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How to submit claims to OHA

How to submit claims to OHA

Learn how to bill OHA for services delivered to clients on a fee-for-service basis.

Questions and answers about fee-for-service billing​

Also refer to the provider guidelines for your program and the General Rules.

If you have other billing questions not answered on this page, call Provider Services at 800-336-6016, or email dmap.providerservices@state.or.us

Can I bill OHA electronically?

Yes; enrolled providers can do individual claim submissions using the Provider Web Portal. Go to our Provider Web Portal page to learn more.

Providers can also submit batches of claims using electronic data interchange. Go to our EDI page to learn more.​

How do I bill for services to OHP members?

Make sure you bill any other payers first. Then verify eligibility and enrollment to determine if your patient is a current OHP member, and to determine whom to bill—OHA or an OHP health plan.

You can bill using the Provider Web Portal, electronic data interchange, or commercially available paper claims.

Visit our OHP billing tips page for more information.​

How do I find out how OHA processed my claim?

The Provider Web Portal will tell you whether OHA will pay or deny your claim as soon as you submit it; however, you will need to wait for your paper remittance advice​ (mailed the week after OHA processes your claim) to find out the exact amount paid.​

What codes does OHA accept for billing?

For billing purposes, OHA uses Current Procedural Terminology (CPT)Level II National Codes (HCPCS) and Current Dental Terminology (CDT) procedure codes.

OHA does not cover all valid codes, and OHA may not allow covered codes in all settings. ​

What should providers do before billing OHA?
  • 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.
  • 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. OHA bases all reimbursement on client eligibility and covered services.
  • Bill other resources first. In most cases, Medicaid is the payer of last resort. For clients with third-party resources (other insurance, including Medicare), OHA pays their maximum allowed rate or fee, less the TPR payment but not to exceed the maximum allowable rate or fee.
  • Do not deduct an OHP client copayment from the fee submitted on the claim. OHA will deduct the amount of the copayment from the amount paid to the provider. 
Should providers bill the full amount to OHA?

OHA expects providers to bill their usual and customary charges unless otherwise specified in the rules for a specific provider program; for example, OHA pays for some services at acquisition costs only.

Generally, OHA pays the maximum allowed rate or fee, less the TPR payment but not to exceed the maximum allowable rate or fee. Visit the OHP fee schedule page to learn more about maximum allowed rates.​

What are your NPI requirements for billing?

NPI is required for all claims.

  • ​When billing OHA, make sure the NPI you bill under is the same one you have reported for your Oregon Medicaid ID. To check your NPI information, contact Provider Enrollment (800-422-5047).
  • To look up the NPI of the ordering, referring, or rendering provider for a claim, use the NPI Registry.

Handbooks, tips, and step-by-step guides

Learn about fee-for-service claim processing, how to bill OHA on paper, and how to bill using the Provider Web Portal​​​​

Provider Web Portal

Adjusting and Resubmitting Claims
Claim Adjustment Handbook
Dental Billing Instructions
Institutional Billing Instructions
Pharmacy Billing Instructions
Professional Billing Instructions
Submit dental claims
Submit institutional claims
Submit pharmacy claims
Submit professional claims
View plan of care and submit professional mental health claims

Paper Claims

Claim Adjustment Handbook
Dental Billing Instructions
Institutional Billing Instructions
OHP 1036 - Helpful reminders for nursing facilities
Pharmacy Billing Instructions
Professional Billing Instructions
UB-04 - Helpful tips for nursing facility providers

​Other Resources

Billing basics
Billing for Child Abuse Assessments and Related Services
Billing for doula services
Billing for LARC postpartum services
Billing rate changes for services that require local match payments
Common FFS billing errors
Diabetic Supply Codes and Fees - Billing Examples, August 2011
How to address claim and PA Issues
ICD-10 Frequently Asked Questions
National Drug Code reporting tips
National Drug Code reporting webinar
National Drug Codes for Diabetic Supplies
NCPDP Unit of Measure (UOM) List
Oregon Medicaid Third Party Liability Requirements
Out of Hospital Birth Reimbursement Guide
Provider Tips - Billing OHP members
Provider Tips - OHP and QMBs