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

Tools for OHP health plans

Tools for OHP health plans

Technical assistance for the coordinated care organizations and dental & mental health plans that coordinate care for over 90 percent of Oregon Health Plan (OHP) clients. 

Questions and answers for health plans

Use the drop-down boxes below to select the category or question you need an answer for. Or, use the search field to search by all fields. For example, enter "OHP meeting" to look for information about OHP-related meetings.

About OHPHow can I get involved?
ACA Section 1202 Rate IncreaseWhen will OHA apply the 2013-2014 primary care rate increase?

OHA will apply the FFS federal primary care rates based on the dates qualified providers submit their attestations. Only services rendered in calendar years 2013 and 2014 qualify for the new rates:

Attestation submitted
Increased FFS rate will apply to
qualifying services rendered on or after:
Jan. 1 to Mar. 31
Jan. 1
Apr. 1 to June 30
Apr. 1
July 1 to Sep. 30
July 1
Oct. 1 to Dec. 31
Oct. 1

Note: OHA began paying the FFS federal primary care rates in July 2013. We reprocessing additional eligible claims to retroactively pay the federal rate increase (details to be determined). 
ACA Section 1202 Rate IncreaseWhich provider types are eligible for the 2013-2014 primary care rate increase?

Physicians with a specialty designation of family medicine, general internal medicine, or pediatric medicine; or

Nurse practitioners and physician assistants billed through, and working under the supervision of, a qualified physician.

ACA Section 1202 Rate IncreaseWhere can OHP health plans learn more about the 2013-2014 primary care rate increase?
BenefitsWhat does OHP Plus cover?

OHP Plus (BMH) is the most comprehensive benefit. It covers most health care services. Services to improve vision (e.g., glasses) are covered for children under age 19 and pregnant adults; for non-pregnant adults, vision services are covered only for specific medical conditions.

OHP with Limited Drug (BMD or BMM) covers the same benefits as OHP Plus, except it does not cover drugs that Medicare Part D should cover.

This chart lists the benefits covered for each OHP benefit package.

BenefitsWhat does OHP Plus Supplemental cover?

OHP Plus Supplemental covers the following services for pregnant women age 21 and over: 

  • Glasses 
  • Contact lenses 
  • Fittings for glasses or contacts 
  • Eye exams for prescribing glasses or contacts 
  • Dental crowns 
  • Dental visits for observation 
  • Replacement of full dentures 
  • Root canals on molars and some other tooth root procedures 
  • Some gum or oral surgery 
  • Some types of dentures and partials

This chart lists the benefits covered for each OHP benefit package.

BenefitsAre eye exams covered?

For non-pregnant adults age 21 or older, OHP Plus (BMM, BMH and BMD) covers medical eye exams for any eye condition except for "disorders of refraction and accommodation" (e.g., nearsightedness, farsightedness, astigmatism). Diagnostic services are still covered.

Eye exams for “disorders of refraction and accommodation” are covered for OHP members under age 21 with BMM, BMH and BMD benefit coverage, and for pregnant OHP members with BMP or CWX benefit coverage.​

BenefitsAre glasses or contact lenses covered?

For non-pregnant adults age 21 or older, OHP Plus (BMM, BMH and BMD) only covers glasses or contact lenses to treat the following medical diagnoses:

  • Pseudoaphakia 
  • Aphakia 
  • Congenital aphakia 
  • Keratoconus

For OHP members under age 21 with BMM, BMH and BMD benefit coverage, and for pregnant OHP members with BMP or CWX benefit coverage, only glasses (not contact lenses) are covered for “disorders of refraction and accommodation.”

BenefitsWill OHP pay for treatment when there is an accident or injury to the eye(s)?

Yes. Urgent/emergent treatment is a covered service for all benefit packages.​

BenefitsDoes OHP cover preventive services?

Yes. The OHP Plus, CAWEM Plus, and OHP with Limited Drug benefit packages cover preventive services, which include immunizations, check-ups, and screening tests (such as mammograms and PAP tests). ​

BenefitsHow do providers know which benefit package applies?

Use Automated Voice Response, the Provider Web Portal, or the 270/271 eligibility inquiry and response. Learn more on the Eligibility Verification page.​

BenefitsWhat if someone wants treatments not included their benefit package?

If an OHP member wants a service that is not covered by their benefit package or is not covered for the condition being treated, the member must sign an Agreement to Pay form that contains all the elements of the OHP 3165 form, as required by OAR 410-120-1280. This form shows that the OHP member understands the service is not covered and agrees to pay for the service.

Without this form, providers may be responsible for costs related to providing excluded and limited services.​

BenefitsHow do OHP members know if a health care service isn't covered?

OHP health plans are required to send out a Notice of Action to their members, as defined in OAR 410-141-0260 and 410-141-3263, which includes the denial of payment for services.

