|About OHP||How can I get involved?|
|ACA Section 1202 Rate Increase||When 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:
Increased FFS rate will apply to
qualifying services rendered on or after:
Jan. 1 to Mar. 31
Apr. 1 to June 30
July 1 to Sep. 30
Oct. 1 to Dec. 31
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 Increase||Which 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 Increase||Where can health care providers learn more about the 2013-2014 primary care rate increase?|
|Access to care||What happens when an OHP health plan member seeks services from a provider that has not been authorized by the plan? |
OHP plans approve services for their members. They are not obligated to pay providers for care that has not been approved by the plan (unless it is an emergency). This is true even if the provider collected a copayment.
The provider should always ask members for their Oregon Health ID (formerly Medical Care ID) before serving them, then verify eligibility, benefit package and plan enrollment to determine who authorizes services (OHA or the plan).
|Access to care||For providers, what are the advantages of managed or coordinated care? |
- Higher reimbursement. Plans usually pay more for services rendered to OHP patients than OHA does.
- Access to highly developed systems. Plans have continuous quality improvement practices. Access to those resources can help providers address issues facing their patients.
|Applying for OHP||How can I help people get medical assistance through the Oregon Health Plan?|
Providers of direct medical services may contract with OHA to help enroll patients in OHP Plus.
Patients who receive an application and get help filling out the application are more likely to get coverage.
|Benefits||Who gets which OHP benefit package? |
The main benefit packages are:
- OHP Plus (BMH): For people eligible for Medicaid or the Children's Health Insurance Program (CHIP), such as children, pregnant women, seniors and people with disabilities.
- OHP with Limited Drug (BMD, BMM): For people who are eligible for both Medicaid and Medicare Part D.
|Benefits||What 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.
|Benefits||What does OHP Plus Supplemental cover?|
OHP Plus Supplemental covers the following services for pregnant women age 21 and over:
- 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.
|Benefits||Are 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.
|Benefits||Are 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:
- Congenital aphakia
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.”
|Benefits||Will 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.
|Benefits||Does 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).
|Benefits||How do providers know which benefit package applies? |
|Benefits||What 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.
|Benefits||How 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).
|Eligibility||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.
|Eligibility||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.
|Benefits||How 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.
|Billing||Can I bill OHA electronically?|
|Billing||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.
|Billing||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.
|Complaints and appeals||If 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 appeals||How can OHP members request a hearing?|
|Complaints and appeals||Can a provider appeal a decision regarding the denial of payment for services? |
|Complaints and appeals||Can a provider represent an OHP member in an appeal regarding the denial of payment for services? |
The OHP member can designate anyone as his or her representative in an appeal or hearing. The member must provide written consent.
|Complaints and appeals||Are 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 appeals||I disagree with a payment decision made by OHA or an OHP health plan. What can I do?|
You can request a provider appeal. The General Rules outline your options and how to use them.
Use the OHP 3085 form to submit your request for provider appeal.
- Claim re-determination – Request to OHA to review your claim due to a technical error.
- Administrative review – Request to OHA to review policy or legal decisions not related to re-determination, contested case hearing, or client appeals.
|Copayments||Who 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.
|Copayments||Who 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.
|Copayments||Do 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.
|Copayments||How 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.
|Copayments||Which 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
|Copayments||Which 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.
|Copayments||How do I know if someone should pay a copayment?|
Starting January 1, 2017, there are no OHP Plus copayments.
The Provider Web Portal eligibility verification request and Automated Voice Response (AVR) Recipient Eligibility response provide copayment amounts for OHP Plus (BMM, BMD, BMH, BMP) services.
- For services delivered before 1/1/2017, enter the actual date of service.
- Copayment amounts ($1 or $3) will only display for members responsible for copayment.
- If an OHP member is exempt from copayment, the copayment will read $0.00 for all services.
|Copayments||How do I know if a service requires a copayment?|
Starting January 1, 2017, there are no OHP Plus copayments.
For services provided before January 1, 2017, the Provider Web Portal eligibility verification request and Automated Voice Response (AVR) Recipient Eligibility inquiry provide copayment amounts for OHP Plus (BMM, BMD, BMH, BMP) services.
If a service requires copayment, the service will list the amount to pay ($1, or $3). Services that do not require copayment will list $0. Table 120-1230-1 in the General Rules also lists the services that require copayment and the amounts that apply.
|Copayments||Are 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.
|Copayments||Who 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.
|Copayments||What 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.
|Copayments||Can 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.
|Copayments||How 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.
|Copayments||Are 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.
|Customer service||What steps should I take before calling Provider Services for help?|
Review the resources available on the OHP Tools for Providers
page to see if existing resources can answer your questions.
If you identify an error or unexpected denial on your paper Remittance Advice or 835 transaction from OHA, research the problem from your end. Many of the calls OHA receives about denied claims can be resolved in your billing office (such as coding or modifier errors, wrong claim form or wrong billing provider number).
|Customer service||What can Provider Services help me with?|
- Interpret Oregon Medicaid rules and policy to help providers resolve billing issues with OHA.
- Help providers with Provider Web Portal access and navigation issues.
- Issue new PIN letters for Provider Web Portal and Automated Voice Response access.
- Research and resolve "problem claims," CAWEM claim reconsiderations, and pharmacy claim reconsiderations.
- Process provider appeals.
- Coordinate with other DHS offices and partners such as Medical Payment Recovery, Health Insurance Group and DHS case workers to resolve technical issues that affect the provider’s ability to bill OHA (e.g., incorrect eligibility/enrollment/TPL information).
|Customer service||What can Provider Services NOT help me with?|
- Perform basic claim status, client eligibility and client enrollment inquiries. Please use Automated Voice Response, the Provider Web Portal, or electronic data interchange to get this information.
- Answer questions about billing, coverage, or prior authorization for services you provide to clients in managed care or coordinated care. You need to contact the client’s OHP health plan for this information.
- Answer technical questions about issues you have submitting electronic data interchange transactions. You need to contact EDI Support Services (888-690-9888) for this information.
- Provide training on how to use the Provider Web Portal. Go to the Provider Web Portal page for self-study resources.
|Training||What provider materials do I need? |
|Forms||How do I stay enrolled as an OHP provider? |
Submit updates within 30 days of the change on the Provider Information Update form. Also send us a copy of your licensure renewal when you receive it from your licensing board.
|Drug coverage||Which 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
|Drug coverage||How does OHA reimburse for compound drugs?|
Each component of a compound prescription, as defined in OAR 410-121-0146 (7) and 410-121-0160 (3) must be billed separately and is paid as above, but with a single dispensing fee.
Any reimbursement received from a third party for compounded prescriptions must be split and applied equally to each component.
|Drug coverage||How does OHA reimburse for drugs dispensed to patients in a long-term care facility or community-based waiver facility?|
|Drug coverage||How does OHA reimburse for mental health drugs?|
For all OHP members, OHA pays for covered mental health drugs on a fee-for-service basis.
- For the purposes of the above payment policy, "mental health drugs" are defined as those drugs classified by First DataBank in the Standard Therapeutic Class equal to Class 07 (Ataractics, Tranquilizers), Class 11 (Psychostimulants, Antidepressants).
