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How to submit claims to DMAP

How to submit claims to DMAP

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

Questions and answers about billing DMAP​

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

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


Answer
Can I bill DMAP 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—DMAP 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 DMAP processed my claim?

The Provider Web Portal will tell you whether DMAP 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 DMAP processes your claim) to find out the exact amount paid.​

What codes does DMAP accept for billing?

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

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

What should providers do before billing DMAP?
  • 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. DMAP bases all reimbursement on client eligibility and DMAP covered services.
  • 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. 
Should providers bill the full amount to DMAP?

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

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

What are your NPI requirements for billing?

NPI is required for all claims.

  • ​When billing DMAP, make sure the NPI you bill under is the same one you have reported to DMAP for your Oregon Medicaid ID. To check your NPI information with DMAP, contact DMAP 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 DMAP claim processing, how to bill DMAP on paper, and how to bill using the Provider Web Portal​​​​

Provider Web Portal

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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
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Paper Claims

  
Claim Adjustment Handbook
Dental Billing Instructions
Institutional Billing Instructions
Nursing facility tips for completing the DMAP 1036
Nursing facility tips for completing the UB-04
Pharmacy Billing Instructions
Professional Billing Instructions

​Other Resources

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Codes Requiring NDC Information (Procedure Group 6069)
Common FFS billing errors
Diabetic Supply Codes and Fees - Billing Examples, August 2011
National Drug Code reporting tips
National Drug Code reporting webinar
National Drug Codes for Diabetic Supplies
NCPDP Unit of Measure (UOM) List
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