All providers should let their patients know whether or not the service is covered before delivering the service, including when services will exceed benefit limits (e.g., more frequent dental care).​

EligibilityHow 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.
EligibilityHow 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.
BenefitsHow does the Prioritized List of Health Services determine what OHP covers?

It ranks pairs of health conditions and treatments according to effectiveness. The higher a condition and treatment pair is ranked, the more likely OHP will cover it. To learn more visit our Prioritized List page.​

Complaints and appealsIf OHP or the plan denies coverage of a service that has already been delivered, can an OHP member appeal the denial?

All OHP members can file a request for hearing if they disagree with a payment decision. Members of OHP health or dental plans who disagree with the plan’s denial of payment can also appeal the decision with their plan.

The OHP member is only responsible for payment if he or she signed a waiver agreeing to be responsible for payment of the non-covered service.
Complaints and appealsAre there federal rules about a Medicaid client's right to a hearing?

Yes. The Code of Federal Regulations (CFR) governs hearing rights. 42 CFR 431.220(b) says we need not grant a hearing when the only issue is a federal or state law that requires an automatic change that adversely affects some or all recipients.​

Complaints and appealsDo OHP members have appeal rights when they are disenrolled from an OHP health or dental plan?

Yes. Our rules list the conditions for disenrollment. The plan must meet those conditions before we will approve the request for disenrollment. (See OAR 410-141-0080 and 410-141-3080).​

CopaymentsWho has to pay copayments?

For services provided before January 1, 2017, copayments only apply to adults (age 19 and over) who receive OHP Plus (BMH) or OHP with Limited Drug (BMM/BMD) benefits who are not exempt from copayments. ​

CopaymentsWho does not have to pay copayments?
Starting January 1, 2017, there are no OHP Plus copayments.

The following groups do not have to pay copayments for services provided before January 1, 2017:
  • Children under age 19
  • Youths in foster care through age 20 
  • Young adults in the Former Foster Care Youth Medical program
  • Adults who receive OHP Plus (BMH, BMM or BMD) benefits who:
    • Are pregnant;
    • Receive services under a home- and community-based waiver: These services include most in-home services or services in an adult foster home or other home or facility paid by Aging and People with Disabilities;
    • Are inpatients in a hospital, nursing facility, or Intermediate Care Facility for the Mentally Retarded (ICF/MR); 
    • Are American Indian/Alaska Native members of a federally recognized Indian tribe or receive services through a tribal clinic;
    • Are receiving hospice care; or
    • Are eligible for the Breast and Cervical Cancer Program.
CopaymentsDo OHP members with other health care coverage have copayments?

Members with both Medicare and Medicaid coverage have copayments for the applicable Medicaid services. Providers cannot charge the member for their TPL copayments, coinsurance or deductibles if they are billing OHP for what TPL did not pay.

For services provided before January 1, 2017, providers should only collect the OHP copayment when the amount TPL paid for the service, plus the OHP copayment amount, is less than the amount OHP would normally pay for the service. This means the amount collected may be less than OHP's normal copayment, depending on how much TPL paid. ​

CopaymentsHow much are copayments?

For services provided before January 1, 2017, OHP charges a $3 copayment for certain types of outpatient services, and a $1 or $3 copayment for certain prescription drugs. The copayment amount depends on the type of prescription filled:

  • $1 for non-preferred Preferred Drug List (PDL) drugs and non-PDL generics costing more than $10; no copayment for preferred PDL generics, non-PDL generics costing less than $10, and preferred PDL brands; 
  • $3 for all other non-PDL brand-name drugs. ​
CopaymentsWhich services have copayments?

Table 120-1230-1 in the General Rules administrative rulebook lists the provider types and services subject to OHP Plus copayments. If provided before January 1, 2017, these include: 

  • Some prescription drugs
  • Office visits 
  • Home visits 
  • Hospital emergency room services when there is not an emergency 
  • Outpatient hospital services 
  • Outpatient surgery 
  • Outpatient treatment for chemical dependency 
  • Outpatient treatment for mental health 
  • Occupational therapy 
  • Physical therapy 
  • Speech therapy 
  • Restorative dental work
  • Vision exams​
CopaymentsWhich services do NOT have copayments?

Starting January 1, 2017, there are no OHP Plus copayments.