- In addition, lamotrigine and divalproate are also considered mental health drugs.
- These drugs are listed in the 7-11 Drug Carveout lists.
|Drug coverage||Who can OHA reimburse for drugs?|
OHA only reimburses enrolled pharmacy providers (type 48) for drugs billed by NDC.
Other provider types are reimbursed for physician-administered drugs and home enteral nutrition using the professional claim format (CMS-1500 or 837P).
|Drug coverage||How does OHA reimburse pharmacies for EPIV services?|
Pharmacies can bill OHA for oral nutritional supplements using the pharmacy claim format (Point of Sale or UCF 5.1) only when the supplement has a valid NDC.
|Drug coverage||How does OHP determine drug coverage? |
To be considered for OHP coverage, drugs must:
|Drug coverage||What drugs does OHP never cover?|
OHP does not cover drugs on the DESI List, and does not cover drugs that are used exclusively for not covered diagnoses (e.g., acne drugs).
|Drug coverage||How do pharmacies request prior authorization for drugs or oral nutritional supplements?|
Or call the Oregon Pharmacy Call Center at 888-202-2126 with the diagnosis code and your NPI.
|Drug coverage||Where can I find the drugs covered by OHP health plans?|
You will need to contact the plan. Some plans have their formularies available through Epocrates, where you can also find the Preferred Drug List (listed as "Oregon Medicaid -- open card").
|Drug coverage||Where can I find information about Medicare Part D coverage?|
Visit the DHS Medicare Modernization Act website. This site provides a quick reference for clients, the general public, department staff, policymakers, stakeholders and providers looking for information on the Medicare prescription drug program.
|Drug pricing||How often does OHA update the Wholesale Acquisition Cost (WAC) of covered medications? |
OHA updates the price files from First DataBank weekly. The file is downloaded from FDB every Thursday.
NDCs must be added to the First DataBank drug file and then loaded to the PBM claim processing system. Upon market release, there may be a one week delay to add new NDCs to First DataBank and another week for loading them to the PBM.
|Drug pricing||How does OHA reimburse pharmacies for drugs?|
Drugs dispensed by retail pharmacies are reimbursed at the lower of:
- Usual and Customary (U/C) or billed amount;
- Average Actual Acquisition Cost (AAAC). Whole Acquisition Cost (WAC) will apply in cases where no AAAC cost is available; or
- Federal Upper Limit (FUL).
Professional dispensing fees for allowable services are based on pharmacy claim values as follows:
- Less than 29,999 claims a year = $14.01;
- Between 30,000 and 49,999 claims per year = $10.14;
- 50,000 or more claims per year = $9.68.
|EDI Production||I 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 Production||How 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 Production||Does 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 Production||What 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 Production||For the 999, what is the turnaround time for your reports?|
|EDI Production||I 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 Production||Since we are required to enter a physical address in our claim submissions, how are you able to send payments to our mailing address?|
We do not use addresses that come in with the claim; instead, we send payment to the Mail-to address in our system (provided when you enrolled with Oregon Medicaid).
|EDI Registration||Can I list all providers on the first page of the TPA, or do I need to list each separately? |
The TPA is for the billing
provider only. For example, if a clinic bills on behalf of its rendering
providers, then only one TPA is required (for the clinic).
Each National Provider Identifier (NPI) must have its own TPA.
If you have multiple providers that bill OHA using the same NPI, they can all be listed on the same TPA if they will all use the same transactions and EDI submitter. Include each provider's Oregon Medicaid provider number.
|EDI Registration||Does Oregon Medicaid accept COB claims?|
Yes. We accept, and process, properly formatted claims that have had prior payers.
|EDI Registration||Which 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 Registration||If I register for the 835 Remittance Advice (RA), can I still receive the paper RA? |
Yes. There is a transition period where you will receive both the electronic Remittance Advice and the paper RA. This period allows you to verify that you can process the 835s you receive.
Oregon Medicaid will continue to produce the paper RAs after a provider begins receiving the 835 remittance advice. You can ask us to stop sending you the paper RA at any time.
|EDI Registration||Does 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 Registration||What 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
|EDI Registration||Can 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 Registration||Are pharmacies required to submit a TPA? |
Pharmacies must complete a TPA for the following:
Pharmacies who only exchange transactions via point of sale or the Provider Web Portal, and who do not want the electronic RA, do not need to submit a TPA or register for transactions.
- To submit 837P Professional claims (e.g., for durable medical equipment or medication management services). Register for the 837P transaction.
- To receive the 835 (Electronic Remittance Advice). Register for the 835 transaction.
|EDI Registration||Can 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 Registration||As a provider, do I need to submit a TPA for my EDI submitter(s) as well as for myself?|
You only need to submit one TPA for your NPI, unless you exchange information on your own behalf but also use an EDI submitter for some of your work, then you will need to include two completed copies of the TPA:
- One copy will indicate the transactions you will exchange;
- The other copy will indicate which transactions your EDI submitter will exchange on your behalf. This copy requires the submitter's information and signature.
|EDI Registration||As a clearinghouse, how do I register with Oregon Medicaid when a provider joins our service?|
An Oregon Medicaid provider would have to designate you as their submitter by completing a new TPA naming you as their submitter.
|EDI Registration||Who 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 Registration||My company name changed, but not my tax identification number. Must I complete a new TPA?|
|EDI Registration||I 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 Testing||When 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 Testing||What 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 Testing||What 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.
|EDMS Coversheet||Why do I need to use the EDMS Coversheet?|
This allows OHA to scan all documents sent under the coversheet into our system and have the documents automatically link to the provider ID or Application Tracking Number listed on the coversheet.
|EDMS Coversheet||What happens if I do not use the EDMS Coversheet?|
If you do not use the EDMS Coversheet when submitting prior authorization or enrollment requests to OHA, they will not be processed or returned to you.
|Eligibility||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.
|Fee schedule||What 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 schedule||What 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 schedule||What 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.
|Forms||Where can I learn about how to complete a form?|
|Forms||I can’t find the form I need. What do I do?|
|Fraud and abuse||Are 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 abuse||How do I report fraud?|
|ICD-10||What 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:
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-10 diagnosis codes must be used for all health care services.
- ICD-10 procedure codes must be used for all hospital in-patient procedures.
|ICD-10||Who 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).
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.
- 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.
|LEMLA||What is the purpose of the Law Enforcement Medical Liability Account (LEMLA)?|
The purpose of LEMLA is to provide a means for reimbursing medical providers for medical expenses incurred from injuries sustained by an individual as a result of law enforcement activity.
Claims are only paid out of the account when recovery from the injured person and/or their insurance carrier fails. Liability for payment by LEMLA ends when the individual is released from actual physical custody.
|LEMLA||How is LEMLA funded? Is it a Medicaid program?|
LEMLA is established separate and distinct from the General Fund. The account is fully funded from amounts collected in state courts as monetary obligations in criminal actions.
It is not a Medicaid program; however, health care providers who want to submit LEMLA claims must enroll with OHA as a Medicaid provider so that we are able to pay the provider.
|LEMLA||What does "injuries related to law enforcement activity" mean?|
It means injuries sustained prior to booking, citation in lieu of arrest or release instead of booking that occur during, and as a result of, efforts by a law enforcement officer to restrain or detain, or to take or retain custody of, the individual.
