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Also refer to the provider guidelines for your program and the General Rules.
Yes; enrolled providers can do individual claim submissions using the Provider Web Portal. Go to our Provider Web Portal page to learn more.Providers can also submit batches of claims using electronic data interchange. Go to our EDI page to learn more.
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.
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.
For billing purposes, OHA uses Current Procedural Terminology (CPT), Level II National Codes (HCPCS) and Current Dental Terminology (CDT) procedure codes.
OHA does not cover all valid codes, and OHA may not allow covered codes in all settings.
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.
Learn about fee-for-service claim processing, how to bill OHA on paper, and how to bill using the Provider Web Portal. Use the search field to find resources by topic, keyword or document name. For example:
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