How to submit claims to OHA

Questions and answers about fee-for-service billing

Also refer to the provider guidelines for your program and the General Rules.

If you have other billing questions not answered on this page, call Provider Services at 800-336-6016, or email dmap.providerservices@dhsoha.state.or.us.
To learn about how to bill for services to CCO members, contact the member's CCO.

Can I bill OHA electronically?

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.

How do I bill for services to OHP members?

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.

How do I find out how OHA processed my claim?

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.

What codes does OHA accept for billing?

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.

What should providers do before billing OHA?

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.
Do not deduct an OHP client copayment from the fee submitted on the claim. OHA will deduct the amount of the copayment from the amount paid to the provider.

Should providers bill the full amount to OHA?

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.

What are your NPI requirements for billing?

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 Provider Web Portal. Use the search field to find resources by topic, keyword or document name. For example:

Enter "web portal" for resources about submitting web portal claims.
Enter "paper claims for resources about submitting paper claims.