It does not include treatment for injuries that are not related to efforts by the law enforcement officer to restrain or detain, or to take the individual into custody. The law enforcement agency will make the decision as to whether the injuries are related to law enforcement activity.
|LEMLA||What are examples of injuries that would be covered under LEMLA?|
- Police dog bites sustained by a suspect during the course of apprehending the individual.
- Injuries sustained by a suspect as a result of a motor vehicle accident that occurred during police pursuit.
- Gun shot wounds inflicted by a police officer attempting to apprehend the individual.
- Injuries to a suspect caused by the law enforcement officer due to the use of any force to effectuate the arrest.
|LEMLA||What are examples of injuries that would not be covered under LEMLA?|
- Injuries sustained by an innocent bystander as a result of police action to apprehend a suspect.
- Injuries sustained by an innocent bystander as a result of the suspect’s actions.
- Injuries sustained in a motor vehicle accident caused by an individual who is DUII, when the individual was not subject of law enforcement activity to restrain or detain, or to take or retain custody of, the individual, prior to the accident.
- Injuries sustained by the suspect during the commission of the crime prior to the law enforcement action such as falls, cuts, burns, and other injuries.
- Medical services that are unrelated to injuries that are covered, such as a pre-existing disease or condition. For example, if an individual being treated for a police dog bite is determined to already have an illness, the injury from the dog bite is covered, but treatment for the illness is not.
- Follow-up services for an individual that occur after the individual has been released from actual physical custody. This might include suture removal, cast removal, additional x-rays, or physical therapy.
|LEMLA||Who are claimants under LEMLA?|
To be eligible for payments from the account the medical provider must have a Medicaid provider number. If you don’t have a Medicaid provider number or you’re not sure of your number, contact LEMLA for assistance.
|LEMLA||How much collection effort must be made before billing LEMLA?|
Medical providers must make every reasonable effort to collect from the individual, the individual’s insurer, or health care contractor.
|LEMLA||When should a LEMLA claim be filed?|
Medical providers may file a claim with LEMLA if they have not been paid within 45 days after billing the patient or the patient’s health care contractor. Claims, however, must be received by LEMLA within one year after the date of injury.
|LEMLA||What are the requirements for a valid LEMLA claim?|
Hospitals and other medical providers must submit a copy of a detailed billing along with documentation that a reasonable effort has been made to collect from the patient or the patient’s insurer or health care contractor. Providers must also provide the claim amount, the amount collected prior to billing LEMLA, the date of the injury, patient’s name, address of patient, cause/nature of injury, the provider’s Medicaid number, and the provider’s name.
In addition to the above requirements, the authorized representative of the law enforcement agency must certify that the claim is for injuries related to law enforcement activity. The law enforcement agency must also provide the date the LEMLA patient was released from actual physical custody. If the LEMLA patient remained in actual physical custody throughout the period covered by the claim, the law enforcement agency should report this on the claim form.
|LEMLA||Where should the LEMLA claim be filed?|
After attaching the required documentation, medical providers should forward the LEMLA claim and all attachments to the law enforcement agency involved in the injury. Contact LEMLA if you need assistance in determining where to forward the claim.
|LEMLA||What happens to the LEMLA claim next?|
The authorized representative of the law enforcement agency will determine whether the injuries are related to law enforcement activity and the date the LEMLA patient was released from actual physical custody. After this information is added, the claim will be sent by the law enforcement agency to LEMLA for processing.
|LEMLA||What amount will LEMLA pay?|
All providers will bill the usual amount billed to the general public.
|LEMLA||When will LEMLA pay the claim?|
Claims are reviewed and processed by LEMLA as soon as they are received. Payments for approved claims are mailed to providers at the end of each month. LEMLA will make every effort to process and pay claims in the same month they are received.
|Local match rates||What is the FMAP?|
The FMAP is the federal government’s share of expenditures for the Medicaid and Children’s Health Insurance Program (CHIP) programs. These programs are jointly funded by the federal, state or local government.
The FMAP determines the local match rate.
|Local match rates||When does the FMAP change?|
Generally, the FMAP changes annually on October 1 (the beginning of the federal fiscal year).
The American Recovery and Reinvestment Act of 2009 (ARRA, Public Law 111-5
) contained provisions that increased Medicaid FMAP rates and the frequency of FMAP changes.
· ARRA increased Medicaid FMAPs from October 1, 2008 – December 31, 2010, through a hold-harmless provision, a 6.2 percentage-point across-the-board increase, and a bonus adjustment related to the change in a state’s unemployment rate. Because the bonus could change each quarter, the FMAP rates were calculated on a quarterly basis.
· Public Law 111-226, enacted in August 2010, provided a two-quarter phased-down extension of the increased FMAP included in ARRA, from January 1, 2011-June 30, 2011.
The annual FMAP schedule resumed Oct. 1, 2011.
|Local match rates||When is the local match rates table updated?|
Approximately one month prior to the start of a new federal fiscal year, the DHS | OHA Budget Planning and Analysis Unit (BPA) receives new rates from the Federal Funds Information for States
The division updates the local match rates table with the new rates once BPA verifies them and distributes them to DHS|OHA staff.
|National Drug Code reporting||Why do I have to bill with National Drug Codes (NDCs) in addition to Healthcare Common Procedure Coding System (HCPCS) codes?|
The Deficit Reduction Act of 2005 (DRA) requires state Medicaid programs to collect rebates on physician-administered drugs for outpatient services in order to receive federal funding for coverage of these drugs.
Since there are often several NDCs linked to a single HCPCS code, the Centers for Medicare and Medicaid Services (CMS) consider the use of NDC numbers critical to correctly identify the drug and manufacturer in order to invoice and collect the rebates.
|National Drug Code reporting||What is the Drug Rebate Program?|
The Medicaid Drug Rebate Program was created by the Omnibus Budget Reconciliation Act of 1990 (OBRA '90) and became effective 1/1/1991. The law requires that drug manufacturers enter into an agreement with CMS to provide rebates for their drug products that Medicaid pays for.
Outpatient Medicaid pharmacy providers have billed with NDC's and submitted for rebates since 1991. The DRA has expanded the rebate requirement to physician-administered drugs.
|National Drug Code reporting||Who is included in "physician-administered" drugs?|
Any medical practitioner whose licensed scope of practice includes administration of drugs.
|National Drug Code reporting||Are hospitals required to report the NDC?|
Yes, for outpatient services only. Inpatient services are not included in the DRA and do not require NDC reporting.
|National Drug Code reporting||Which codes require NDC reporting?|
The only CPT codes that require NDC information are immune globulin codes 90281 through 90399. Generally, diagnostics, radiopharmaceuticals and vaccines are exempt from the NDC reporting requirements.
OHA will require NDC reporting for drugs billed using HCPCS codes, including:
- A,C, J, Q (except for contrast materials, codes Q9951-Q9968), and S codes. "Not otherwise classified" (NOC) and "Not otherwise specified" (NOS) drug codes (e.g., J3490, J999 and C9399).