For services provided before January 1, 2017, copayments are not charged for: 

  • Emergency services 
  • X-ray and lab services 
  • Durable medical equipment and supplies 
  • Routine immunizations 
  • Drugs ordered through our home-delivery pharmacy program  
  • Family planning services and supplies 
  • Diagnostic and preventive dental services – These include oral examinations to identify changes in your health or dental status. They also include routine cleanings, x-rays, lab work and tests needed to make a diagnosis or treatment decision. 
  • For members enrolled in an OHP health or dental plan, the services and drugs covered by that plan (copayments can apply to managed care plan services, but most plans have chosen not to charge copayments).
  • For members with Medicare and other health coverage resources (third-party liability, or TPL), any services and drugs paid by the TPL where the TPL's payment is as much or more than what OHA would normally pay for the service/drug.
  • Services to treat "health-care acquired conditions" (HCAC) and "other provider preventable conditions" (OPPC) services as defined in OAR 410-125-0450.
CopaymentsAre copayments charged per procedure, per visit, per day, etc.?

For services provided before January 1, 2017, providers may charge the applicable copayment per visit per day. Pharmacies may charge for each fill.​

CopaymentsWho collects the copayment, and when will it be collected?

The health care provider or pharmacy collects the copayment. They may collect it at the time of service or during the regular billing cycle.​

CopaymentsWhat happens if a member does not pay the copayment?

The member will still be able to receive the health care service or drug; however, the provider can choose whether to collect it at a later time.

OHP members who do not pay the copayment should see the provider's billing clerk to discuss the situation and options. Only the provider can waive the copayment. However, the provider may also turn the debt over to a collection agency.​

CopaymentsCan providers refuse to serve OHP members who do not pay a copayment?

No. This does not relieve the member of the responsibility to pay and it does not stop the provider from attempting to collect the copayments. The copayment is a legal debt, and is due and payable to the provider.​

CopaymentsHow does OHA account for OHP copayments?

For services provided before January 1, 2017, we compute the total OHP copayment due for services billed. We pay the total allowable amount, minus the correct copayments and any third-party payments. Our explanation of benefits (EOB) identifies copayment deductions. ​

CopaymentsAre FQHCs and RHCs required to charge copayments to OHP health plan members?

Yes, for services provided before January 1, 2017. See OAR 410 Division 147 for useful information on this topic.

About OHPHow do I keep informed?
PoliciesAre there policies I need to follow as a contracted health plan?

Yes. The division's policies, rules and guidelines outline benefit coverage, billing requirements, and other information.

We recommend that plans sign up to receive rules for all programs, including Oregon Health Plan and General Rules updates.

EDI RegistrationHow do I submit encounter data to OHA?

Sign up for EDI and follow our Encounter Data Submission Guidelines.​ To find all resources related to encounter data, visit our Encounter Data page.

Provider enrollmentHow do I report contracted providers to OHA?
Fax the Plan Provider Enrollment Request to 503-378-3074 (Salem) using an EDMS Coversheet.​
Provider enrollmentHow do I make sure our provider files are current?

View our weekly active and inactive provider files ​on the Tools for Plans page.

Drug coverageWhich rules tell me about the drugs that OHP covers?
If a drug is administered by a physician, identified by HCPCS code, coverage is dictated by the Medical Surgical Rules.
If a drug in dispensed by pharmacies using an NDC, it is covered by Pharmaceutical Rules. ​
EDI ProductionI have been blacklisted from the Oregon Medicaid SFTP server in the past due to unsuccessful logon attempts. How can I prevent this from happening?

Be sure to change passwords before they expire. Passwords for the Oregon Medicaid SFTP server expire every 45 days. Also make sure that any software you use has “retries” set to zero.

EDI ProductionHow does Oregon Medicaid handle scripts that run to submit transactions and/or pick up response transactions?
Oregon Medicaid does not have a policy against running scripts, but we strongly advise against it. This may be one of the reasons some users frequently get blacklisted.
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.
EDI ProductionDoes my password to the mailbox ever expire?
Passwords expire every 45 days.  No notifications are sent.
This time starts from the time you are assigned a password and you change it for the first time.
EDI ProductionWhat are the maximum transactions per file?

Claims files should be limited to 30,000 claims. It is recommended that large transmissions be sent before noon Thursday to ensure processing before our Friday financial cycle begins.

EDI ProductionFor the 999, what is the turnaround time for your reports?

Around 10 minutes.​

EDI ProductionI did not receive a response 999 or TA1. Should I re-submit my transactions?

No. Please contact EDI Support (DHS.EDISupport@state.or.us) if you have not received a 999, TA1, or NCPDP Response file within an hour.  Resending the file, before the issue is researched, may result in duplicate claims.

EDI RegistrationWhich File Level Acknowledgement (typically 997 or 999 only) does Oregon Medicaid support?

X12 requires the “Implementation Acknowledgement for Health Care Insurance” (999) when an Acknowledgement is returned for 5010 version HIPAA transactions.

EDI RegistrationDoes Oregon Medicaid have EDI software available?

No.  Oregon Medicaid does not provide, or recommend, EDI software.  Your current billing/practice management software may already be set up for EDI.

