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Medical Payment Recovery

About medical payment recovery

The Medical Payment Recovery Unit recovers fee-for-service Medicaid funds that have been spent on Medicaid-eligible people when other insurance coverage should have been the primary payer.

  • If a person has Medicaid and private health insurance, providers are generally required to bill the third party liability (TPL) resource before billing Medicaid (OHP).
  • After 30 days, if the third party resource doesn't respond, the provider can bill Medicaid.
  • If Medicaid pays a claim when other insurance should have been the primary payer, the State will bill the third party insurance for reimbursement. We work with insurance carriers, medical providers, clients, other state agencies and contracted vendors to make sure appropriate payments are made.
  • We do not recover funds for Coordinated Care Organizations (CCOs).

For questions about provider refunds, contact us.

Include whether this is for a medical claim or a prescription claim.

For questions about billing, adjustments or other claims issues, contact OHP Provider Services.

Also see Oregon Administrative Rule 410-120-1280 for billing requirements.

Frequently asked questions

​No. Medicaid is a benefit funded by federal and state governments. It is delivered to eligible individuals under the Oregon Health Plan (OHP).

When an OHP member 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 member has private health insurance and Medicaid has already paid claims on their behalf, the State will bill the third party insurance for reimbursement.​

​OHP members ​and providers are required to report th​ird party insurance.

Visit our Third Party Liability page and click on “Report or update TPL."

​If Medicaid (OHP) has paid medical bills related to an injury, the OHP member ​must file a claim against the liable third party.

See Personal Injury Liens for information on how to report an injury.​

​Before you send in a refund,​ review OAR 410-120-1280​ to see if it ​is appropriate to refund a payment.

If you find that you should be refunding, include 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, include a copy of the insurance Explanation of Benefits (EOB).

If you don't 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

​For ​questions about claims processing, contact OHP Provider Services ​​at ​at 800-336-6016.

​Contact the OHP Provider S​ervices at 800-336-6016, or see ​OHP Tools for Providers for other resources.

​For information about claim adjustments, contact OHP Provider Services ​at 800-336-6016.​

​A prior authorization (PA) needs to be in place before the insurance carrier will pay the claim. It ​can often be approved and used retroactively for recovery purposes.

​Yes. Providers are required to comply with the recovery ​request from the State.

Contact us