- For hospitals, Revenue Codes 251-259 and 634-636 will require a CPT/HCPCS code and NDC reporting.
|National Drug Code reporting||Do vaccines/immunizations require an NDC?|
No. OHA does not include vaccines in the rebate requirements. However, other payers may have different requirements. This quick reference includes examples of the codes and descriptors used for billing vaccines.
|National Drug Code reporting||Are Medicare crossover claims included in the NDC reporting requirements?|
Yes. Because the state may pay a portion of the Medicare crossover claim (e.g., Medicare coinsurance/deductibles and drug procedure codes not covered by Medicare), physician-administered drug claims for Medicare-Medicaid recipients also require NDCs with the HCPCS codes.
|National Drug Code reporting||Do I need to submit an NDC on claims that I purchased as 340B discounted prices?|
Yes. The 340B Drug Pricing Program resulted from the enactment of the Veterans Health Care Act of 1992, which is Section 340B of the Public Health Service Act. Providers are able to acquire drugs through that program at significantly discounted rates. Because of the discounted acquisition cost, these drugs are not eligible for the Medicaid Drug Rebate Program.
State Medicaid programs are obligated to ensure that rebates are not claimed on 340B drugs. The DRA 2005 does not exclude 340B drugs; therefore, all providers must also meet these requirements. In order for providers to identify 340B drugs dispensed in an outpatient or clinic setting, the National Medicaid Electronic Data Interchange HIPAA workgroup has recommended use of the "UD" modifier. Oregon Medicaid has instructed its providers to also bill with the "UD" modifier in its supplemental billing guides.
|National Drug Code reporting||How do I know if an NDC is rebateable?|
When you need to report NDCs for outpatient physician-administered drug services, you must use the 11-digit NDC listed on the drug packaging. To find out if the NDC is rebateable, search for the NDC in the CMS drug rebate file (click on "Drug Product Data File"). If the NDC is on file, it is rebateable.
|National Drug Code reporting||Where do I find information on specific HCPCS code billing information?|
|National Drug Code reporting||What Revenue Code(s) must I use for billing hospital outpatient drugs?|
Revenue Codes 251-259 and 634-636 will require a CPT/HCPCS code and NDC reporting.
|National Drug Code reporting||What is an NDC and how do I enter it on claims?|
The NDC is the number which identifies a drug. The NDC number consists of 11 digits in a 5-4-2 format. The first 5 digits identify the manufacturer of the drug and are assigned by the Food and Drug Administration. The remaining digits are assigned by the manufacturer and identify the specific product and package size.
Some packages will display fewer than 11 digits, but leading "0"s can be assumed and need to be used when billing. For example:
NDC on label
Configuration on label
NDC in required 5-4-2 format
The NDC is found on the drug container (i.e. vial, bottle, tube). The NDC submitted to Medicaid must be the actual NDC number on the package or container from which the medication was administered.
Do not bill for one manufacturer's product and dispense another. The benefits of accurate billing include reduced audit, telephone calls and manufacturers' dispute of their rebate invoices.
It is considered a fraudulent billing practice to bill using an NDC other than the one administered.
|National Drug Code reporting||Do I need to include units for both the HCPCS code and the NDC?|
Yes. Provider reimbursement is based on the HCPCS description and units of service. The state's mandated rebate submission is based on the NDC and those units.
|National Drug Code reporting||Are the HCPCS code units different from the NDC units?|
Yes. Use the HCPCS code and service units as you have in the past; this is the basis for your reimbursement.
NDC units are based upon the numeric quantity administered to the patient and the unit of measurement. The unit of measurement (UOM) codes are:
- F2 = International Unit
- GR= Gram
- ML = Milliliter
- UN = Unit (Each)
The actual metric decimal quantity administered and the unit of measurement are required for billing. If reporting a fraction, use a decimal point. For example: Three 0.5ml vials are dispensed, the correct quantity to bill is 1.5 ml.
|National Drug Code reporting||If the physician administered a vial of medication to a patient, do I bill the NDC units in grams, milliliters, or units?|
It depends on how the manufacturer and CMS have determined the rebate unit amount. The rule of thumb is:
- If a drug comes in a vial in powder form and has to be reconstituted before administration, then bill each vial (unit/each) used. (UN)
- If a drug comes in a vial in a liquid form, bill in milliliters. (ML)
- Grams are usually used when an ointment, cream, inhaler, or a bulk powder in a jar are dispensed. This unit of measure will primarily be used in the retail pharmacy setting and not for physician-administered drug billing. (GR)
- International Units will mainly be used when billing for Factor VIII-Antihemophilic Factors. (F2)
A patient received 4 mg Zofran IV in the physician's office. The NDC you used was 00173-0442-02, which is Zofran 2 mg/ml in solution form. There are 2 milliliters per vial.
- You would bill J2405 (ondansetron hydrochloride, per 1 mg) with 4 HCPCS units.
- Since this drug comes in a liquid form, you would bill the NDC units as 2 milliliters. (ML2)
A patient received 1 gram of Rocephin IM in the physician's office. The NDC of the product used was 00004-1963-02, which is Rocephin 500 mg vial in a powder form that you needed to reconstitute before the injection.
- You would bill J0696 (ceftriaxone sodium, per 250 mg) with 4 HCPCS units.
- Since this drug comes in powder form, you would bill the NDC units as 2 Units (also called 2 Each). (UN2)
Please note: NDCs listed above have hyphens between the segments for easier visualization. When submitting NDCs on claims, submit as an eleven digit number with no hyphens or spaces between segments.
|National Drug Code reporting||How do I bill for a drug when only a partial vial was administered?|
If the drug is packaged in a multi-dose vial (can be used for more than one patient), then only bill for the units administered.
If the drug is packaged in a single dose vial that cannot be used for multiple injections, payment is allowed for the amount of the drug or biological discarded along with the amount administered, up to the maximum number of allowed units. The units billed must correspond with the smallest dose (vial) available for purchase from the manufacturer(s) that could provide the appropriate dose for the patient.
When calculating the NDC units, the HCPCS procedure code units should be converted to the NDC units, using the proper decimal units. For example, if a patient received only 2 mg of Zofran and you used the NDC which for Zofran 2 mg/ml in a 2 ml vial, the billing would look like this: HCPCS J2405 (ondansetron hydrochloride, per 1 mg) 2 units NDC 00173044202 ML1.
|National Drug Code reporting||How will NDC information be billed on electronic and paper claims forms?|
|National Drug Code reporting||If NDC is not reported, will my claim deny?|
Only the detail line that required NDC reporting will deny. Other services billed on the claim will process as usual.
|National Drug Code reporting||If the NDC is not rebateable or I am not sure which NDC was used, can I pick another NDC under the J-Code and bill with it?|
No. The NDC submitted to Medicaid must be the actual NDC number on the package or container from which the medication was administered. It is considered a fraudulent billing practice to bill using an NDC other than the one administered.
|National Drug Code reporting||Our system does not accommodate a CPT/HCPCS for the Revenue Codes that now require one. Can we continue billing with these codes without a CPT/HCPCS?|
No. If you do bill without a CPT/HCPCS, services billed under those Revenue Codes will deny.
|National Provider Identifier||Do I need a National Provider Identifier (NPI)? |
All covered entities under HIPAA (i.e., health care service providers) must use NPIs in standard HIPAA transactions. Atypical service providers (e.g., non-emergent transportation service providers) are not subject to NPI requirements.