We recommend contacting your business software team, your local professional association, or review the resources on our main EDI page.

EDI RegistrationWhat is a Trading Partner Agreement (TPA)?
The TPA defines the “terms of agreement” between the Trading Partner, the EDI submitter (entity sending/receiving the transactions) and Oregon Medicaid.
It requires the signature of the people authorized to enter into this contract.
You will also indicate the transactions authorized and who will send/receive them.
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 exchange EDI transactions with Oregon Medicaid to sign a Trading Partner Agreement before testing.

A TPA is not required for access to the Provider Web Portal at https://www.or-medicaid.gov.
EDI RegistrationCan we have multiple contact persons on the TPA?
Yes. Multiple contacts are allowed.  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.
If you want to have additional contacts you may add them.  Additional contact information should be on “Company Letterhead” and attached to the TPA or may be written on the back of the form.
EDI RegistrationCan I fax or email my TPA once it is completed?

No. We require a hardcopy with an original signature before completing the TPA process.  As with any legal document, do not use correction fluid.

EDI RegistrationWho should sign the TPA?

The TPA should be signed by a person in your company that is authorized to enter into contracts.

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. ​

EDI RegistrationMy company name changed, but not my tax identification number. Must I complete a new TPA?

Yes.  Also please be sure to contact our Provider Enrollment staff (800-422-5047) to update your records.​

EDI RegistrationI realized I checked a transaction that I am not going to be submitting. Do I need to make any changes to the TPA?

Yes.  Complete a new TPA that correctly lists the transactions you want to submit.

EDI TestingWhen reporting a problem to EDI Support Services, is it necessary to tell you if it's a test or production file?

Yes. Please identify if it in test or production.  You should also include the mailbox (MB######) number, transaction type (837P, 873I, 270, etc.) date submitted, file name, NPI, and your OHA “EDI Registration Number”.​

EDI TestingWhat type of claims should I use during testing? Can I use sample/dummy data? How many claims should I put in a test data file?

You should submit claims that mirror what you will be submitting in production.  For example, if you only plan to submit claims for “office visits” you should submit 837 Professional claims.  Batch test files should contain between 25 to 50 records. 

Oregon Medicaid expects 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. ​

EDI TestingWhat is Oregon Medicaid's expectation for passing business-to-business testing?

You should be able to submit records and have them successfully process in our MMIS system.

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. ​

EligibilityWhat 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.
  • ​​
Fee scheduleWhat does the medical-dental fee-for-service fee schedule tell me?

It provides general information on the Healthcare Common Procedure Coding System (HCPCS) Level II codes, such as:

  • The maximum allowed payment
  • The effective date of the current rate
Fee scheduleWhat does the medical-dental FFS fee schedule does NOT tell me?

The following information is not covered in the medical-dental FFS fee schedule, but is covered in the rules for your program:

  • Whether you can bill for a particular code
  • Whether prior authorization (PA) is required 
  • Which restrictions, limitations or exclusions apply, if any
  • Which conditions of coverage apply, if any
  • Any other rules you need to consider before you can determine whether OHA will cover the service​
Fee scheduleWhat else do I need to know about the fee schedule?

The FFS fee schedule must be used in conjunction with all applicable OARs.

The FFS fee schedule is normally updated quarterly.

FormsWhere can I learn about how to complete a form?

Review OHP Billing Tips or the provider guidelines for your program for more information.

Learn how to complete EDI forms on our EDI page.
FormsI can’t find the form I need. What do I do?

If you cannot find the form you need on our Forms page, go to the DHS/OHA Forms Search Page for other DHS/OHA forms, and to find versions of DHS/OHA forms in Spanish and other languages.

Fraud and abuseAre there specific fraud and abuse requirements I need to follow?

Entities who receive or pay at least $5 million in Medicaid funds annually are required to educate their employees, and maintain written policies and protocols about fraud and abuse and the federal False Claims Act. Read the Employee Education guide to learn more.​

Fraud and abuseHow do I report fraud?

Use the DHS online reporting database or call 1-888-FRAUD01. Go to the DHS Fraud Reporting website to learn more.

