The department's Medical Payment Recovery Unit is responsible for recovering fee-for-service Medicaid funds that have been expended on behalf of a Medicaid eligible client where other insurance coverage should have been the primary source for payment. MPR does not recover funds for coordinated care organizations (CCOs).
About Medical Payment Recovery
With few exceptions, providers are required to bill Third Party Liability (TPL) resources prior to billing Medicaid. 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, other state agencies and contracted vendors to ensure appropriate payments are made by the primary payer.
Frequently Asked Questions
Is Medicaid an insurance company?
No. Medicaid is a benefit funded by federal and state governments. It is delivered to eligible individuals under the Oregon Health Plan (OHP). If a Medicaid recipient has private health insurance, and Medicaid has already paid claims on their behalf, the department will bill 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 usually the payer of last resort.
If an OHP (Medicaid) client has a third party insurance (TPI) and it is not showing in MMIS, who do I contact?
Clients and providers are required to report third party insurance. Go to www.reportTPL.org and click on the “Submit Now” button in the top right-hand corner of the page.
I am treating a Medicaid-covered individual for a vehicle or work-related injury. Who do I contact?
If Medicaid has paid medical bills related to an injury, the client must file a claim against the liable third party. See Contact information at the top right-hand corner of this page for information on where to report an injury.
I need to send in a refund check. What do I need to include with it?
Before initiating a refund please review OAR 410-120-1280 to review when it is appropriate to refund a payment. If you determine you should be refunding, 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
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.
Does a physician need to do a PA when MPR sends them a request?
Yes. Providers are required to comply with the request.
If a provider's claim did not process correctly, who should they contact?
You can refer questions about claims processing to the Oregon Health Authority (OHA), Provider Services Unit (PSU) at 800-336-6016.
Who should I refer a provider to if they have questions about Oregon Health Authority policies or billing practices?
Refer them to Oregon Health Authority Provider Services at 800-336-6016 or OHP Tools for Providers for other resources.
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.