Only providers with an NPI linked to their Oregon Medicaid provider number can access the Provider Web Portal.
All providers must submit NPI information, if applicable, in order to enroll as an Oregon Medicaid provider.
|National Provider Identifier||How do I get an NPI? |
Follow the directions on the National Plan and Provider Enumeration System (NPPES) website. Enrolled Oregon Medicaid providers should notify Provider Enrollment, (800-422-5047), when they have changes or additions to their NPI and taxonomy information. Include your Oregon Medicaid provider number, NPI and the taxonomy code(s) you selected.
|National Provider Identifier||Do I need taxonomy codes? |
If you are a provider that has one NPI and multiple Oregon Medicaid provider numbers, a unique taxonomy code for each provider number is preferred. If this isn't possible, then you will need to report a unique name, address or ZIP+4 for each provider number. This allows OHA to make a positive one-to-one match between each Oregon Medicaid provider number and your unique NPI.
If you have only one Oregon Medicaid provider number, then you do not need to use a taxonomy.
|National Provider Identifier||How do I enter NPI information on claim submissions? |
On electronic data interchange submission, use the NPI and taxonomy OHA has on file for your Oregon Medicaid provider number. On paper submissions, enter the NPI and Oregon Medicaid provider number.
If the NPI information on the claim does not match what OHA has on file for the Oregon Medicaid provider number used for billing, OHA will try to link the claim to the correct NPI by matching the provider name, address, ZIP+4 or other identifying information.
|National Provider Identifier||How do I find out what OHA has on file for my NPI information? |
|National Provider Identifier||How can I find out which NPI and taxonomy codes I chose? |
Call the NPI Enumerator at 800-465-3203, or look it up in the online NPI Registry.
|National Provider Identifier||What if I have more than one NPI? |
If you have more than one NPI but only one Oregon Medicaid provider number, OHA must add new Oregon Medicaid provider numbers for the additional NPIs.
Registered Oregon Medicaid trading partners must contact EDI Support Services (888-360-9888) whenever they obtain additional Oregon Medicaid provider numbers. Include the following information:
EDI Support will be able to link your new Oregon Medicaid provider number(s) with your trading partner ID so that your Electronic Remittance Advice (835) gets created when you bill using the new number(s).
- Your trading partner ID
- New provider number(s)
- The NPI and Oregon Medicaid provider number currently associated with your trading partner ID.
|Patient-Centered Primary Care Home Program||How do OHP providers earn PCPCH supplemental payments ?|
|Patient-Centered Primary Care Home Program||Where can I learn more about the Patient-Centered Primary Care Homes program?|
|Direct deposit||How 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.
|Payment Error Rate Measurement||What is Payment Error Rate Measurement (PERM)?|
PERM is a federally mandated review of Medicaid and CHIP claim payments. Each state is reviewed once every three years. Oregon's last PERM cycle began September 2013 for FFY 2014 (Oct. 1, 2013 to Sept. 30, 2014). Oregon's next PERM cycle will be during the Federal Fiscal Year 2017 (October 1, 2016 to September 30, 2017)
|Policies||How do I find out about upcoming changes to OHP policies, rules and guidelines?|
|Policies||Are there rules I need to follow as an OHP provider?|
We recommend that all providers sign up to receive Oregon Health Plan and General Rules updates, in addition to updates for your specific provider program.
|Preferred Drug List||What is the Preferred Drug List (PDL)?|
During the 2001 Oregon Legislative session, Senate Bill 819 created the Practitioner-Managed Prescription Drug Plan (PMPDP). The PMPDP requires the Oregon Health Plan (OHP) to maintain a list of the most cost-effective drugs to prescribe for fee-for-service members. This list is called the Preferred Drug List (PDL).
- New prescriptions for non-preferred physical health drugs (not listed on the physical health PDL) require prior authorization (PA) Non-preferred mental health drugs do not require PA.
- All non-preferred prescriptions are subject to OHP Plus (BMM, BMH, BMD) copayments when applicable.
|Preferred Drug List||Who created the PDL? |
Local doctors, pharmacists, nurse practitioners and consumers recommended drugs from selected classes for the PDL.
The Health Resources Commission (HRC) worked with the Oregon Health and Science University's Center for Evidence-Based Policy to gather clinical data, as well as information from pharmaceutical manufacturers and public testimony. They evaluated all information according to established evidence methods and in a public forum.
The HRC submitted recommendations to the division for pricing and the division made cost-effective selections, creating the PDL.
|Preferred Drug List||Why do we have a PDL?|
The PDL identifies the most effective and safe drugs for the majority of patients, based on the information available. Oregon researchers and experts have carefully considered the comparative safety and effectiveness of the drugs recommended for inclusion on this list. Of the drugs recommended, only those representing the best value to the OHP are included.
|Preferred Drug List||How do I use the PDL?|
The PDL is a tool to identify the most cost-effective drugs for open-card OHP patients. OHA asks that when practitioners start a new drug, to consider the drugs on the PDL first.
|Preferred Drug List||Where can I find the Preferred Drug List (PDL)?|
You can view the current PDL (PDF) or use the Searchable PDL. The Searchable PDL is an interactive database that includes preferred/non-preferred status, copayment information and prior authorization criteria, if applicable, for all active rebateable drugs.
|Preferred Drug List||How do drugs get added to the PDL?|
|Preferred Drug List||When is the next Pharmacy & Therapeutics Committee meeting? How can I get notified of future meetings?|
|Prior authorization||What services require prior authorization?|
The following services require prior authorization (PA):
- Durable medical equipment, prosthetics, orthotics and supplies (DMEPOS – Division 122)
- Home health services (Division 127)
- Home Enteral/Parenteral and IV services (Division 148)
- Hospital dentistry and certain dental services (Division 123)
- Physical and occupational therapy (Division 131)
- Private duty nursing (Division 132)
- Speech and hearing services (Division 129)
- Certain pharmaceutical, medical-surgical, mental health, vision, and hospital services
The PA Handbook provides an overview of the programs that may require PA and how to request PA from OHA.
Contact the member’s OHP health plan to find out about the plan’s PA requirements.
|Prior authorization||How do I request prior authorization for medical or dental services?|
If the member is in an OHP coordinated care organization (CCOA or CCOB) or dental plan (DCO), contact the plan.
For members not in an OHP plan, use the Provider Web Portal, or complete the DHS/OHA 3971. Fax appropriate documentation to OHA under a completed EDMS Coversheet.