ICD-10What is ICD-10?
ICD-10 is the 10th edition of the International Classification of Diseases Clinical Modification/Procedure Coding System. ICD-10 expands the number of codes from 18,000 ICD-9 codes to more than 140,000 ICD-10 codes. This quick reference explains the similarities and differences between the two coding systems. Once ICD-10 is implemented: 
  • ICD-10 diagnosis codes must be used for all health care services.
  • ICD-10 procedure codes must be used for all hospital in-patient procedures.
More detailed coding is helpful and brings the United States in line with non-U.S. practices. The ICD-10 codes allow for more accurate information to accompany a claim, which will allow for more accurate claims payment and coverage decisions.
ICD-10Who does ICD-10 affect?
ICD-10 affects all health care entities (including providers, plans and clearinghouses) that use ICD-9 codes for medical coding or processing of health care transactions (e.g., claims).
  • Once implemented, ICD-10 codes must be used on all HIPAA transactions, including outpatient claims with dates of service, and inpatient claims with dates of discharge on and after the implementation date. Otherwise, your claims and other transactions will be rejected, and you will need to resubmit them with the ICD-10 codes.
  • This will impact your reimbursements, so it is important to start preparing for the changeover to ICD-10 codes.
  • This change does not affect CPT coding for outpatient procedures.
We are evaluating the potential impact of ICD-10 on provider reimbursement, contracting and clinical operations. ICD-10 conversion was not intended to transform payment or reimbursement. However, it may result in reimbursement methodologies that more accurately reflect patient status and care.
Direct depositHow do I sign up for direct deposit?

Complete the DHS 189 form and return to DHS/OHA Financial Services as indicated on the form. Include a copy of a voided check or letter from the bank verifying account ownership, routing number and bank account number.

BenefitsWhat services are plans required to cover?
The OHP Rules explain plan coverage. Generally, plan coverage must be comparable to OHA's fee-for-service coverage.
Mental health drugs​ are always billed to OHA. All other prescriptions are billed to physical health plans (CCOA, CCOB).
PoliciesHow do I find out about upcoming changes to OHP policies, rules and guidelines?
Preferred Drug ListWhen is the next Pharmacy & Therapeutics Committee meeting? How can I get notified of future meetings?
Prioritized ListHow does the Prioritized List work?
The Oregon Health Evidence Review Commission (HERC) ranks health care condition and treatment pairs in order of clinical effectiveness and cost-effectiveness.
The Prioritized List emphasizes prevention and patient education. In general:
  • Treatments that help prevent illness are ranked higher than services that treat illness after it occurs.
  • OHP covers treatments that are ranked on a covered Prioritized List line for the client's reported medical condition.
Prioritized ListWhat lines are currently covered on the Prioritized List of Health Services?

Effective Jan. 1, 2017, OHP covers Prioritized List lines 1 through 475.

Prioritized ListWhere do I find past, current and proposed Prioritized Lists of Health Services?
Use the following links on the HERC website. You can also eSubscribe to receive e-mail updates from HERC whenever Prioritized List information changes or view all recent HERC updates.
Public notices and meetingsHow do you notify the public of upcoming changes to OHP?
Services covered by OHP benefit plans, prior authorization criteria, and billing requirements are outlined in the division's Oregon Administrative Rules.
Any time we want to change what OHP covers or whom OHP serves, OHA must ask the federal Centers for Medicare and Medicaid Services (CMS) to approve the change. Sign up for OHP Public Notices and Meetings to find out when we have sent such a request to CMS.
We send OHP provider announcements to inform affected providers about changes to our fee-for-service payment rates. Sign up for OHP Provider Announcements to get these notifications.
Public notices and meetingsWhat are public meetings?
According to Oregon law, any meeting related to medical assistance is a public meeting. The division holds the following meetings and posts them on the OHP Public Meetings Calendar:
  • Rule Advisory Committees for Oregon Administrative Rules
  • OHP Contractor Workgroups
  • Pharmacy and Therapeutics Committee
  • Other policy or stakeholder workgroups, listed on the Public Meetings page
RatesHow does OHP set payment rates for its contracted health plans?

The OHA Actuarial Services Unit calculates the cost of providing health care to each OHP member, and uses this information to calculate new payment rates annually. To learn more, view the Per Capita Cost and Capitation Rate reports on the OHP Rate Development page.

RatesWhat are OHP’s maximum allowable fee-for-service rates?

View the fee-for-service fee schedule for an overview of OHP's maximum allowable rates.

ACA Section 1202 Rate IncreaseWhy did Oregon have a 2013-2014 primary care rate increase?

In November 2013, the Centers for Medicare and Medicaid Services (CMS) announced that practitioners who meet their new definition of primary care provider would see an increased Medicaid reimbursement rate for two years under section 1202 of the federal Affordable Care Act (ACA).

CMS revised sections 1902(a)(13), 1902(jj), 1905(dd) and 1932(f) of the Social Security Act to require increased payment for certain Medicaid primary care services provided in calendar years 2013 and 2014.
The final rule also updated the interim regional maximum fees that providers may charge for vaccine administration under the Vaccines for Children (VFC) program.
ACA Section 1202 Rate IncreaseWhat services are eligible for the 2013-2014 primary care rate increase?

The increase applies to evaluation and management (E/M) and vacc​ine administration services​​ and the administration fee for Vaccines for Children serum​, when delivered to Oregon Medicaid clients by eligible providers.

