Text Size:   A+ A- A   •   Text Only
Find     
Site Image

Oregon Health Plan eligibility
  • Applicants can use Oregon Helps to find out if they may be eligible for various forms of assistance, including OHP. They can also visit a qualified hospital to see if they are eligible for immediate and temporary medical assistance' through the Hospital Presumptive Eligibility process
  • Clients are sent an OHP coverage letter that describes the current eligibility for all members of their household. Learn more in the OHP Client Handbook.
  • Providers can use multiple systems to verify OHP eligibility. Clients should present their Oregon Health ID (formerly Medical Care ID) at each health care visit so that providers can check eligibility using the Client ID Number printed on the card. 
If you have questions not answered on this page, go to the Contact Us page and send your question to the appropriate DMAP contact.
 
 

 OHP-Faqs

 
  
Answer
How do providers verify eligibility for OHP Plus dental benefits?

Most dental services, including hygiene and restorative services, are covered for all OHP Plus clients. OHP Plus children, CAWEM Prenatal (CWX) adults, and OHP Plus adults with the OHP Plus - Supplemental Benefits plan (BMP) get additional dental services. Refer to the Covered/Non-Covered Services table for a list of services affected.

To verify eligibility for the additional OHP Plus dental services:
  • Members under age 21: Verify the member’s date of birth and that client has the BMH benefit plan.
  • Members age 21 or older: Verify the member has the BMP benefit plan and the BMH benefit plan.
How do providers verify eligibility for OHP Plus vision benefits?

Remember that medical vision services are covered for all OHP Plus clients. Only OHP Plus children, and adults with CAWEM Prenatal (CWX) or OHP Plus - Supplemental Benefits (BMP) are eligible for services to improve visual acuity (e.g., glasses or exams to prescribe glasses). Refer to the Visual Services administrative rules for the services affected.

To verify eligibility for OHP Plus vision services:
  • Members under age 21: Verify the client’s date of birth and client has the BMH benefit plan.
  • Members age 21 or older: Verify the client has the BMP benefit plan and the BMH benefit plan.
What happens when a change occurs in an OHP member’s household (e.g., pregnancy, household members moving in or out, change in income)?

All OHP members must report household changes to their worker. 

  • The changes may make the member ineligible for medical assistance, or make the member eligible under a different benefit package.
  • If the reported changes affect medical eligibility, the member will receive a letter telling how eligibility has changed.
  • ​​
How do providers verify eligibility and enrollment for OHP members?

Use Provider Web Portal​, the electronic data interchange (EDI) 270/271 transaction, or Automated Voice Response. 

  • You will need to enter the 8-digit Oregon Medicaid client ID, plus the client’s name or date of birth, as listed on the client’s Oregon Health or DHS Medical Care ID.
  • See our eligibility verification page to learn more.
Where can providers go to verify Oregon Medicaid eligibility?

​Provider Web Portal (PWP) - To learn about how to use PWP, visit our Provider Web Portal page.

Automated Voice Response - 866-692-3864 (press 1 for Recipient Eligibility)

EDI 270/271 Transaction - Through your billing software or clearinghouse. To learn more, visit our EDI page​.

Why do providers need to verify eligibility?

The General Rules provider guidelines include the Oregon Administrative Rule (OAR) that requires providers to verify eligibility before providing service. 

DMAP will not pay for services rendered to clients who are not eligible on the date the service was rendered.

Clients should present their Oregon Health ID at each visit to make sure providers know they are on OHP and services are billed to the correct payer (DMAP or the client's CCO/health plan).

How do providers know if a client is eligible to receive a specific service?

Coverage of a specific service depends on two things:

 

What information do providers need to verify client eligibility?

​You will need to enter the client's 8-digit Oregon Medicaid client ID, plus the client’s name or date of birth, as listed on the client’s Oregon Health or DHS Medical Care ID.

Due to Oregon Administrative Simplification​ requirements, we no longer allow eligibility verification using Social Security number.

How long will OHP coverage last before clients need to reapply? 

Clients must reapply after 12 months. An OHP application will be mailed at the end of the tenth month of coverage. ​

​​​​​​