Refer to the administrative rules for your program to find out what documentation is required for your PA request to OHA.
|Prioritized List||How does the Prioritized List work?|
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 List||What lines are currently covered on the Prioritized List of Health Services?|
Effective Jan. 1, 2017, OHP covers Prioritized List lines 1 through 475.
|Prioritized List||Where do I find past, current and proposed Prioritized Lists of Health Services?|
|Prioritized List||Where can I learn more about Prioritized List coverage?|
To find out whether a specific procedure is potentially covered according to the Prioritized List, providers can use the HSC List inquiry on the Provider Web Portal at https://www.or-medicaid.gov or call the OHP Code Pairing and Prioritized List Hotline at 800-393-9855 or 503-945-5939 (Salem).
|Provider Web Portal||Can you tell me where the PIN letter for my office will be mailed to? |
The PIN letters will go to the mailing address on file for each provider. If you have multiple locations or providers to bill for and want to know which location your PIN letters will go to, contact Provider Enrollment (800-422-5047).
|Provider Web Portal||What happens if I lose or misplace my PIN letters? |
You will need to contact Provider Services (800-336-6016) with your Oregon Medicaid provider number so that they can send a new PIN letter to you by U.S. mail. It will take 3-5 business days to arrive.
|Provider Web Portal||What are the system requirements for the Provider Web Portal?|
You will need a compatible browser and an internet connection. If you have support staff who do not have internet access and you want them to perform certain functions of the Web portal, make sure you get them appropriate access.
- Microsoft Internet Explorer 6
- Microsoft Internet Explorer 7 Service Pack 2
- Microsoft Internet Explorer 8, 9, and 10
- Mozilla FireFox 2.0
|Provider Web Portal||Can I look up Primary Care Provider (PCP) information? |
No. To obtain information about the member's PCP, you would continue to contact the member's OHP managed care plan.
|Provider Web Portal||What is the best way to handle password resets for a large number of clerks? Are there any other options than requesting resets by phone? |
To avoid password resets, you need to make sure that employees know to not do more than two (2) failed login attempts.
After the second failed login, don't try a third time. Instead, click the reset password button to go straight to the reset password screen of the Web portal. Reset your password by answering one of your secret questions (answers are case-sensitive).
|Provider Web Portal||Can I use the Provider Web Portal on a Mac instead of a PC? |
The Provider Web Portal supports Mozilla Firefox 2 on PCs, but at this time, we do not know whether the Provider Web Portal supports Mozilla Firefox 2 on Macs. Ensuring Web portal support of Macs is planned as a future enhancement.
|Provider Web Portal||How often do Provider Web Portal passwords expire? |
They expire every 90 days.
|Provider Web Portal||If the Web portal maintains six years of claims data, do I still need to keep my own claims on file for auditing purposes? |
The availability of historical claims data on the Web portal does not replace your office's recordkeeping requirements, or any existing state and federal rules for keeping necessary claims documentation on file.
|Provider Web Portal||We are a facility with individual practitioners working for us. Will our practitioners have access? |
Your individual providers may get PIN letters if they have their own state Medicaid ID. This will be in addition to the PIN letter your group/clinic gets.
- If your individual providers have separate Web portal access, anything they submit will be tied to their Medicaid ID number, not the facility's.
If everything done at your company needs to be tied to the group/clinic's ID, you may decide not to set up Web portal accounts for your individual providers.
- You might opt to set up your primary account, and all clerk accounts, underneath the clinic/group's ID using the corresponding PIN letter.
- Then, when you submit something such as a claim or PA that must be tied to a specific provider, you can enter the provider's NPI in the rendering/servicing provider ID field on the Web portal.
|Provider Web Portal||When using the "search" links to locate codes and other values, will the results start with the search criteria I entered or will results contain the search criteria I entered? |
The search links return results that start with the search criteria you entered.
- For example, searching for the word "viral" will return all results that start with the word "viral."
- It will not return all possible results containing the word "viral."
|Provider Web Portal||Is the Web portal secure? |
Yes, it is secure. The Provider Web Portal is available only to enrolled providers authorized to use the portal. Users must have a secure username and password to access the portal.
|Provider Web Portal||How will providers get access to the Provider Web Portal?|
OHA will send authorized providers an initial logon ID and PIN via U.S. ground mail. Providers will then need to login and select a unique username and password in order to start using the Provider Web Portal.
|Provider Web Portal||How far back will providers be able to access historical claims? |
All claims on file in the MMIS will be available to providers. Initially, this will include six years of converted historical claims (plus all lifetime procedure claims), and will eventually grow to include 10 years of historical claims.
|Provider Web Portal||We are a billing agency that bills for many providers. Can we get one Web Portal ID set up for us to access all of our providers' information? |
No. You will need to contact each of your customers and ask them to give you access to their Web portal accounts.
- One of your customers will have to create a Web portal account for you so that you are in the Web portal system.
- Once that account is created, you can communicate the information for your account to your other customers so that they can search for you and add you as a clerk on their own Web portal accounts.
|Provider Web Portal||What if the Third-Party Liability (TPL) panel does not show the same health coverage information than what we have for an OHP member? |
Report the resource to the DHS|OHA Office of Payment Accuracy and Recovery at www.ReportTPL.org.
|Provider Web Portal||Does the Medicare Paid Amount field allow negative dollar amounts? |
No. The paid amount must be greater than or equal to zero.
|Provider Web Portal||Can we search for more than a one-month eligibility time span? |
The Web portal allows you to view up to 13 months of historical eligibility data (through the date of inquiry). You can't request eligibility verification for future dates.
|Provider enrollment||How do I become an OHP provider?|
To serve OHP members enrolled in health or dental plans, contact the plan. To bill OHA for services not covered by a plan, enroll with OHA. Go to our Provider Enrollment page to learn more.
|About OHP||What other resources are available to providers?|
The following resources available through the Oregon Health Authority:
|Provider enrollment||I was denied participation in a CCO's provider network. What can I do?|
If you were denied participation in an OHP medical plan's provider network, read about the OHA Provider Discrimination Review process and form.
|Provider enrollment||How do I check my enrollment status with OHA?|
|Public notices and meetings||How 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 meetings||What 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
|Rates||What are OHP’s maximum allowable fee-for-service rates?|
|Training||What training is available?|
- Provider Web Portal
- Prior authorization
- Eligibility verification
|Medical payment recovery||What is medical payment recovery?|
With some specific exceptions, providers are required to bill Third Party Liability (TPL) resources prior to billing Medicaid for the purpose of coordination of benefits. If, after 30 days, the third party resource doesn't respond, the provider can bill Medicaid.
The Medical Payment Recovery Unit works with insurance carriers, medical providers, clients and other state agencies to ensure appropriate payments are made by the primary payer.
|Medical payment recovery||Is Medicaid an insurance company? |
No. Medicaid is a benefit the state provides for eligible clients under the Oregon Health Plan (OHP). If the client has private health insurance, and Medicaid has already paid the claims, the department then bills the third party insurance for reimbursement.
When a Medicaid client has third party insurance providers are required to bill the private insurance carrier before billing the state because Medicaid is always the payer of last resort.
|Medical payment recovery||If an OHP (Medicaid) client has a third party insurance and it is not showing in MMIS, who do I contact?|Providers are required to report third party insurance to DHS/OHA. To do this, go to www.reporttpl.org.
|Medical payment recovery||I am treating an OHP (Medicaid) patient for a vehicle- or work-related injury. Who do I contact? |If Medicaid has paid medical bills related to that injury, the client must file a claim against the liable third party. Contact Personal Injury Liens at 503-378-4514 or 1-800-377-3841 or e-mail email@example.com. The client must complete and submit to DHS either the:
|Medical payment recovery||I need to send in a refund check. What do I need to include with it? |
You will need a copy of the Remittance Advice (RA) indicating the claim and the amount that is being refunded for each claim. If you are refunding because other insurance has paid, please enclose a copy of the insurance Explanation of Benefits (EOB).