ICD-10What is OHA doing?
We plan to meet all related timeframes for compliance. We expect providers and clearinghouses that we work with will also meet those timeframes. Our current areas of focus are:
  • Code set mapping: OHA has developed an ICD-10 master equivalence map that includes all existing ICD-9 and ICD-10 codes. This map is a general reference map only; it is not intended to be used as an ICD-10 conversion or crosswalk tool. OHA expects to release a second, more specific map to remediate our internal business and policy processes in Fall 2013.
  • Business and systems preparation: We have completed system requirements to accommodate ICD-10 and are now working on system development, business process remediation, and policy remediation.
  • Testing: We started internal system testing in April 2013. Once we complete internal testing, we will begin parallel testing with selected trading partners for external (business-to-business) testing. We expect to begin external testing in early 2014.
  • Communications: We will keep providers informed about our progress on the ICD-10 conversion, including timelines and testing.
  • Contingency planning: OHAdoes not plan to support ICD-9 codes for dates of service after the ICD-10 compliance date. However, we will continue to closely follow communications from CMS and adapt our approach as permitted. 


ContractsHow can I view a copy of the model contracts for OHP health plans?

To view a copy of the model contracts, contact Kellie Skenandore. ​

Non-emergent medical transportationWhat is a transportation brokerage?
A transportation brokerage is a local government entity that contracts with the Oregon Health Authority to provide non-emergent transportation services to Oregon Health Plan (OHP) clients who receive OHP Plus (BMM, BMH, BMD, CWX) benefits.
Non-emergent medical transportationCan you arrange transportation outside the brokerage (i.e., directly with a preferred transportation provider)?

No. All medical ride requests must go through the brokerage.

  • The rides must be authorized and assigned to a brokerage sub-contracted provider that meet the client’s needs most appropriately and are the lowest cost. 
  • If a facility or branch arranges transportation without the broker's authorization, the transportation provider will not be paid through Medicaid. 
  • When the brokerage is closed, clients should call the brokerage’s after-hours number if a ride is needed for an urgent medical issue.
Non-emergent medical transportationDoes the brokerage call center offer any choices when it sets up rides?
The brokerage or call center staff must meet two main criteria:
  1. Find the most appropriate ride for the client based on actual need, not want.
  2. Find the ride that is the lowest cost. 

Oregon's federal waiver and current federal law allow the state to limit a client's freedom of choice with NEMT. Freedom of choice, in this context, refers to the general right a Medicaid participant has to choose service providers.

Non-emergent medical transportationWhat questions do brokerages ask when an OHP member calls for a ride?
The brokerage will check the eligibility of the person, verify if the ride is to a Medicaid-covered service, and assess the client’s ability and needs. These questions are requirements brokerages ask to meet Medicaid standards: 
  • Where do you want to go? 
  • Are you going to an OHP-covered health care service? (If a client is unsure whether the service is covered, and it is unclear whether the service is a covered service, the brokerage will follow up with the provider.)
  • Do you have any other means of transportation? 
  • Do you have any special needs?​
Non-emergent medical transportationOHP members at residential facilities expect to be helped (from their room, into the van, into the doctor’s office, etc.). Who provides this level of service?

The drivers are there to drive. If a client needs a care attendant, it is the facility's or the client's responsibility to provide one. 

The brokerage contract does not allow drivers to enter clients' rooms or escort clients to their appointments. Clients will need to be ready at the front door of the pick-up address. ​

Non-emergent medical transportationSome OHP clients have limited mobility; will the driver assist them with getting onto the van?

Yes, ride requests should identify their special needs, so the drivers will know to provide assistance boarding and de-boarding the vehicle.

Non-emergent medical transportationWill the brokerages transport children less than 12 years old unescorted?

No, the brokerage will not transport children less than 12 years old unescorted. 

The exception is when a Department of Human Services (DHS) volunteer is available to drive the child, primarily because of  protocols established by the DHS Child Welfare program and because of liability issues.

Non-emergent medical transportationWhat would happen if the hospital needs to discharge a patient at 9:30 p.m.?

Brokerages have their own processes and protocols for after-hours transportation that allow for the transport to take place with authorization to follow. 

Hospitals should follow the after hours procedure for the brokerage and contact the appropriate after hours providers. Ambulance providers should not be used unless an ambulance is the appropriate mode for the client.

Non-emergent medical transportationCan anyone ride with the client to their appointment?

If the client has a medical need to have an attendant travel with them, or the client is less than 12 years old, one attendant is allowed to accompany the client on the transport.  

Otherwise, whether or not an extra person can ride along on the transport depends on whether the transportation provider agrees to allow the extra person at no additional cost. 

In addition, this must be negotiated with the brokerage call center, and is subject to available space.

