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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.
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.
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 third party insurance.
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.
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:
For questions about claims processing, contact OHP Provider Services at at 800-336-6016.
Contact the OHP Provider Services 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.
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