OHP fee schedule for fee-for-service providers
This page lists quarterly updates (normally posted at the end of Feb. May, Aug. and Nov.) of the maximum allowable payment rates that apply to services directly billed to DMAP, in compliance with applicable law.
The fee schedules are for general information only. They do not define service coverage and do not reflect fees for all programs. Rates may change without notice. Due to a rounding error on some rates, there may be a few cents' difference between the posted rate and the rate applied in our system.
For rates and covered procedures for chemical dependency and mental health services, go to the AMH Tools for Providers.
For reimbursement rates for services to OHP managed care clients, contact the client's managed care plan.
For questions about the rates listed on the fee schedule, contact DMAP Provider Services at dmap.providerservices@state.or.us.
Fee schedule
- Last updated Feb. 2012
The fee schedule shows rates in effect during the month posted. These rates may or may not continue to be in effect after the month posted. Only codes with rate changes in 2011 will show a 2011 effective date.
Download the fee schedule in comma delimited text (CSV), PDF or Excel format. A description of recent changes is available.
Older versions of the fee schedule are available online.
File specifications
- Updated Aug. 2011
This table lists the fields in the current FFS fee schedule, as read from left to right. A procedure code in combination with any applicable modifier is uniquely associated with a specific price.
| Field |
Description |
| Procedure Code |
Procedure Code - For billing purposes, DMAP uses Current Procedural Terminology (CPT), Level III National Codes (HCPCS) and Current Dental Terminology (CDT). |
| Description |
Procedure code description |
| Modifier 1 |
First modifier associated with procedure code. (Blank indicates no modifier.) |
| Modifier 2 |
Second modifier associated with procedure code. (Blank indicates no modifier.) |
| Rate Type |
An "A" in this field indicates that this rate is an ambulatory surgical rate.
A "P" in this field indicates that this rate is a Primary Care rate.
If this field is blank, the rate is not an ambulatory surgical rate or a Primary Care rate. |
| Price |
Price effective during month reported. |
| Effective Date |
Date current price became effective (YYYYMMDD) |
Maximum allowable rates
The following table describes the maximum allowable payment rates for the main types of service listed in the FFS fee schedule.
Rates for Professional services are based on Medicare's 2010 Transitional Non-Facility Total Relative Value Unit (RVU) weights (available on the CMS Web site), multiplied by the base rates below. Instructions on how to find the Relative Value Unit (RVU weights) on the CMS website are available.
| Type of service |
Rate description |
| Professional services - Default rate |
$26.00 base rate |
| Professional services - Obstetric/delivery codes (59400-59622) |
$41.61 base rate |
| Professional services - Vision codes (92340-92342 and 92352-92353) |
$26.81 flat rate |
| Professional services - Primary care codes |
When rendered by a primary care provider: $27.82 base rate
When rendered by a non-primary care provider: $26.00 base rate |
| Surgical assist |
20% of the surgical rate. |
| Anesthesia services (codes 00100-01996) |
$21.20, base rate, per unit of service |
| Non-RVU-weight based clinical lab codes |
70% of the 2011 Medicare clinical lab fee schedule |
| Ambulatory Surgical Center |
80% of Medicare's 2010 fee schedule |
| Physician-administered drugs |
100% of the current quarter's Medicare Average Sale Price (ASP), when available. When no ASP rate is available, DMAP bases reimbursement on the Wholesale Acquisition Price (WAC) plus 6.25%.
Pricing information for WAC is provided by First Data Bank. If no WAC is available, then the drug will be reimbursed at Acquisition Cost. |
| Vision materials and supplies |
Contracted rates, which include acquisition cost plus shipping and handling. |
| Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS) |
Medicare-covered codes: A percentage of Medicare's fee schedule.
Unspecified item codes (e.g., K0108 and E1399) and codes that require manual pricing: Acquisition cost plus 20%. |
| Dental |
A percentage of commercial insurers' fee, provider usual and customary fees, or through comparison with other state Medicaid reimbursement rates. |
Other resources
- See the OHP Billing Tips, DMAP General Rules, and OHP Administrative Rules for more information about how to bill DMAP, how to determine service coverage, accepted codes and DMAP payment policies.
- For information on prior authorization information, 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. Find out how to use this feature online.
- For program-specific rates not listed in the OHP fee schedule and any program-specific payment policies that may apply, refer to your provider guidelines, rules or contracts.
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