If you do not have a copy of the Remittance Advice you will need to send:
- Provider NPI number
- Claim date(s) of service
- Recipient name and case number
- Claim ICN (internal control number)
- The amount you are refunding for each claim
- The reason for the refund
|Medical payment recovery||Why is it necessary to get a prior authorization (PA) for a service that has already been denied? |
A prior authorization needs to be in place before the carrier will pay the claim and frequently can be approved and used retroactively for recovery purposes.
|Medical payment recovery||Does a physician need to do a PA when MPR sends them a request? |
Yes. Providers are required to comply with the request.
|Medical payment recovery||If a provider's claim did not process correctly who should they contact?|
For any fee-for-service claims processing questions you can refer them to the Provider Services Unit (PSU) at 800-336-6016.
|Medical payment recovery||There was an adjustment that took back a claim payment. How can I find out why this happened? |
For information regarding claim adjustments you can contact the Provider Services Unit at 800-336-6016.
|Medical payment recovery||Who can I contact if I have more questions regarding third party insurance or medical payment recovery? |
For more information call Medical Payment Recovery at 503-378-2005. Please tell us if you are calling about a medical claim or a prescription claim.
|ACA Section 1202 Rate Increase||Does this change Oregon's definition of a primary care provider?|
No. Oregon did not change its definition of Medicaid primary care provider. Instead, Oregon added the federal definition alongside Oregon's definition in order to identify primary care providers who qualify for the 2013-2014 rate increase.
The CMS definition only determines which providers may qualify for the increase; it does not reduce or change reimbursement for other providers or programs. Oregon's primary care providers who meet CMS's definition receive an enhanced rate for 2013-2014; those who do not receive their existing Oregon primary care rate
|ACA Section 1202 Rate Increase||Why 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.
|ACA Section 1202 Rate Increase||What services are eligible for the 2013-2014 primary care rate increase?|
|ICD-10||What do providers need to do?|
Don't delay: The ICD-10 compliance date may seem far off, but the complexity of conversion requires immediate action. ICD-10 conversion will affect nearly all provider systems and many processes.
For more information to help you prepare, visit the CMS ICD-10 Provider Resources page
- Identify and plan for the ways ICD-10 will change how you do business with all payers, including OHA. The largest impacts will likely be in clinical and financial documentation, billing and coding.
- Contact your billing or software vendor and let them know your business needs and implementation schedule. Ask questions to understand their plans for conversion and testing.
|ICD-10||What 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.
|Contracts||How can I view a copy of the model contracts for OHP health plans?|
|Training||Where can I get training?|
|Non-emergent medical transportation||What 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 transportation||Can 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 transportation||Does the brokerage call center offer any choices when it sets up rides?|
The brokerage or call center staff must meet two main criteria:
Find the most appropriate ride for the client based on actual need, not want.
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 transportation||What 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 transportation||OHP 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 transportation||Some 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 transportation||Will 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 transportation||What 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 transportation||Can anyone ride with the client to their appointment?|
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.
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
In addition, this must be negotiated with the brokerage call
center, and is subject to available space.
|Non-emergent medical transportation||What 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 transportation||If 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 transportation||What 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 transportation||Do 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 transportation||What 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.
|EDI Production||What is your Payor ID?|
Oregon Medicaid's Payor ID is ORDHS.
|Billing||What codes does OHA accept for billing?|
|Billing||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.
|Billing||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.
|Fraud and abuse||Who investigates fraud?|
Medicaid Fraud Control Unit (MFCU)
1515 SW 5th Avenue, Suite 410, Portland, OR 97201
Phone (971) 673-1880, or fax (971) 673-1890
Provider Audit Unit (PAU)
3406 Cherry Ave NE, Salem, OR 97303
Phone (888) 372-8301, or fax (503) 378-2577
Fraud Investigations Unit (FIU)
P.O. Box 14150, Salem, OR 97309-5027
Phone (888) 372-8301, or fax (503) 373-1525
|Remittance advice||What is in the paper remittance advice (RA)?|
Information in the RA will appear in the following order, as applicable:
- Banner messages: Messages from DHS/OHA
- Paper check: If you don't want a paper check, sign up for direct deposit.
- Claim information: By type of bill and Internal Control Number (ICN) - paid, denied, in process, adjustments
- Third-party liability (TPL) information: Third-party resources for each client, in order of ICN
- Financial transactions: Non-claim-specific payouts to or refunds from providers; accounts receivable information
- Leverage Claims Payable - Not paid: Lists the claims the providers must pre-pay before OHA can process them. Learn how to read this section and your RA summary to find out how much you need to pay.
- Summary: All activity reported to the RA
- EOB Code Descriptions: For all the Explanation of Benefit (EOB) codes listed in the RA
|Remittance advice||Are there other ways to get claim status information?|
|Remittance advice||I want to stop receiving the paper remittance advice (RA). How do I do this?|
Contact Provider Enrollment (800-422-5047) and ask to stop receiving the paper RA. Please provide the Provider ID listed in the "Payee ID" or "NPI ID" field in the top right corner of the paper RA.
|Non-emergent medical transportation||What 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 transportation||Who 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 transportation||What 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 transportation||When 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 transportation||Can 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 transportation||Who 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 transportation||Rules 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 transportation||Can 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 transportation||Is 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 transportation||Can 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 transportation||How 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 transportation||What 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 transportation||When 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.
|Billing||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.
|Direct deposit||How long does it take to set up direct deposit?|
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 deposit||What 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 deposit||Is 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 deposit||How 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 deposit||How 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.
|Eligibility||Where can providers go to verify Oregon Medicaid eligibility?|
|Eligibility||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.
OHA 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 (OHA, the client's CCO/health plan, or other payers).
|Eligibility||How do providers know if a client is eligible to receive a specific service?|
Coverage of a specific service depends on two things:
|Eligibility||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.
|Hospital Presumptive Medical||Can any hospital in Oregon determine Hospital Presumptive Eligibility (HPE)?|
No. Only hospitals that have contacted the Oregon Health Authority (OHA), completed an application and signed an agreement with OHA to perform HPE determinations per OHA standards and rules may do so.
|Hospital Presumptive Medical||Will hospitals or providers be paid for services rendered during the HPE period even if a service is below the funding line on the Prioritized List?|
No. In order for a provider to be paid for a service rendered during the HPE period, the service must be a covered service under OHP.
|Hospital Presumptive Medical||Is hospital presumptive eligibility (HPE) limited to patients only, or can hospitals make a PE decision for a person that walks into the hospital seeking assistance with enrollment?|
Hospitals may make HPE determinations for a patient of the hospital or a community member, even if the individual has not used, and/or does not intend to use, hospital services.
|Hospital Presumptive Medical||Can a HPE decision be made after the patient is discharged from the hospital (e.g., Emergency Department patients who come in overnight & discharge before regular business hours)?|
Yes, if the hospital submits the decision to OHA within 5 calendar days following the date of service. The date of service becomes the “Date of notice” on the Approval Notice, or proof of coverage, given to the patient.
