Learn about Fee-for-Service Billing
Also refer to the
provider guidelines for your program and the
General Rules.
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 Oregon Medicaid Provider Portal, electronic data interchange, or commercially available paper claims.
Visit our OHP billing tips page for more information.
The Oregon Medicaid Provider 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.
- 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.
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.
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 (800-336-6016).
- To look up the NPI of the ordering, referring, or rendering provider for a claim, use the NPI Registry.
Handbooks, Tips, and Step-by-Step Guides
Learn about fee-for-service claim processing, how to bill OHA on paper, and how to bill using the Oregon Medicaid Provider Portal. Use the search field to find resources by topic, keyword or document name. For example:
- Enter "portal" for resources about submitting web portal claims.
- Enter "paper claims" for resources about submitting paper claims.