the general fee schedule information posted on this Web site.
- The fee schedules provide general information on DMAP's maximum allowable rates. However, a procedure code listed with a fee does not mean that DMAP covers the procedure in all cases. For information on whether a specific procedure code is covered for an OHP client or benefit plan, or whether it is included on the Prioritized List of Health Services, use the Benefits and HSC List Inquiry search on the secure Provider Web Portal at https://www.or-medicaid.gov. To find out how to use this feature, click here.
- The fee schedules do not provide information about prior authorization requirements or replace the requirements applicable to payment for covered services. Please refer to your provider guidelines or rules, or the HSC List Inquiry feature on the Provider Web Portal for this information.
- The fee schedules do not reflect fees for all DMAP programs. Refer to your provider guidelines, rules or contracts for program-specific rates not listed in the fee schedules.
- Rates for RVU-assigned codes may also be downloaded from the CMS Web site. Please refer to the instructions listed on the Maximum Allowable Rate-Setting page for information on the file to download (look under "Relative Value Unit Assigned Codes").
About DMAP rates
DMAP's maximum allowable reimbursement rates are outlined in General Rules OAR 410-120-1340 (Payment), as well as the administrative rules for your individual provider program. These rates are specific for services directly billed to DMAP. For program-specific information, go to the maximum allowable rate setting page.
- Providers must use all applicable administrative rules (OARs) to determine if there are any coverage criteria, limitations, restrictions, exclusions or client benefit limitations related to a specific procedure code.
- DMAP does not cover all valid codes, and DMAP may not allow covered codes in all settings. See General Rules OAR 410-120-1280 (Billing) for more information.
- The federal Centers for Medicare and Medicaid Services (CMS) establishes Oregon's allowable rate for administration of vaccines supplied by the Vaccines for Children program; this rate is excluded from any state adjustments.
- DMAP expects providers to bill their usual and customary charges unless otherwise specified; for example, DMAP pays for some services at acquisition costs only.
- DMAP bases all reimbursement on client eligibility and DMAP covered services. Refer to DMAP's General Rules, OHP administrative rules, and other appropriate administrative rules and guidelines for payment policies.
Billing DMAP
Make sure you are billing DMAP as outlined in the General Rules and the specific provider guidelines for your program. For more detailed information about billing, go to the OHP Billing Tips Web page.
- Maintain documentation of all services provided that support the fee or rate you bill; the date of service; the individual who provided the service; and any other documentation required by rule, provider guidelines or contract.
- Bill other resources first. In most cases, Medicaid is the payer of last resort. For DMAP clients with third-party resources (other insurance, including Medicare), DMAP pays the DMAP-allowed rate or fee, less the TPR payment but not to exceed DMAP's maximum allowable rate or fee.
- Do not deduct a DMAP client copayment from the fee submitted on the claim. DMAP will deduct the amount of the copayment from the amount paid to the provider.
Back to top
|