|Hospital Presumptive Medical||Can a HPE decision be backdated to a Date of Service within a certain time-frame (e.g., for recently discharged Emergency Department patients)?|
Yes, if the hospital submits the decision to OHA within 5 calendar days following the date of service. This date becomes the “Date of notice” on the Approval Notice, or proof of coverage, given to the patient.
|Hospital Presumptive Medical||Is there a timeframe under which the HPE form must be submitted by the hospital to OHP Customer Service?|
Yes, within 5 days of the HPE determination.
|Hospital Presumptive Medical||Is an applicant’s, or applicant’s representative’s, signature required on the HPE application (OHP 7260)?|
A signature is highly preferable, but not absolutely required, for HPE.
|Hospital Presumptive Medical||Once a hospital approves HPE for an individual, how long does it take for the individual to get coverage?|
Individuals are entered into the Medicaid Management Information System (MMIS) within a week of submitting the required forms. Hospitals and providers should check MMIS at that time to find out about the individual's coverage.
|Hospital Presumptive Medical||Is the 5% MAGI disregard included for eligibility determination? (e.g. can patients with incomes between 133%-138% of the FPL be eligible for HPE?|
HPE determinations do not use the MAGI 5% disregard. They are based on straight household income.
|Hospital Presumptive Medical||When the person’s HPE eligibility has been approved, on what date does it take effect?|
HPE eligibility takes effect on the date the hospital makes the HPE eligibility decision. The HPM eligibility decision is an immediate determination so that the following all happens on the same date:
This is generally prior to service delivery.
- The HPE eligibility application (OHP 7260) is completed;
- The hospital makes the eligibility determination;
- The hospital gives the individual a notice of approval or denial.
|Hospital Presumptive Medical||When and for whom are hospitals responsible for completing a Notice of Denial?|
All applicants who are denied HPE must receive a Notice of Denial, and all denials must be reported to OHP Customer Service within 5 working days of the denial.
|Hospital Presumptive Medical||If someone has a denial on file, will it exclude them from an HPE approval in the future, or can they simply re-apply at any time?|
A denied applicant may re-apply at any time.
|Hospital Presumptive Medical||Do hospitals have to help the HPE applicant complete the OHA 7210 (OHP application) for ongoing eligibility)?|
Hospitals are only required to give the applicant the OHA 7210 and information on getting assistance with completing and submitting it (e.g., contact information for local Application Assisters).
However, since hospitals will be evaluated on the number of full applications completed by the individuals they approved for HPE, it is to their advantage to ensure the application is completed and submitted.
|Hospital Presumptive Medical||How does the hospital mark the OHA 7210 (OHP application) for ongoing coverage)?|
When giving applicants the full 7210 application for ongoing coverage:
- The hospital should clearly mark “Hospital Presumptive” at the top of the form for individuals approved for Hospital Presumptive coverage.
- Individuals denied Hospital Presumptive coverage should get an unmarked 7210 application to complete, or be referred to a community partner to get help applying for OHP.
|Hospital Presumptive Medical||Does HPE cover all OHP services? |
HPE covers all services covered under OHP, including dental, vision and mental health, with one exception.
Exception: Pregnant women are covered only for ambulatory care (all OHP-covered services) during the prenatal period. Labor and delivery are not covered.
|Hospital Presumptive Medical||Are newborns born to HPE-eligible women considered Assumed Eligible Newborns (AEN)?|
No, these newborns are not deemed eligible. Only those born to mothers determined to be fully Medicaid-eligible are deemed AEN.
|Hospital Presumptive Medical||Is retroactive coverage possible under the HPE decision process, or would the patient only have the possibility of retroactive coverage if they complete the full application?|
Retroactive coverage will only be available if the individual completes the full application and is determined eligible for Medicaid. Retroactive coverage will only be available for covered medical costs up to three months prior to the period of full eligibility.
Retroactive coverage does not apply to the HPE period.
|Hospital Presumptive Medical||Are HPE-eligible individuals entered as OHP open card for billing?|
Yes, HPE-eligible individuals will be fee-for-service (open card) and will not be enrolled into CCOs, or any managed care entity, until and unless determined fully eligible via a OHA 7210 application.
|Hospital Presumptive Medical||Can an attendant/responsible party supply the information for a person?|
|Hospital Presumptive Medical||Are hospital ancillary services covered for a hospital stay?|
Yes, all services provided by any enrolled OHP provider
that are covered services under the person’s benefit package will be
|Hospital Presumptive Medical||Can hospitals take the HPE application information over the phone?|
This is not preferable, but allowable if the individual is indisposed and unavailable to apply in person.
|Forms||How can I order copies of the OHP Handbook (OHP 9035)?|
Submit orders to the DHS|OHA Distribution Center using the MSC 8100 form.
|Local match rates||How do unit of government providers submit local match prepayments for MMIS claims?|
- Submit prepayment with the DMAP 3049 form (Word) (PDF) by 5 p.m. Wednesday of the week that claims are submitted. Otherwise, the claims will suspend until prepayment is received.
- For the amounts you need to prepay, refer to the Leverage Claims Payable - Not Paid" section of the paper RA for each service provider.
- You can also use the local match rates, based on the claim's payment date.
|Local match rates||How do unit of government providers submit local match prepayments for Medicaid Administrative Claiming (MAC)?|
- Submit prepayment with the MSC 1419 form.
- For the amounts you need to prepay, refer to the federal financial participation (FFP) amount indicated in your Intergovernmental Agreement (IGA).
|Access to care||How can CCO providers help patients change CCOs in order to continue seeing their chosen provider?|
CCO providers can use the process described in the CCO Provider Change Request Guide. This process is only for CCO members to switch CCOs in order to keep their physical health Primary Care Provider.
For any other changes, members should contact their CCO/plan or OHP Customer Service.
|Inmate Project||Who may be eligible under this process?|Oregon inmates who have inpatient hospitalizations during their incarceration, or will soon be released from incarceration.
|Inmate Project||Is retroactive eligibility possible?|
Retroactive eligibility is possible under certain limited circumstances (up to 90 days prior to the eligibility determination date), providing the individual would have been Medicaid-eligible at the time.
|Inmate Project||How do I get Provider Web Portal access to review for current eligibility?|
Register as a non-payable Oregon Medicaid provider using the OHP 3113 form. OHA will issue you a PIN letter for Provider Web Portal access once you are enrolled.
|Hospital Presumptive Medical||Can we complete an HPE application for someone who already applied for OHP, but hasn't heard whether the application was approved?|
It is best to contact the Outreach Team to find out about the person's application status. To do this, email OHP.Outreach@state.or.us or call 1-800-699-9075 (select the "Community Partners" option).
|Hospital Presumptive Medical||Where can I find the Oregon Administrative Rules about HPE?|
410-200-0105 (Hospital Presumptive Eligibility) in the OHP Medical Eligibility Policy rules sets out when an individual
is presumptively eligible for MAGI Medicaid/CHIP, BCCTP, and Former Foster Care
Youth Medical based on the determination of a qualified hospital.