Non-emergent medical transportationWhat would happen if all of the transportation providers refused to give an OHP member a ride due to scheduling conflicts?
The brokerage would ask the provider whether the appointment could be re-scheduled or delayed without doing harm to the client. If not, the brokerage would secure a provider from a different service level or from outside of the region. The client would be given options.

Non-emergent medical transportationIf a provider gets a call after hours directly from a client asking for a ride, how does the provider know they'll get paid if they provide the ride?

Providers take a risk when they accept this type of ride. They can ask to see the client’s medical card or call the toll-free number for the Automated Voice Response​ (AVR) to see if the person is eligible for services. 

Non-emergent medical transportationWhat is a client "no-show"?

If a client has a scheduled ride and is not at the pick-up location as arranged, the driver will report a "no-show" to the brokerage.

Clients cannot be billed, and the brokerage cannot pay providers for these trips.

If a client needs to cancel a ride, the client should call the brokerage.

Repeated “no-shows” may result in requiring the client to phone in to confirm rides before pick up, schedule no more than one ride at a time, travel with a specific provider, or travel with an escort.

The “no-show” policy holds clients accountable for using their ride benefits appropriately.

Non-emergent medical transportationDo the brokerages fulfill same-day ride requests?

The broker will try to arrange for same-day rides; however, it will depend on whether there is a provider available and whether prior authorization can be completed.

Transportation providers may already be booked with other clients’ appointments. Brokerages make urgent-care needs their highest priority. Clients should, whenever possible, schedule rides in advance.

Non-emergent medical transportationWhat if clients have complaints about a certain driver or transportation service?

The most direct way to process concerns and complaints is to share them with the brokerage. 

After the complaint is researched, the brokerage may sanction or terminate a provider which is unable to provide on-time, safe services.​

Non-emergent medical transportationWhat does the brokerage do?
Each brokerage has a call center that arranges rides for clients going to Medicaid-covered health care services. Call center duties include:
  • Verifying that the client is eligible to receive a ride,
  • Verifying that the appointment is for a Medicaid-covered service,
  • Verifying that the client does not have other means to get to the appointment, and
  • Authorizing the most appropriate type of transportation service based on the client’s needs.
Non-emergent medical transportationWho provides the actual rides for the clients?

The brokerage sub-contracts with drivers and transportation providers to provide rides they have arranged.​

Non-emergent medical transportationWhat type of authorization is necessary for NEMT?

Requests for NEMT must be prior authorized.  This includes requests for rides or reimbursement of transportation expenses such as mileage, meals and lodging.  ​

Non-emergent medical transportationWhen lodging and meal expenses arise from an emergency situation, are lodging and meals considered NEMT expenses or something else? Who is responsible for authorizing and reimbursing them?

In this kind of situation (for example, when an emergency ambulance takes a child and parent to Doernbecher Children’s Hospital, and the parent qualifies as a medically necessary attendant whose expenses are allowable under the NEMT program), only the ride is considered an emergency expense.

Any other allowable travel expenses would be considered NEMT expenses, and the client or their representative must contact the brokerage as soon as possible within 30 days of the transport for authorizing and reimbursement of these expenses.​

Non-emergent medical transportationCan a transportation brokerage reimburse overnight lodging and meals for an attendant who stays with the client when the client is admitted as in inpatient to a hospital?

No. Once a client is admitted as an inpatient, NEMT benefits can no longer pay for an attendant because the medical facility provides all of the client’s care. There are some exceptions:

  • If the doctor says in writing that the attendant is medically necessary, or
  • If it is less expensive to pay for the attendant’s meals and lodging than to return the attendant home and bring the attendant back again when the client is released.​
Non-emergent medical transportationWho authorizes reimbursement for medical-related lodging and meals?

Brokerages now authorize and reimburse clients for medical-related lodging and meals in all counties.

Non-emergent medical transportationRules allow reimbursements to clients for expenses less than $10 to be held until they reach the $10 amount, but may reimbursements be processed for less than$10?

Yes. The $10 threshold exists to avoid writing checks for very small amounts, but reimbursements can be processed for less than $10 if the brokerage allows. 

Non-emergent medical transportationCan clients get rides to any provider they want to go to for Medicaid-covered services?

​No, rides are only covered to the providers in the client’s local area, unless there is no provider available in the local area. 

Brokerages will seek guidance from the client’s primary care or referring provider. 

Although clients may choose to go out of their local area to any provider that will accept Medicaid, the transportation may not be covered if there is an appropriate local area provider available.​

Non-emergent medical transportationIs there a time limit on how long a client must wait if they are in a grouped ride?

​Wait times on shared rides are reviewed individually and factor in client needs​.

Non-emergent medical transportationCan NEMT be used to shop for a new care facility, or relocate to another care facility or out of state?

