Provider taxonomy codes and other codes are available on the Washington Publishing Company website.

At this time, Oregon Medicaid accepts claims for payment in the 837 Professional, Institutional and Dental formats for fee-for-service and encounter.

 

Oregon Medicaid does not endorse or recommend any HIPAA software. For more information about how to select an EDI vendor (for software, billing or clearinghouse services), go to our Getting Started page.

Yes, Oregon Medicaid does require an agreement between a healthcare provider wishing to submit claims electronically and Oregon Medicaid for payment. Please see the FAQ on Trading Partner Agreements and our Registration and Testing page for more information.

Oregon Medicaid will continue to produce the paper RAs after a provider begins receiving the 835 remittance advice.

The 837 is the standard transaction for all health care providers wishing to send claims to payers electronically. There are three types: the professional, institutional and dental. The professional most closely relates to the current CMS-1500 or NSF format, the institutional to the UB-04 for inpatient and outpatient and the dental to the ADA form or NSF format. There are additional differences with regard to fee-for-service claims versus managed care encounter claims.

The 837 Dental (D), Institutional (I) and Professional (P) Technical Reports (TR3s) detail the specifics of creating, and/or receiving electronic data interchange of health care claims/encounters information. These are electronic formats and no paper equivalent exists.

 

While there are no forms specifically formatted for these transactions, they were based on commonly used paper forms such as the ADA Dental claim form for the 837 D, the CMS-1500 for the 837 P, and the 837 I for the UB-04.

 

However, there is no one-to-one relationship to the data on the paper forms and the data required in the 837 formats. You will need to review the TR3s and your current system to determine what changes your current system will require.

 

The TR3s are available for purchase from the Washington Publishing Company Web site.

Oregon Medicaid does not have software that can be used to submit electronic claims. We recommend contacting your local professional association, checking the Internet, CMS Web site, or review the resources on the Getting Started page of our website.

The Trading Partner Agreement (TPA) is a binding agreement between Oregon Medicaid and a provider (OAR 943-120-0100). Oregon Medicaid requires all of those planning to do electronic business with Oregon Medicaid to sign a Trading Partner Agreement before testing.

Exhibit B of the TPA allows for seven different contacts: Two provider contacts for contact or authorized signer, another two provider contacts for claims inquiries, and three contacts for the EDI submitter.

The answer is yes and no.

• Yes, if the pharmacy electronically submits durable medical equipment (DME) claims, they must complete a TPA and register for the 837 Professional transaction.
• Yes, if the pharmacy is receiving an electronic RA, they must register to receive the 835 RA transaction.
• Yes, if the pharmacy only submits electronically through point of sale (POS), they must register to receive the 835 RA transaction.
• No, if the pharmacy submits paper claims only, Oregon Medicaid will only return claims information on the paper RA.

The TPA is designed to identify the two relationships Oregon Medicaid must understand: 1) Who the provider is (the trading partner), and 2) Who will be submitting the compliant transaction to Oregon Medicaid for payment or adjudication (the EDI submitter).

 

In this scenario, we are only interested in the clearinghouse that ultimately submits the claim to Oregon Medicaid. If the relationship between the trading partner and their identified EDI submitter changes, the trading partner must notify Oregon Medicaid using Exhibit C - EDI Registration Change Form available on our Web site.

If each provider receives their own check, they each have to fill out a TPA. If a clinic or group of providers receives the payment, then only one TPA is required. Instructions on how to complete registration for multiple individuals are available in the EDI Registration Packet.

Because Oregon Medicaid requires original inked signatures, we must have the original TPA on file. As with any legal document, do not use correction fluid.

If you submit on your own behalf but also use an EDI submitter for some of your work, then yes. One TPA will indicate the transactions you will submit; a separate TPA will indicate which transactions your EDI submitter will send on your behalf. The second scenario requires the TPA to go to the submitter for their information and signature.

The authorized signer is the person of authority in the provider's office. This does not include a billing service. The authorized signer can delegate another person to have signing authority such as an office manager to make changes to the TPA. If you choose to have a deleted signer in addition to the authorized signer, make sure to clearly identify the delegate on the TPA.

Oregon Medicaid does not anticipate any significant changes to the TPA registration process. However, HIPAA is a federally mandated requirement and Oregon Medicaid must comply as the requirements change.

You can download the information on our Registration and Testing page. If you have additional questions call 503-947-5347, 888-690-9888, or email DHS.EDIsupport@state.or.us.

No. You can update this information using Exhibit C (EDI Registration Change Form).

Yes. Oregon Medicaid tracks and uses this information when setting up profiles for submission of transactions. To update your list of authorized transactions, complete Exhibit C.

If you submit claims to DMAP electronically in the 837 transaction, you have the option at this time to receive the electronic 835 RA response or the paper RA.

Oregon Medicaid has committed to responding to email questions within 2-5 business days. Questions are answered in the order they are received based on how technical the question.

The Oregon Medicaid business-to-business email address is not used for questions and answers. Please use the DHS.EDIsupport@state.or.us address.

Oregon Medicaid expects a test file to contain at least 25 claims, but no more than 100 live claims. Oregon Medicaid strongly encourages providers to test the coordination of benefit segments. Oregon Medicaid will run the file through Edifecs and Claredi edits before setting the file up to process in our test environment.

 

If the file passes the structural and data requirements of Edifecs and Claredi, Oregon Medicaid will process the file in our test environment and generate an error report. If the file has not exceeded the threshold of any more than 10% error rate, Oregon Medicaid will notify you of a provisional pass status for production. If the file exceeds the 10% error rate, review the error report for possible modifications.

Oregon Medicaid is a health care provider and is under the same federal requirements as set forth by HIPAA. The Implementation Guide (IG) is a document maintained and published by the Washington Publishing Company. We can not advise any health care provider, software vendor or clearinghouse on how to interpret the IG.

Oregon Medicaid you to use real, live claims for testing purposes. Test data must not have dates more than 365 days from the original date of service, and you must include 25-100 claims per data file tested.

FTP

FTP

The paper RA is from Oregon Medicaid's current Medicaid Management Information System (MMIS), which still requires a TOS code to be present. To process claims in the existing system, Oregon Medicaid created a workaround where TOS is automatically entered for each claim based on provider type, modifier usage and procedure code.

 

If the TOS entered based on this information is incorrect, the claim does not pay. The RA will show non-payment due to a TOS error, which is based on the combination of data elements used to determine the TOS.

 

When the replacement MMIS goes live, this RA report will go away. The HIPAA-compliant adjustment reason codes are the ones that you should become familiar with to prepare for the change.

No, contact Oregon Medicaid through the DHS.EDIsupport@state.or.us email address, or call 888-690-9888.

The provider must submit a new or revised Trading Partner Agreement (TPA) to Oregon Medicaid. If the provider/trading partner has a TPA on file indicating a different submission process (e.g., different clearinghouse), then the provider can submit Exhibit C (Registration Change Form).

You will need to change your password every 60 days. This time starts from the time you are assigned a password and you change it for the first time. The SFTP mailbox does not offer any reminders to warn you that your password is ready to expire.

Oregon Medicaid does not have a business decision or policy against running scripts, but we strongly advise against it. Scripts do not typically address password requirements, resulting in calls to reset the password. If you do not disable the script, we cannot easily reset the password.