​NEMT can only cover moves to a new care facility for clients who have had a change in condition, noted in their DHS care plan, resulting in a need for a new service setting with a higher or lower level of care.  

NEMT cannot cover shopping for another facility, moving to another facility of the same level of care or moving out of state. 

DHS has some non-medical funds that may be available for some of these moves. Clients should talk with their local case workers to find out what may be available to them.

Non-emergent medical transportationHow should an ambulance company bill ambulance services when medical personnel determine it was not an emergency?

​It should be billed as a non-emergent ambulance service if the ride was provided or as an aid call if the ambulance personnel do not transport the client. This is an exception to the guidance that brokerages authorize non-emergent ambulance trips.​

Non-emergent medical transportationWhat is the brokerage’s responsibility regarding non-emergent ambulance trips?

​Brokerages authorize non-emergent ambulance trips. The ambulance companies will bill OHA directly for reimbursement.​

Non-emergent medical transportationWhen a transportation brokerage pre-authorizes a non-emergent ambulance trip using the 405T, what should they enter as the dollar amount authorized?

​The brokerage may write “fee schedule” on the 405T. OHA will pay based on the fee schedule. 

The authorized amount must not be completely blank. The brokerage must either write “fee schedule” or list an actual dollar amount based on a bid price for the ride if there are circumstances that prevent the ride from being reimbursed at the fee schedule amount.

Direct depositHow long does it take to set up direct deposit?

It only takes a few minutes to set up; however, it could take a week or more to become active depending on how quickly the bank responds with a confirmation.

Direct depositWhat are the benefits of direct deposit?

​Getting your payments deposited electronically into your checking or savings account is:

  • Simple—easy to set up and use 
  • Safe—ensures confidentiality and reduces fraud 
  • Smart—saves time and processing costs 
  • Green—helps protect the environment

For more information about the benefits of direct deposit, visit www.electronicpayments.org​

Direct depositIs direct deposit faster?

OHA delivers paper checks with your paper remittance advice (RA).

  • If your RA is 8 or more pages, your RA and check will get in the mail the Wednesday after OHA processes your payment. 
  • If your RA is less than 8 pages, your RA and check will get in the mail the Monday after OHA processes your payment. 

Once the check is in the mail, it takes 2 to 4 days for delivery.

With direct deposit, the payment enters your bank account no later than the Wednesday after OHA processes your payment (excluding Federal Reserve Banking Holidays).

Direct depositHow will direct deposit affect my remittance advice?

Your paper remittance advice (RA) will come the same way.  The only change is that you will not receive a paper check with it.

Direct depositHow do I change the bank account information?

To have your direct deposit payments go to a different bank account, complete a new DHS 189 form​ and return to DHS|OHA Financial Services.

Make sure to check the “Change” box in section A under “Type of Action”. Include a copy of a voided check or letter from the bank verifying account ownership, routing number and bank account number.​ 

FormsHow can I order copies of the OHP Handbook (OHP 9035)?

Submit orders to the DHS|OHA Distribution Center using the MSC 8100 form.​

Recent updates for health plans

Click the “Issue Date” heading to sort or filter by date. To view all recent announcements, visit our Announcements page​. You can also view staff transmittals for other updates.

Applies To
5/15/2017Procedure code H2023 and IPS Supported Employment servicesCCOs
3/10/2017Requirements and resources for mental health parity self-assessmentsCCOs
2/28/2017Centralized Medicaid Eligibility and Integrated Eligibility ProjectAll interested parties
1 - 3Next

Forms for health plans

Click the "Form and Description" heading to sort or select by Form. You can also click "Language" to sort or filter by Language. To view all OHP forms and publications, visit our Forms page​.

OHP 3030OHP 3030 - Notice of Hearing RightsEnglish
OHP 3108OHP 3108 - Managed Care Provider Enrollment FormEnglish
OHP 3160OHP 3160 - PWP Quick Setup GuideEnglish
1 - 3Next

Weekly provider files

OHA posts these files by noon each Tuesday. Click the format you need (PDF, XLS or XLSM) to open a zip file that contains the active and inactive provider files for the week. To get the password for these files, contact your Encounter Data Liaison.

Weekly Provider File, 05-22-2017
Weekly Provider File, 05-15-2017
Weekly Provider File, 05-08-2017
1 - 3Next

7-11 Drug Carveout List

7-11 Drug Carveout List, First Quarter 2017
7-11 Drug Carveout List, Fourth Quarter 2016
7-11 Drug Carveout List, Third Quarter 2016
1 - 3Next

Need help?

Contact information
For help with

Your Encounter Data Liaison​

Encounter data reporting, provider enrollment, weekly provider file

Member enrollment issues

Your Account Representative​

Information updates​